report to the board of directors 2014/15 · rep/bod/ah1605/v1 attachment 9 report to the board of...

30052014 Clinical Audit Forward Plan Anna Hills, Associate Director of Governance, Safety and Compliance May 2014 REP/BOD/AH1605/V1

Attachment 9

Report to the Board of Directors 2014/15

Date 30 May 2014

Subject 2014/15 Clinical Audit Forward Plan

Report from Medical Director

Author Sharon Boothby, Clinical Risk Manager

Previously considered by N/A

Board action required

Approval X Discussion

Decision Information

Executive Summary and purpose

The attached documents represent the Clinical Audit Forward Plans for each division for 2014/15. These contain audits identified as planned for the year (with a minimum dataset including evidence base; start and finish dates and senior personnel), as well as audits already registered and confirmed to take place in the year. In accordance with PwC recommendations, emphasis is placed on the priority 1 and 2 (respectively, external must-do and internal must-do) audits, which are included first on each division’s list, sorted by quarter. In line with the Trust’s objectives for 2014/15, the aim will be for all of these audits to be completed within the year. It should be noted that this is a working document which can be added to as the year progresses. However there is a requirement that a complete as possible plan is signed off at the beginning of the financial year. The Board of Directors is asked to approve the report as providing sufficient assurance on the actions being taken.

Board Assurance Framework (link to strategic objectives)

1 Implement the first year's objectives of the Trust's Quality Strategy

This paper provides positive assurance against the Trust objective(s) identified X

This paper is to close a gap in control/assurance in relation to the objective(s) X


Legal/regulatory Care Quality Commission

NHS Litigation Authority

Equality Impact/risks: Equality Delivery System 2 – EDS2 Nov 2013)

Impact

Positive

X

Negative

Assurance/monitoring Clinical Effectiveness Committee reporting through the Safety and Quality Governance Committee, with exception reporting to the Board of Directors for any areas requiring additional actions to be taken.

Clinical Audit Forward Plan 2014/15 - Corporate

ID

FP=PlannedREG=Registered

Title Evidence Base / Rationale Start dateFinish

dateProject Leader

Senior Clinician/Manager

Priority Rating

Quarter 1 (Must-Do Audits - Priority 1 & 2)

Infection Control

REG1424 Discharge information for Clostridium Difficile positive patients

JPUH Clostridium difficile Trust Policy. [Link to Risk Register: ref 36]

01/04/2014 31/05/2014 Mandy Hoadley

Linda Hawtin

2

Risk & Governance

REG1256 RCA audit of Safety Thermometer reports of new UTI in patients with in dwelling urinary catheter

CQUIN 01/04/2013 30/04/2014 Jack Copping

Jacky Copping

2

Trustwide

REG1397 Falls NICE Audit NICE: CG161. 01/01/2014 31/05/2014 Helen Ashby

Jacky Copping

2

FP0228 VTE Prophylaxis & Re-assessment re-audit NICE CG92 01/02/2014 01/05/2014

Jacky Copping/Dr Zaidi

2

REG1434 Re-audit of INTRAN Face to Face Booking Process

Audit rationale: Monitor compliance with new INTRAN booking request process

01/04/2014 18/07/2014 Anna Hills

Anna Hills

2

Corporate Forward Plan Report for 2014/15 Report generated: Page 1 of 529/04/2014

ID



dateProject Leader


Priority Rating


Trustwide

FP0231 Intravenous fluid therapy in adults in hospital NICE CG174 31/08/2014 30/11/2014

Jacky Copping

2


ID



dateProject Leader


Priority Rating


Trustwide

FP0256 Misidentification of Patients National Patient Safety Alert 01/10/2014 31/12/2014

Anna Hills

2


ID



dateProject Leader


Priority Rating


Blood Transfusion

REG1428 Transfusion Practice re-audit Audit rationale: Clinical Governance 01/01/2015 31/03/2015 Julie Jackson

Cesar Gomez

2


ID



dateProject Leader


Priority Rating

Continuous National Audits

Patient Care

REG1252 Dementia Carers Audit as part of the national dementia CQUIN

National Audit: Dementia CQUIN. 01/05/2013 Becki Ballard

J Hunt

2

Trustwide

REG0344 NCEPOD Confidential Enquiry into Patient Outcome and Death (National Audit)

National Audit: Yes [Continuous]. Quality Accounts

Dr M Wright

Dr M Wright

1


Clinical Audit Forward Plan 2014/15 - Elective Division

ID



dateProject Leader


Priority Rating


General Surgery

REG1421 Choles Study / Audit National Audit: Choles. 01/03/2014 15/07/2014 Mr Chitre / Mr Tuffaha

Mr Velchuru

1

FP0244 Negative pressure wound therapy for the open abdomen

NICE IPG467 01/04/2014 31/03/2015

Mrs Downey

2

Microbiology

REG1439 An audit of management of Community Acquired Pneumonia (CAP)

Royal College Audit: Royal College of Pathologists. [Risk register relevant: ref 36]

03/03/2014 03/06/2014 Dr Lasantha Ratnayake

Dr Maya Venu

2

Obstetrics & Gynaecology

FP0155 No of Patient Women who are not known to have comorbidities (such as pelvic inflammatory disease, previous ectopic pregnancy or endometriosis) and been offered hysterosalpingography (HSG) to screen for tubal occlusion

NICE CG156 01/03/2014 31/05/2014 Mr A Elfara

Mr A Elfara

2

REG1433 Audit of unexplained infertility and hysterosalpingogram

NICE: CG156. 01/03/2014 31/05/2014 Mr A Elfara / Dr Paul Timmons

Mr A Elfara

2

FP0237 Re-Audit of Appropriate Use of Physiotherapy in the Post Natal Period

CNST 3.3, 3.5 and 2.6, Local Guidelines. Re-audit

01/04/2014 30/04/2014 Karen Crossan

Karen Crossan

2

Ophthalmology

FP0261 NICE Compliance NICE [Specific guidance being queried by Mr Butler as of April 14]

01/03/2014 31/05/2014 B Sharpe-Brash

B Sharpe-Brash

2

Elective Forward Plan Report for 2014/15 Report generated: Page 1 of 1230/04/2014

ID



dateProject Leader


Priority Rating

Orthopaedics

REG1373 Hypothermia in Recovery NICE: Surgical Site Infection [QS49, CG74].

04/12/2013 30/06/2014 Diane Crosby

Dr Ail

2

FP0248 Human Tissue Authority (HTA) Temperature Records Audit

HTA, re-audit 01/02/2014 01/05/2014 David Locke

Gail Banham

2

FP0247 Human Tissue Authority (HTA) Documentation Audit Trail


Gail Banham

2

FP0246 Human Tissue Authority (HTA) Standard Operating Procedure Examination Audit


Gail Banham

2

Paediatrics

REG1107 Epilepsy 12 (National Audit) Re-audit. National Audit: RCPCH. NICE: CG137. Quality Accounts 12/13

01/01/2013 30/06/2014 Dr Nirmal

Dr Nirmal

1

REG1125 Paediatric Chest X Rays Audit rationale: High risk (as non reporting of bones in chest X-Rays may result in missed NAI)

28/01/2013 01/04/2014 Dr Chapman/ S Raja

Dr Chapman

2

REG1393 Re-audit of Medical Coding Audit Audit rationale: Frequently occuring issue, affects funding

20/01/2014 31/01/2015 Sophie Wheatcroft

Dr Ambadkar

2

REG1435 Looked after health assessments action plan Re-audit. CQC 01/04/2014 30/04/2014 Donna Milner

Dr Ambadkar

1

REG1441 Attention deficit hyperactivity disorder (ADHD) - services for children and young people

NICE: CG72. 03/04/2014 03/08/2014 Dr Victoria Clarke

Dr A Oppong-Odiseng

2

REG1442 Autism diagnosis in children & young people & the management of children & young people on the autism spectrum

NICE: CG128, CG170. 03/04/2014 03/08/2014 Dr Victoria Clarke, Robyn Webb

Dr A Oppong-Odiseng

2


ID



dateProject Leader


Priority Rating

FP0251 Audit of Febrile Neutropenia in Paediatric oncology patients attending Ward 10 JPUH

Re-audit, Cancer Network guidelines 01/06/2014 01/09/2014

Dr Stocks

2

Urology

FP0249 Prostate Cancer (Continuous National Audit starting 2014)

NICE CG175, HQIP National Audit for Quality Accounts

01/04/2014

Mr Frymann

1


ID



dateProject Leader


Priority Rating


General Surgery

FP0243 Audit of DVT Prophylaxis in General Surgical patients (Re-audit)

Re-audit, NICE CG92 01/08/2014 30/09/2014

Mr Velchuru

2

Paediatrics

FP0252 NICE Paediatric Obesity Audit NICE CG43 30/09/2014 31/12/2014

Dr Shareef

2


ID



dateProject Leader


Priority Rating


Paediatrics

REG1437 BTS National Asthma Audit National Audit: BTS. HQIP National Audits for Quality Accounts

01/11/2014 28/02/2015 Dr John Chapman; others TBA

Dr J Chapman

1


ID



dateProject Leader


Priority Rating


Paediatrics

FP0254 Audit of Paediatric Diabetic Services NICE CG15, re-audit 01/01/2015 31/03/2015

Dr Raman

2

FP0253 Audit of DNA/CNA policy for children under 16 years

Re-audit (ID1409), JPUH policy 01/01/2015 31/03/2015

Donna Milner

2


ID



dateProject Leader


Priority Rating

Departmental/Clinical Interest Audits - Priority 3 & 4

Anaesthetics

REG1130 Complications & Efficacy of Steroid Lumbar Epidural injections for pain management

National Healthcare Standards: Yes. 01/04/2013 01/12/2014 Dr Andreas Brodbeck, George Nadakavukaran, Emily Tshangela

Dr D Ail

4

FP0198 Airway management training for novice anaesthetists (re-audit)

RCOA 01/01/2014 01/04/2014

Dr P Wright/Dr P Nathan

4

REG1452 Audit of Enhanced Recovery of LSCS - Stage 1

Audit of maternal outcomes following introduction of Enhanced recovery in obstetric surgery for protocol for Elective LSCS patients (International Journal of Obstetric Anaesthesisa 2013, 22, page S8)

29/04/2014 18/07/2014 Dr K Dasari, Dr S Sagadai

Dr Sagadai

4

FP0273 Postoperative Hb estimation proposal AAGBI Guideline "Management of Proximal Femoral Fractures 2011 /2012".

01/08/2014 31/08/2014 Dr Arnth Engel

Dr Arnth Engel

3

General Surgery

REG1340 Audit of the accuracy of surgical death certificates

Audit rationale: It is known that a significant proportion of death certificates contain errors. Death certificates are an important source of mortality data and used for allocation of funding.

23/10/2013 23/05/2014 Mr Velchuru

Mr Velchuru

3

REG1419 Time taken to obtain radiological investigations once requested by on call surgical team

Audit rationale: There can be significant delays in obtaining radiological investigations. What is exact time frame?

01/02/2014 31/07/2014 Stephen Lam

Signed - query name

4

REG1429 Compliance with documentation of urethral catheterisation

NHS Quality Improvement 20/03/2014 20/04/2014 Dr Michael Akinfala and Dr Jesse Lee

Mr Gupta

3


ID



dateProject Leader


Priority Rating

REG1440 Retrospective Audit of Clinical Outcomes following Removal of Normal Looking Appendix at Laparoscopy (2013) - 2 Centre Audit (NNUH+JPUH)

National Audit: 2-centre audit, NNUH+JPUH.

01/04/2014 31/07/2014 Dr Vasileios Bonatsos, Mr Roshan Lal, Miss Ioanna Panagiotopoulou

Mr R Lal

3

FP0241 Outcomes of perforated Duodenal ulcer perforation

Service Evaluation 01/04/2014 30/09/2014

Mr Tuffaha/Mr Chitre

3

FP0242 Recurrence rates following rectal cancer Audit 01/05/2014 31/12/2014

Mr Velchuru/Dr Biswas

4

FP0163 Appendicectomy - LOS and wound infection rates.


Mr Chitre

3

FP0167 Management of Acute Pancreatitis Regional 01/10/2014 31/03/2015

Mr Chitre

3

Microbiology

FP0245 Infection rates following Bowel surgery Audit 14/01/2014 31/08/2014

Microbiology Department

3


REG1430 Return to theatre after Gynaecological surgery Good medical practice 03/02/2014 31/05/2014 Dr Prasanth Perilakalathil

Mr Hassanaien

4

Ophthalmology

FP0131 Atropine-occlusion: visual outcomes Service Evaluation 01/01/2013 08/03/2013

C. Philpott

4

REG1299 Evaluation of risk for 2nd eye in AMD Audit rationale: We see lucentis patients for OCT less often than some units. Is this disadvantaging our patients?

01/09/2013 31/07/2014 Ben Burton

B Burton

4

FP0263 Outcome of new referrals in Glaucoma [Evidence base being queried by Mr Butler as of April 14]

01/03/2014 31/05/2014

K Pulley / S Cotton

4

FP0262 Nurse led drop teaching technique pt evaluation

[Evidence base being queried by Mr Butler as of April 14]

01/03/2014 31/05/2014

K Metcheva

4


ID



dateProject Leader


Priority Rating

FP0260 Trabeculectomy (SM) outcomes [Evidence base being queried by Mr Butler as of April 14]

01/03/2014 31/05/2014

R Sharma

4

FP0259 SLT – audit of outcomes [Evidence base being queried by Mr Butler as of April 14]

01/03/2014 31/05/2014

R Nadler

4

FP0269 ARMD time from referral to treatment/ follow up frequency


01/07/2014 30/09/2014

?Rob Nadler

4

FP0265 Avastin for CNV in patients with good presenting VA: an audit of outcomes


01/07/2014 30/09/2014

K Pulley, R Nadler, B Burton

4

FP0264 Evaluation of risk for 2nd eye AMD [Evidence base being queried by Mr Butler as of April 14]

01/07/2014 30/09/2014

T Khatib, B Burton

4

FP0270 Audit of biometry accuracy – IOLmaster vs Ultrasound


01/09/2014 30/11/2014

Mr Butler

4

FP0271 Thyroid Eye Disease and Immunosuppression [Evidence base being queried by Mr Butler as of April 14]

01/09/2014 30/11/2014

B Hemmant

4

FP0272 Audit of audits: departmental audit protocol and follow-up


01/09/2014 30/11/2014

M Ohn

4

Orthopaedics

REG1438 Retrospective Evaluation of Transfusion Requirements in Paients Undergoing Total Knee Replacement

Audit rationale: To evaluate current practice with regards to total knee replacements.

03/02/2014 01/05/2014 Dr Wellington

Mr Deo

4

Paediatrics

REG1352 The use of Melatonin in children with sleep disorders

NICE: ESUOM02. Local shared care prescribing information for Circadin ® for sleep disorders & JPUH guidelines

01/09/2013 01/09/2014 Dr Amma Oppong-Odiseng, Dr Sheima Hamad

Dr Chapman

3


ID



dateProject Leader


Priority Rating

REG1364 Appropriateness of Follow-Up in Community Paediatrics

Audit rationale: Long community paediatric follow-up times. Limited staff capacity to provide any additional clinics. Assessments delayed due to long waits

01/12/2013 31/07/2014 Dr A Oppong-Odiseng

Dr P Ambadkar

3

FP0229 Nephrotic Syndrome Nottingham Hospital shared care guidelines

01/01/2014 31/05/2014 Dr Bentsi-Enchill

Dr Bentsi-Enchill

3

Urology

REG1391 Re-audit - audit to assess the appropriate use of IV antibiotics in the Dx of Urosepsis & other emergency urological admissions

Local sepsis guidelines 09/01/2014 09/05/2014 Dr N. N. Ghosh

Mr Gupta

4

FP0250 Antibiotic use in patients referred to urology from A&E. Comparison with Best Practice

Re-audit 01/04/2014 01/07/2014

Mr Gupta

3


ID



dateProject Leader


Priority Rating


Anaesthetics

REG0131 National Obstetric Anaesthesia Database (NOAD)

National Audit: Yes [Continuous]. 13/06/2011 Dr Sagadai

Dr Sagadai

1

REG1301 National Emergency Laparotomy Audit (NELA) HQIP Quality Accounts NCAPOP 01/12/2013 31/01/2016 Dr Ail, Mr Chitre

Dr Ail

1

ENT

REG0386 Head & Neck Cancer (DAHNO) National Audit: Yes [Continuous]. Quality Accounts

Mr Tassone/Tracy Church

Mr Tassone

1

General Surgery

REG0385 Bowel Cancer (National Bowel Cancer Audit Programme) (NBOCAP)


Linda Hayes / Steve Wright

REG0380 Elective Surgery (National PROMs Programme)


01/04/2009 Helen French

Helen French

1


REG0360 Invasive Cervical Cancers (National Audit) National Audit: Yes [Continuous]. Dr Preston

Dr Preston

1

REG1096 Maternal, Newborn and Infant Clinical Outcomes Review Programme (MBRRACE) (Formerly CEMACH/CMACE)

National Audit: MBRRACE [Continuous]. Quality Accounts

01/04/2011 Carol Mutton

Carol Mutton

1

Orthopaedics

REG1080 National Hip Fracture Database (NHFD) National Audit: Yes [Continuous]. NICE: TA161. Quality Accounts

Patsy Hindley

Patsy Hindley

1

REG0524 National Joint Registry (NJR) National Audit: Yes [Continuous]. NICE: [TA304]. Quality Accounts

Mr Cohen

Mr Cohen

1


ID



dateProject Leader


Priority Rating

Paediatrics

REG1078 National Neonatal Audit Programme (NNAP) National Audit: Continuous. Quality Accounts

Dr V Jayalal, Dr Ambadkar

Dr Ambadkar

REG1161 National Paediatric Diabetes Audit (NPDA) (Continuous)

National Audit: RCPCH [Continuous]. Quality Accounts

02/07/2012 Dr Raman, Pauline Phillips

Dr Raman

Urology

REG1015 Nephrectomy audit (BAUS National Audit) National Audit: British Association of Urological Surgeons [Continuous]. NICE: CG27.

01/08/2008 Mr R Frymann

Mr Rob Frymann

1


Clinical Audit Forward Plan 2014/15 - Emergency Division

ID



dateProject Leader


Priority Rating


Gastroenterology

REG1396 Quality and Safety indicators for PEG insertion - JPUH 2013, ongoing rolling audits over 12 months

RCP - JAG - Rolling endoscopy GRS audits

01/02/2014 31/05/2014 Dr Dana Ismail

R Badreldin

1

FP0119 Alcohol Dependence and Harmful Use NICE CG115 01/05/2014 01/08/2014 Dr Sheikh, Pauline Bowie (left Trust)

Dr Sheikh

2

General Medicine

REG0954 IBD National Audit (Round 4) National Audit: IBD. Quality Accounts 12/13

01/01/2013 30/06/2014 Dr A DeSilva, Dr Samuel Keable, Dr Judith Herbert

Dr A DeSilva

1

MRI & CT Services

REG1369 Sedation of paediatric patients undergoing MRI Audit rationale: To eliminate wasted slots in MRI with paediatraics with sedation

16/09/2013 01/12/2014 Alison Mcleod

Anita Haylett

2

Pharmacy

REG1402 Medicines Management audit (Clinic) - Quality assurance

National Healthcare Standards: CQC Outcome 9.

01/01/2014 01/08/2014 Nicola Rudge

Prof Carol Farrow

2

REG1403 Medicines Management audit (Wards) - Quality assurance


01/03/2014 01/07/2014 Nicola Rudge

Prof Carol Farrow

2

REG1404 Medicines Management audit (Theatres) - Quality assurance


01/05/2014 01/09/2014 Nicola Rudge

Prof Carol Farrow

2

Emergency Forward Plan Report for 2014/15 Report generated: Page 1 of 629/04/2014

ID



dateProject Leader


Priority Rating

Radiology

REG1347 Re-audit of cannulation Audit rationale: Efficient cannulation reduces patient discomfort

15/10/2013 15/04/2014 Steve Gowen

Dorothy Wheatman

1

REG1450 Pregnancy questioning in CT scanning Re-audit. IRMER standard operating procedure

01/04/2014 30/04/2014 Alison MacLeod

Dr Disini

1

REG1449 Audit in relation to IRMER authorisation of requests for CT scans, is the justification process available to view on CRIS

Re-audit. IRMER standard operating procedure

01/04/2014 30/06/2014 Alison MacLeod

Dr Disini

1

Respiratory

REG1432 COPD National Audit National Audit: Yes. 01/02/2014 31/05/2014 Dr Blackburn

Dr Blackburn

1

FP0120 Non invasive ventilation in hospital BTS/NICE 01/05/2014 01/08/2014 Dr Cotter

Dr Cotter

2

Rheumatology

FP0121 Use of Anti-TNF in Rheumatoid Arthritis NICE CG79 (& related TAGs) 01/05/2014 01/08/2014 Dr Thomas, Dr Makkuni

Dr Thomas, Dr Makkuni

2


ID



dateProject Leader


Priority Rating


General Medicine

REG1412 Referrals to patient pathway co-ordinator when upper GI malignency supsected at Endoscopy

National Audit: GRS Endoscopy Audit. SOP for GI malignancy found at endoscopy

16/09/2013 30/04/2014 Dr Williams / Dr Malpas 4

REG1446 Audit of out of hours / weekend handovers Academy of Medical Royal Colleges 04/04/2014 16/05/2014 Dr Elizabeth McClenaghan

Dr Williams

3

REG1451 The Quality of Discharge Letters on EADU Audit rationale: Complaints from GP's about lack of relevant information being included, lack of follow up being arranged

01/05/2014 31/08/2014 Dr Viveka Biswas

Dr Maya Venu

3

Haematology

REG1384 Audit of Consent Procedures in Chemotherapy National Healthcare Standards: NHSLA. NCAG

01/12/2013 30/04/2014 Cheryl Pearce

Rachel Conway

3

Oncology

REG1443 Audit of Cytotoxic Extravasations Audit rationale: Increase in frequency of extravasations during recent months

03/04/2014 30/06/2014 Cheryl Pearce

Rachel Conway

4

Pharmacy

REG1398 An audit to determine the quality of electronic discharge summaries at JPUH

Re-audit. Royal Pharmaceutical society guidelines

25/01/2014 30/04/2014 Emma Hunt

Nicola Rudge

3

Radiology

REG1339 A retrospective audit on LMP forms (Last menstral period) including femur, pelvis, abdomen and lumbar spine with the effects of radiation in the first trimester of pregnancy

Audit rationale: The fetus is more susceptible to the effects of radiation within the first 3 months of pregnancy. A form is completed to confirm pregnancy is negative.

01/10/2013 04/04/2014 Katie Steele

Dorothy Wheatman

3


ID



dateProject Leader


Priority Rating

REG1338 To assess the adequacy of images of the AP ankle to determine if the mortise view is visualise, from A&E referrals

Audit rationale: Radiation dose can be affected by repeat procedures being performed. Misdiagnosis of small fractures can also occur from positioning errors

01/10/2013 04/04/2014 Mary Waters

Dorothy Wheatman

3

REG1395 Cannulation, Radiology nurses Audit rationale: Proficiency in cannulating

27/01/2014 27/04/2014 Wendy Lewis

Joyce Lightfoot

4

REG1420 A Clinical Audit investigating Emergency CT KUB at James Paget Hospital

National Healthcare Standards: Yes. Local audit

25/02/2014 25/05/2014 Ahmed Elowaidy

Dr Disini

4

Renal

REG1329 Clinical Outcome measures in chronic kidney disease

National Audit: Renal Nutrition group audit.

16/09/2013 01/06/2014 Sue Allen

Victoria Marks

4

Rheumatology

REG1444 An audit of prior fragility fractures in patients presenting with hip fractures

Audit rationale: High risk problem. Large numbers of patients at risk of fragility fractures

15/04/2014 31/07/2014 Dr Thomas and Dr Malpas

Dr Thomas

3

Stroke

REG1447 Investigation & Management of UTI in Older Adults (>65 years)

SIGN Guidelines 13/01/2014 01/06/2014 Dr Aban Dasgupta

Dr M Zaidi

3


ID



dateProject Leader


Priority Rating


Cardiology

REG0381 Myocardial Ischaemia National Audit Project (MINAP)

National Audit: Yes [Continuous]. NICE: CG94, CG48. Quality Accounts

Dr Ryding / Janet Shreeve 1

REG0460 SSNAP Sentinel Stroke National Audit Programme


01/04/2011 Dr Wyllie

Dr Wyllie

1

Coronary Care

REG0459 Heart Failure Audit National Audit: Yes [Continuous]. NICE: CG108. Quality Accounts

Janet Shreeve

Dr Ryding

1

Gastroenterology

REG0461 Oesophago-gastric Cancer National Audit (NOGCA)


Dr M Williams

Dr M Williams

1

General Medicine

REG0373 Cardiac Arrest (National Cardiac Arrest Audit NCAA)


Pam Cushing / Dr Crawfurd

Dr Crawfurd

1

Intensive Care

REG0377 Adult Critical Care Units ICNARC CMP National Audit: Yes. Quality Accounts 01/04/1994 Dr Karlikowski

Dr Karlikowski

Mammography

REG1184 Adjuvant Audit (Breast screening) National Audit: NHSBSP. 01/04/2011 Melanie Taylor

Melanie Taylor

1

REG1185 KC62 (Breast screening) National Audit: NHSBSP/DOH. 01/04/2012 Melanie Taylor

Melanie Taylor

1

REG1186 British Association of Surgical Oncology National Audit: NHSBSP. 01/04/2012 Melanie Taylor

Melanie Taylor

1

REG1187 Survival Audit National Audit: NHSBSP. 01/08/2013 Melanie Taylor

Melanie Taylor

1


ID



dateProject Leader


Priority Rating

Organ & Transplant

REG1087 Potential Donor Audit (National Audit) National Audit: NHS Blood and Transplant [Continuous]. NICE: [CG135]. Quality Accounts (On list but not required for QA reporting)

01/04/2009 Samantha Major

Karl Blenk

1

Renal

REG1090 Renal Registry (National Audit) National Audit: Yes [Continuous]. Quality Accounts

01/04/2008 Deborah Proctor (NNUH)

Dr Alex Heaton (NNUH)

Respiratory

REG1356 National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme

National Audit: Yes. NICE: CG101. Dr A Blackburn

Dr Blackburn

1

REG0384 Lung Cancer (LUCADA/NLCA National Audit) National Audit: Yes [Continuous]. Quality Accounts

Dr Mahadevan

Dr Mahadevan

1

Rheumatology

REG1378 Rheumatoid and early inflammatory arthritis(new NCAPOP audit)

National Audit: Yes. 01/02/2014 31/03/2017 Dr Thomas

Dr Thomas

1

Trauma

REG0388 Severe Trauma (Trauma Audit & Research Network) TARN


Mr Peacock/Audit Team

Mr Peacock

1

Ultrasound

REG1416 Ultrasound Fetal Abnormalities National Audit: NICE. 01/04/1999 Sally Holloway

Penny Smith

1


Clinical Audit Forward Plan 2014/15 - All Divisions

ID



dateProject Leader


Priority Rating


Emergency Division

Gastroenterology

REG1396 Quality and Safety indicators for PEG insertion - JPUH 2013, ongoing rolling audits over 12 months

RCP - JAG - Rolling endoscopy GRS audits

01/02/2014 31/05/2014 Dr Dana Ismail

R Badreldin

1

FP0119 Alcohol Dependence and Harmful Use NICE CG115 01/05/2014 01/08/2014 Dr Sheikh, Pauline Bowie (left Trust)

Dr Sheikh

2

General Medicine

REG0954 IBD National Audit (Round 4) National Audit: IBD. Quality Accounts 12/13

01/01/2013 30/06/2014 Dr A DeSilva, Dr Samuel Keable, Dr Judith Herbert

Dr A DeSilva

1

MRI & CT Services

REG1369 Sedation of paediatric patients undergoing MRI Audit rationale: To eliminate wasted slots in MRI with paediatraics with sedation

16/09/2013 01/12/2014 Alison Mcleod

Anita Haylett

2

Pharmacy

REG1402 Medicines Management audit (Clinic) - Quality assurance


01/01/2014 01/08/2014 Nicola Rudge

Prof Carol Farrow

2

REG1403 Medicines Management audit (Wards) - Quality assurance


01/03/2014 01/07/2014 Nicola Rudge

Prof Carol Farrow

2

REG1404 Medicines Management audit (Theatres) - Quality assurance


01/05/2014 01/09/2014 Nicola Rudge

Prof Carol Farrow

2

Trustwide Forward Plan Report for 2014/15 Report generated: Page 1 of 1830/04/2014

ID



dateProject Leader


Priority Rating

Radiology

REG1347 Re-audit of cannulation Audit rationale: Efficient cannulation reduces patient discomfort

15/10/2013 15/04/2014 Steve Gowen

Dorothy Wheatman

1

REG1450 Pregnancy questioning in CT scanning Re-audit. IRMER standard operating procedure

01/04/2014 30/04/2014 Alison MacLeod

Dr Disini

1

REG1449 Audit in relation to IRMER authorisation of requests for CT scans, is the justification process available to view on CRIS

Re-audit. IRMER standard operating procedure

01/04/2014 30/06/2014 Alison MacLeod

Dr Disini

1

Respiratory

REG1432 COPD National Audit National Audit: Yes. 01/02/2014 31/05/2014 Dr Blackburn

Dr Blackburn

1

FP0120 Non invasive ventilation in hospital BTS/NICE 01/05/2014 01/08/2014 Dr Cotter

Dr Cotter

2

Rheumatology

FP0121 Use of Anti-TNF in Rheumatoid Arthritis NICE CG79 (& related TAGs) 01/05/2014 01/08/2014 Dr Thomas, Dr Makkuni

Dr Thomas, Dr Makkuni

2

Trustwide

REG1448 Sepsis Six Care Bundle Audit rationale: Evidence suggests that mortality for sepsis can be reduced significantly with the delivery of 6 key intervention within one hour.

01/02/2014 30/06/2014 Donna Wade, Bridget Inyang

Dr Wade

2

Elective Division

General Surgery

REG1421 Choles Study / Audit National Audit: Choles. 01/03/2014 15/07/2014 Mr Chitre / Mr Tuffaha

Mr Velchuru

1

FP0244 Negative pressure wound therapy for the open abdomen

NICE IPG467 01/04/2014 31/03/2014

Mrs Downey

2


ID



dateProject Leader


Priority Rating

Microbiology

REG1439 An audit of management of Community Acquired Pneumonia (CAP)

Royal College Audit: Royal College of Pathologists. [Risk register relevant: ref 36]

03/03/2014 03/06/2014 Dr Lasantha Ratnayake

Dr Maya Venu

2


REG1433 Audit of unexplained infertility and hysterosalpingogram

NICE: CG156. 01/03/2014 31/05/2014 Mr A Elfara / Dr Paul Timmons

Mr A Elfara

2

FP0155 No of Patient Women who are not known to have comorbidities (such as pelvic inflammatory disease, previous ectopic pregnancy or endometriosis) and been offered hysterosalpingography (HSG) to screen for tubal occlusion

NICE CG156 01/03/2014 31/05/2014 Mr A Elfara

Mr A Elfara

2

FP0237 Re-Audit of Appropriate Use of Physiotherapy in the Post Natal Period

CNST 3.3, 3.5 and 2.6, Local Guidelines. Re-audit

01/04/2014 30/04/2014 Karen Crossan

Karen Crossan

2

Ophthalmology

FP0261 NICE Compliance NICE [Specific guidance being queried by Mr Butler as of April 14]

01/03/2014 31/05/2014 B Sharpe-Brash

B Sharpe-Brash

2

Orthopaedics

REG1373 Hypothermia in Recovery NICE: Surgical Site Infection [QS49, CG74].

04/12/2013 30/06/2014 Diane Crosby

Dr Ail

2

FP0248 Human Tissue Authority (HTA) Temperature Records Audit


Gail Banham

2

FP0247 Human Tissue Authority (HTA) Documentation Audit Trail


Gail Banham

2

FP0246 Human Tissue Authority (HTA) Standard Operating Procedure Examination Audit


Gail Banham

2


ID



dateProject Leader


Priority Rating

Paediatrics

REG1107 Epilepsy 12 (National Audit) Re-audit. National Audit: RCPCH. NICE: CG137. Quality Accounts 12/13

01/01/2013 30/06/2014 Dr Nirmal

Dr Nirmal

1

REG1125 Paediatric Chest X Rays Audit rationale: High risk (as non reporting of bones in chest X-Rays may result in missed NAI)

28/01/2013 01/04/2014 Dr Chapman/ S Raja

Dr Chapman

2

REG1393 Re-audit of Medical Coding Audit Audit rationale: Frequently occuring issue, affects funding

20/01/2014 31/01/2015 Sophie Wheatcroft

Dr Ambadkar

2

REG1435 Looked after health assessments action plan Re-audit. CQC 01/04/2014 30/04/2014 Donna Milner

Dr Ambadkar

1

REG1442 Autism diagnosis in children & young people & the management of children & young people on the autism spectrum

NICE: CG128, CG170. 03/04/2014 03/08/2014 Dr Victoria Clarke, Robyn Webb

Dr A Oppong-Odiseng

2

REG1441 Attention deficit hyperactivity disorder (ADHD) - services for children and young people

NICE: CG72. 03/04/2014 03/08/2014 Dr Victoria Clarke

Dr A Oppong-Odiseng

2

FP0251 Audit of Febrile Neutropenia in Paediatric oncology patients attending Ward 10 JPUH

Re-audit, Cancer Network guidelines 01/06/2014 01/09/2014

Dr Stocks

2

Urology

FP0249 Prostate Cancer (Continuous National Audit starting 2014)

NICE CG175, HQIP National Audit for Quality Accounts

01/04/2014

Mr Frymann

1

Corporate Division

Infection Control

REG1424 Discharge information for Clostridium Difficile positive patients

JPUH Clostridium difficile Trust Policy. [Link to Risk Register: ref 36]

01/04/2014 31/05/2014 Mandy Hoadley

Linda Hawtin

2


ID



dateProject Leader


Priority Rating

Risk & Governance

REG1256 RCA audit of Safety Thermometer reports of new UTI in patients with in dwelling urinary catheter

CQUIN 01/04/2013 30/04/2014 Jacky Copping

Jacky Copping

2

Trustwide

REG1397 Falls NICE Audit NICE: CG161. 01/01/2014 31/05/2014 Helen Ashby

Jacky Copping

2

FP0228 VTE Prophylaxis & Re-assessment re-audit NICE CG92 01/02/2014 01/05/2014

Jacky Copping/Dr Zaidi

2

REG1434 Re-audit of INTRAN Face to Face Booking Process

Audit rationale: Monitor compliance with new INTRAN booking request process

01/04/2014 18/07/2014 Anna Hills

Anna Hills

2


ID



dateProject Leader


Priority Rating


Elective Division

General Surgery

FP0243 Audit of DVT Prophylaxis in General Surgical patients (Re-audit)

Re-audit, NICE CG92 01/08/2014 30/09/2014

Mr Velchuru

2

Paediatrics

FP0252 NICE Paediatric Obesity Audit NICE CG43 30/09/2014 31/12/2014

Dr Shareef

2

Corporate Division

Trustwide

FP0231 Intravenous fluid therapy in adults in hospital NICE CG174 31/08/2014 30/11/2014

Jacky Copping

2


ID



dateProject Leader


Priority Rating


Elective Division

Paediatrics

REG1437 BTS National Asthma Audit National Audit: BTS. HQIP National Audits for Quality Accounts

01/11/2014 28/02/2015 Dr John Chapman; others TBA

Dr J Chapman

1

Corporate Division

Trustwide

FP0256 Misidentification of Patients National Patient Safety Alert 01/10/2014 31/12/2014

Anna Hills

2


ID



dateProject Leader


Priority Rating


Elective Division

Paediatrics

FP0254 Audit of Paediatric Diabetic Services NICE CG15, re-audit 01/01/2015 31/03/2015

Dr Raman

2

FP0253 Audit of DNA/CNA policy for children under 16 years

Re-audit (ID1409), JPUH policy 01/01/2015 31/03/2015

Donna Milner

2

Corporate Division

Blood Transfusion

REG1428 Transfusion Practice re-audit Audit rationale: Clinical Governance 01/01/2015 31/03/2015 Julie Jackson

Cesar Gomez

2


ID



dateProject Leader


Priority Rating


Emergency Division

General Medicine

REG1412 Referrals to patient pathway co-ordinator when upper GI malignency supsected at Endoscopy

National Audit: GRS Endoscopy Audit. SOP for GI malignancy found at endoscopy

16/09/2013 30/04/2014 Dr Williams / Dr Malpas 4

REG1446 Audit of out of hours / weekend handovers Academy of Medical Royal Colleges 04/04/2014 16/05/2014 Dr Elizabeth McClenaghan

Dr Williams

3

REG1451 The Quality of Discharge Letters on EADU Audit rationale: Complaints from GP's about lack of relevant information being included, lack of follow up being arranged

01/05/2014 31/08/2014 Dr Viveka Biswas

Dr Maya Venu

3

Haematology

REG1384 Audit of Consent Procedures in Chemotherapy National Healthcare Standards: NHSLA. NCAG

01/12/2013 30/04/2014 Cheryl Pearce

Rachel Conway

3

Oncology

REG1443 Audit of Cytotoxic Extravasations Audit rationale: Increase in frequency of extravasations during recent months

03/04/2014 30/06/2014 Cheryl Pearce

Rachel Conway

4

Pharmacy

REG1398 An audit to determine the quality of electronic discharge summaries at JPUH

Re-audit. Royal Pharmaceutical society guidelines

25/01/2014 30/04/2014 Emma Hunt

Nicola Rudge

3

Radiology

REG1338 To assess the adequacy of images of the AP ankle to determine if the mortise view is visualise, from A&E referrals

Audit rationale: Radiation dose can be affected by repeat procedures being performed. Misdiagnosis of small fractures can also occur from positioning errors

01/10/2013 04/04/2014 Mary Waters

Dorothy Wheatman

3


ID



dateProject Leader


Priority Rating

REG1339 A retrospective audit on LMP forms (Last menstral period) including femur, pelvis, abdomen and lumbar spine with the effects of radiation in the first trimester of pregnancy

Audit rationale: The fetus is more susceptible to the effects of radiation within the first 3 months of pregnancy. A form is completed to confirm pregnancy is negative.

01/10/2013 04/04/2014 Katie Steele

Dorothy Wheatman

3

REG1395 Cannulation, Radiology nurses Audit rationale: Proficiency in cannulating

27/01/2014 27/04/2014 Wendy Lewis

Joyce Lightfoot

4

REG1420 A Clinical Audit investigating Emergency CT KUB at James Paget Hospital

National Healthcare Standards: Yes. Local audit

25/02/2014 25/05/2014 Ahmed Elowaidy

Dr Disini

4

Renal

REG1329 Clinical Outcome measures in chronic kidney disease

National Audit: Renal Nutrition group audit.

16/09/2013 01/06/2014 Sue Allen

Victoria Marks

4

Rheumatology

REG1444 An audit of prior fragility fractures in patients presenting with hip fractures

Audit rationale: High risk problem. Large numbers of patients at risk of fragility fractures

15/04/2014 31/07/2014 Dr Thomas and Dr Malpas

Dr Thomas

3

Stroke

REG1447 Investigation & Management of UTI in Older Adults (>65 years)

SIGN Guidelines 13/01/2014 01/06/2014 Dr Aban Dasgupta

Dr M Zaidi

3

Elective Division

Anaesthetics

REG1130 Complications & Efficacy of Steroid Lumbar Epidural injections for pain management

National Healthcare Standards: Yes. 01/04/2013 01/12/2014 Dr Andreas Brodbeck, George Nadakavukaran, Emily Tshangela

Dr D Ail

4

FP0198 Airway management training for novice anaesthetists (re-audit)

RCOA 01/01/2014 01/04/2014

Dr P Wright/Dr P Nathan

4


ID



dateProject Leader


Priority Rating

REG1452 Audit of Enhanced Recovery of LSCS - Stage 1

Audit of maternal outcomes following introduction of Enhanced recovery in obstetric surgery for protocol for Elective LSCS patients (International Journal of Obstetric Anaesthesisa 2013, 22, page S8)

29/04/2014 18/07/2014 Dr K Dasari, Dr S Sagadai

Dr Sagadai

4

FP0273 Postoperative Hb estimation proposal AAGBI Guideline "Management of Proximal Femoral Fractures 2011 /2012".

01/08/2014 31/08/2014 Dr Arnth Engel

Dr Arnth Engel

3

General Surgery

REG1340 Audit of the accuracy of surgical death certificates

Audit rationale: It is known that a significant proportion of death certificates contain errors. Death certificates are an important source of mortality data and used for allocation of funding.

23/10/2013 23/05/2014 Mr Velchuru

Mr Velchuru

3

REG1419 Time taken to obtain radiological investigations once requested by on call surgical team

Audit rationale: There can be significant delays in obtaining radiological investigations. What is exact time frame?

01/02/2014 31/07/2014 Stephen Lam

Signed - query name

4

REG1429 Compliance with documentation of urethral catheterisation

NHS Quality Improvement 20/03/2014 20/04/2014 Dr Michael Akinfala and Dr Jesse Lee

Mr Gupta

3

REG1440 Retrospective Audit of Clinical Outcomes following Removal of Normal Looking Appendix at Laparoscopy (2013) - 2 Centre Audit (NNUH+JPUH)

National Audit: 2-centre audit, NNUH+JPUH.

01/04/2014 31/07/2014 Dr Vasileios Bonatsos, Mr Roshan Lal, Miss Ioanna Panagiotopoulou

Mr R Lal

3

FP0241 Outcomes of perforated Duodenal ulcer perforation


Mr Tuffaha/Mr Chitre

3

FP0242 Recurrence rates following rectal cancer Audit 01/05/2014 31/12/2014

Mr Velchuru/Dr Biswas

4

FP0167 Management of Acute Pancreatitis Regional 01/10/2014 31/03/2015

Mr Chitre

3


ID



dateProject Leader


Priority Rating

FP0163 Appendicectomy - LOS and wound infection rates.


Mr Chitre

3

Microbiology

FP0245 Infection rates following Bowel surgery Audit 14/01/2014 31/08/2014

Microbiology Department

3


REG1430 Return to theatre after Gynaecological surgery Good medical practice 03/02/2014 31/05/2014 Dr Prasanth Perilakalathil

Mr Hassanaien

4

Ophthalmology

FP0131 Atropine-occlusion: visual outcomes Service Evaluation 01/01/2013 08/03/2013

C. Philpott

4

REG1299 Evaluation of risk for 2nd eye in AMD Audit rationale: We see lucentis patients for OCT less often than some units. Is this disadvantaging our patients?

01/09/2013 31/07/2014 Ben Burton

B Burton

4

FP0259 SLT – audit of outcomes [Evidence base being queried by Mr Butler as of April 14]

01/03/2014 31/05/2014

R Nadler

4

FP0260 Trabeculectomy (SM) outcomes [Evidence base being queried by Mr Butler as of April 14]

01/03/2014 31/05/2014

R Sharma

4

FP0262 Nurse led drop teaching technique pt evaluation


01/03/2014 31/05/2014

K Metcheva

4

FP0263 Outcome of new referrals in Glaucoma [Evidence base being queried by Mr Butler as of April 14]

01/03/2014 31/05/2014

K Pulley / S Cotton

4

FP0269 ARMD time from referral to treatment/ follow up frequency


01/07/2014 30/09/2014

?Rob Nadler

4

FP0264 Evaluation of risk for 2nd eye AMD [Evidence base being queried by Mr Butler as of April 14]

01/07/2014 30/09/2014

T Khatib, B Burton

4


ID



dateProject Leader


Priority Rating

FP0265 Avastin for CNV in patients with good presenting VA: an audit of outcomes


01/07/2014 30/09/2014

K Pulley, R Nadler, B Burton

4

FP0271 Thyroid Eye Disease and Immunosuppression [Evidence base being queried by Mr Butler as of April 14]

01/09/2014 30/11/2014

B Hemmant

4

FP0272 Audit of audits: departmental audit protocol and follow-up


01/09/2014 30/11/2014

M Ohn

4

FP0270 Audit of biometry accuracy – IOLmaster vs Ultrasound


01/09/2014 30/11/2014

Mr Butler

4

Orthopaedics

REG1438 Retrospective Evaluation of Transfusion Requirements in Paients Undergoing Total Knee Replacement

Audit rationale: To evaluate current practice with regards to total knee replacements.

03/02/2014 01/05/2014 Dr Wellington

Mr Deo

4

Paediatrics

REG1352 The use of Melatonin in children with sleep disorders

NICE: ESUOM02. Local shared care prescribing information for Circadin ® for sleep disorders & JPUH guidelines

01/09/2013 01/09/2014 Dr Amma Oppong-Odiseng, Dr Sheima Hamad

Dr Chapman

3

REG1364 Appropriateness of Follow-Up in Community Paediatrics

Audit rationale: Long community paediatric follow-up times. Limited staff capacity to provide any additional clinics. Assessments delayed due to long waits

01/12/2013 31/07/2014 Dr A Oppong-Odiseng

Dr P Ambadkar

3

FP0229 Nephrotic Syndrome Nottingham Hospital shared care guidelines

01/01/2014 31/05/2014 Dr Bentsi-Enchill

Dr Bentsi-Enchill

3

Urology

REG1391 Re-audit - audit to assess the appropriate use of IV antibiotics in the Dx of Urosepsis & other emergency urological admissions

Local sepsis guidelines 09/01/2014 09/05/2014 Dr N. N. Ghosh

Mr Gupta

4


ID



dateProject Leader


Priority Rating

FP0250 Antibiotic use in patients referred to urology from A&E. Comparison with Best Practice

Re-audit 01/04/2014 01/07/2014

Mr Gupta

3


ID



dateProject Leader


Priority Rating


Emergency Division

Cardiology

REG0381 Myocardial Ischaemia National Audit Project (MINAP)

National Audit: Yes [Continuous]. NICE: CG94, CG48. Quality Accounts

Dr Ryding / Janet Shreeve 1

REG0460 SSNAP Sentinel Stroke National Audit Programme


01/04/2011 Dr Wyllie

Dr Wyllie

1

Coronary Care

REG0459 Heart Failure Audit National Audit: Yes [Continuous]. NICE: CG108. Quality Accounts

Janet Shreeve

Dr Ryding

1

Gastroenterology

REG0461 Oesophago-gastric Cancer National Audit (NOGCA)


Dr M Williams

Dr M Williams

1

General Medicine

REG0373 Cardiac Arrest (National Cardiac Arrest Audit NCAA)


Pam Cushing / Dr Crawfurd

Dr Crawfurd

1

Intensive Care

REG0377 Adult Critical Care Units ICNARC CMP National Audit: Yes. Quality Accounts 01/04/1994 Dr Karlikowski

Dr Karlikowski

Mammography

REG1184 Adjuvant Audit (Breast screening) National Audit: NHSBSP. 01/04/2011 Melanie Taylor

Melanie Taylor

1

REG1185 KC62 (Breast screening) National Audit: NHSBSP/DOH. 01/04/2012 Melanie Taylor

Melanie Taylor

1

REG1186 British Association of Surgical Oncology National Audit: NHSBSP. 01/04/2012 Melanie Taylor

Melanie Taylor

1


ID



dateProject Leader


Priority Rating

REG1187 Survival Audit National Audit: NHSBSP. 01/08/2013 Melanie Taylor

Melanie Taylor

1

Organ & Transplant

REG1087 Potential Donor Audit (National Audit) National Audit: NHS Blood and Transplant [Continuous]. NICE: [CG135]. Quality Accounts (On list but not required for QA reporting)

01/04/2009 Samantha Major

Karl Blenk

1

Renal

REG1090 Renal Registry (National Audit) National Audit: Yes [Continuous]. Quality Accounts

01/04/2008 Deborah Proctor (NNUH)

Dr Alex Heaton (NNUH)

Respiratory

REG0384 Lung Cancer (LUCADA/NLCA National Audit) National Audit: Yes [Continuous]. Quality Accounts

Dr Mahadevan

Dr Mahadevan

1

REG1356 National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme

National Audit: Yes. NICE: CG101. Dr A Blackburn

Dr Blackburn

1

Rheumatology

REG1378 Rheumatoid and early inflammatory arthritis(new NCAPOP audit)

National Audit: Yes. 01/02/2014 31/03/2017 Dr Thomas

Dr Thomas

1

Trauma

REG0388 Severe Trauma (Trauma Audit & Research Network) TARN


Mr Peacock/Audit Team

Mr Peacock

1

Ultrasound

REG1416 Ultrasound Fetal Abnormalities National Audit: NICE. 01/04/1999 Sally Holloway

Penny Smith

1

Elective Division


ID



dateProject Leader


Priority Rating

Anaesthetics

REG0131 National Obstetric Anaesthesia Database (NOAD)

National Audit: Yes [Continuous]. 13/06/2011 Dr Sagadai

Dr Sagadai

1

REG1301 National Emergency Laparotomy Audit (NELA) HQIP Quality Accounts NCAPOP 01/12/2013 31/01/2016 Dr Ail, Mr Chitre

Dr Ail

1

ENT

REG0386 Head & Neck Cancer (DAHNO) National Audit: Yes [Continuous]. Quality Accounts

Mr Tassone/Tracy Church

Mr Tassone

1

General Surgery

REG0385 Bowel Cancer (National Bowel Cancer Audit Programme) (NBOCAP)


Linda Hayes / Steve Wright

REG0380 Elective Surgery (National PROMs Programme)


01/04/2009 Helen French

Helen French

1


REG0360 Invasive Cervical Cancers (National Audit) National Audit: Yes [Continuous]. Dr Preston

Dr Preston

1

REG1096 Maternal, Newborn and Infant Clinical Outcomes Review Programme (MBRRACE) (Formerly CEMACH/CMACE)

National Audit: MBRRACE [Continuous]. Quality Accounts

01/04/2011 Carol Mutton

Carol Mutton

1

Orthopaedics

REG1080 National Hip Fracture Database (NHFD) National Audit: Yes [Continuous]. NICE: TA161. Quality Accounts

Patsy Hindley

Patsy Hindley

1

REG0524 National Joint Registry (NJR) National Audit: Yes [Continuous]. NICE: [TA304]. Quality Accounts

Mr Cohen

Mr Cohen

1

Paediatrics

REG1078 National Neonatal Audit Programme (NNAP) National Audit: Continuous. Quality Accounts

Dr V Jayalal, Dr Ambadkar

Dr Ambadkar


ID



dateProject Leader


Priority Rating

REG1161 National Paediatric Diabetes Audit (NPDA) (Continuous)

National Audit: RCPCH [Continuous]. Quality Accounts

02/07/2012 Dr Raman, Pauline Phillips

Dr Raman

Urology

REG1015 Nephrectomy audit (BAUS National Audit) National Audit: British Association of Urological Surgeons [Continuous]. NICE: CG27.

01/08/2008 Mr R Frymann

Mr Rob Frymann

1

Corporate Division

Patient Care

REG1252 Dementia Carers Audit as part of the national dementia CQUIN

National Audit: Dementia CQUIN. 01/05/2013 Becki Ballard

J Hunt

2

Trustwide

REG0344 NCEPOD Confidential Enquiry into Patient Outcome and Death (National Audit)


Dr M Wright

Dr M Wright

1


report to the board of directors 2014/15 · rep/bod/ah1605/v1 attachment 9 report to the board of...

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