Month: April 2023

We provided specialist support to an acute trust to accelerate improvement by developing a risk management program to reduce risks, assuring quality by making recommendations, and developing a risk dashboard for executive oversight.

Background​

MLCSU were approached by a North-West Integrated Care Board (ICB) to provide specialist support to an acute trust. The trust had received a ‘Requires Improvement’ notice following a Care Quality Commission (CQC) visit earlier in the year. An improvement plan had been formulated, and the trust required the capacity and capability to accelerate progress in several key areas of improvement. ​

Requirement: To review the risk management process to support the Board Assurance Framework (BAF) ward to board corporate risk register and to provide support with implementing governance systems and processes to aid improvement.​

Action​

An MLCSU workstream lead with specialist expertise undertook a preliminary diagnostic exercise capturing key concerns and identifying improvement recommendations.​​​

An initial 6-week immediate action delivery plan was devised to:​​

– Develop and deliver risk management training to the trust’s corporate risk and governance team, triumvirates and corporate divisions. ​​

– To review divisional risk registers.​

– To work with key trust members to data cleanse the Datix Risk module.​

– Ensure all documentation and guidance is up-to-date and would support a workable process for staff.​

Impact​

Developed a comprehensive Risk Training programme to support the improvement of Trust reporting and management of risk​​

Reduced the number of open risks on the corporate risk register through data cleansing, risk review and identifying actions to mitigate or close risks.​​

Reduced departmental level of risk through review of risk registers and provision of support to identify mitigation actions. ​​

Assurance of quality of the Board Assurance Framework through review against best practice.​​

Made recommendations on improving risk management processes and supporting risk management in Datix. ​​

​Developed a risk dashboard for divisions enabling the flow of information to the executive level to provide clear executive direction and oversight.

We made a significant impact on an acute trust’s clinical audit processes by providing a thorough diagnostic report and recommendations aligned with best practices, resulting in improved quality of care, patient safety, and outcomes.

Background

MLCSU was approached by an acute trust in the North-West of England to assist with a review of the organisation’s clinical audit process. This was part of a broader improvement support programme to ensure the trust had effective arrangements in place for monitoring and continually improving the quality of healthcare provided to patients. To achieve this, the trust needed to have robust systems, processes, and procedures in place for monitoring, auditing, and improving quality.

The objective of MLCSU’s engagement was to assess how the trust was managing clinical audits and to identify how the continuous cycle of clinical audits could be used more effectively as part of the trust’s wider quality improvement process. The aim was to provide assurance against best practices. The assessment focused on ensuring that the trust had robust systems, processes, and procedures in place for monitoring, auditing, and enhancing quality.

Action

We deployed our senior professional expertise to review the trust’s clinical audit processes against best practices by carrying out the following actions:

– Reviewing existing evidence, such as the trust’s clinical audit strategy, clinical audit policy, audit plans, reports and minutes of audit and governance meetings.
– Meeting with key staff, including the clinical audit team, divisional audit leads and members of the executive team, to gain a comprehensive understanding of how the process works in practice.
– Attending team and audit meetings to observe the clinical audit process in action.
– Sampling and reviewing completed and ‘in progress’ audits on Datix, the trust’s clinical audit platform.
– Triangulating the information obtained through the above actions to produce a diagnostic report and recommendations for the organisation.

Through these actions, we were able to provide the trust with a thorough review of their clinical audit processes and offer recommendations for improvement.

Impact

The project had a significant impact on the trust’s clinical audit processes, leading to improvements in the quality of care, patient safety, and outcomes for patients. By aligning the project with the recognised best practice in the clinical audit framework from the Healthcare Quality Improvement Partnership (HQIP), we were able to systematically identify areas of good practice and recommend changes to maximise the impact of clinical audit in the following four areas:

Management of the clinical audit programme: We evaluated the process for defining, agreeing, and monitoring the trust’s audit programme, and recommended mechanisms for improving reporting and escalation. We also considered the available support for clinical audit, including training, capacity, and capability at all levels.

Performance measurement: We reviewed the processes in place for providing assurance that care is delivered against standards and measuring performance. We also assessed how performance was reported within the trust.

Acting on findings: We evaluated how the trust acted on the findings of clinical audits to ensure that improvements and changes were made. We recommended the development of robust action plans and presentations to evidence these improvements.

Sustainability: We assessed how the trust sustained improvements and identified areas where re-audits should be undertaken to ensure the continuous improvement of clinical audit processes.