Completed clinical audit forms example - updated 09

1 (front of form ) (back of form ). clinical audit PROPOSAL POPULATION DESCRIPTION (patients, service users, events or situations). Breast care team DIRECTORATE, SERVICE OR All people referred to the breast care team in July Include Timeliness and effectiveness of assessments by the breast care team .. clinical audit .. Exclude breast care team Patient or service user ages All ages Only between .. and .. years of age clinical audit OBJECTIVE(S) 160 40. Number in a year .. or 6 months .. or 1 month .. or 1 week .. Ensure that assessments carried out by the breast care team are timely and effective.

2 POPULATION OR SAMPLE AND TIME PERIOD FOR THE clinical audit .. All Population .. 1 July cases from .. 31 July to .. number date date Sample Type .. Size .. sample number BACKGROUND TO THE clinical audit (Reason(s) subject and objective(s) were selected). The team wants to have evidence of its performance in comparison with national .. DATA COLLECTION STRATEGY. guidelines .. Retrospective Concurrent Other (specify) .. DATA SOURCES TO BE USED.. Patient or service user records Other (specify) .. STAKEHOLDERS AND THEIR INVOLVEMENT (Those involved in or affected by the clinical audit and how they will be involved) clinical audit MEASURES (see form ).

3 Involvement (tick as many as apply) Source of clinical audit measures Data Review Plan Other Design National standard or guideline source findings action Research study(ies) Other (specify) .. Breast care team Systematic review or meta-analysis Group consensus .. Local protocol or guideline .. Manager of the service .. General practitioners .. Additional data to be collected for information only .. Patients .. WORK PLAN.. Planned date(s) Planned date(s). ETHICS SCREENING LIST Does the clinical audit .. Any yes response requires ethics review Start by 31 Aug.

4 Problems and causes analysed by 15 Oct .. Completed clinical audit forms example Data collected by 10 Sep .. Action plan implemented by 1 Dec .. infringe on any patient's rights or risk breaching any patient's collect any data that could be used to identify any patient confidentiality or privacy? Yes No or any practitioner? ( clinical audit data must be anonymized.) Flagged' cases reviewed by .. 30 Sep Repeat measurement Completed by .. 31 Mar pose any risk for or burden on a patient beyond those of his or her Yes No Findings reviewed by.

5 10 Oct Report submitted by* .. 1 Jan routine care? Yes No have someone carrying out the audit who does not normally involve any clinically significant departure from usual clinical care? have access to patients' records or information? Yes No *The report may be updated if more than one measure act measure cycle is needed to achieve any desired improvements. Yes No involves a potential conflict of obligation to patients such as a gather any information about a patient beyond that collected in trade-off between cost and quality or patient safety Yes.

6 No HELP NEEDED. routine patient care? Yes No involve the use of any untested clinical or systems intervention? Yes No collect data directly from any patient or carer, and if so, could the Is help or support from any other department or service needed to complete the audit ? Yes No audit subject a patient or carer to more than minimal burdens or allocate any interventions differently among groups of patients risks if it is time consuming or requests sensitive information? or staff? Yes No If yes, describe whose help is needed and the nature of the help Yes No clinical audit proposal for an audit on timeliness and effectiveness of assessments by the.

7 COMMITMENT AND SUPPORT .. I will ensure that the team undertaking this clinical audit is supported to achieve improvement in the quality of care or service or to refer recommendations for improvement to those responsible and accountable for the service. COPY Send a copy of the signed proposal, including the clinical audit measures to the following: clinical audit Lead 1. clinical Director/Service Manager/Team Leader clinical Governance Department .. 29 Aug .. 29 Aug signature date signature date .. Healthcare Quality Quest Ltd, 2009.

8 Healthcare Quality Quest Ltd, 2009. example Completed clinical audit forms example Copyright Healthcare Quality Quest Ltd, 2009. Copyright Healthcare Quality Quest Ltd, 2009. (inside of form ). Timeliness and effectiveness of assessments by breast care team SUBJECT .. 22 August DATE .. 2. clinical AUD. DIT MEASURES. Measure Evidence of quality of care or service (criterion) Standard Exception(s) Definitions and instructions for data collection breast care team no. (% compliance). 1.. The outpatient apppointment is <10 working .. 100%.

9 A. Patient choice .. See date referral received and date .. days after the referral is received .. of outpatient appointment.. Referral means written referral or .. verbal (telephone) referral.. Day means 24-hour period.. Days means consecutive working days.. 2.. In a single visit, the patient has: .. 100%.. A. Patient declines for (b).. See outpatient notes for clinical .. (a) clinical examination and .. or (c).. examination.. (b) Ultrasound or mammography and .. See ultrasound or mammography and .. (c) Core biopsy or fine needle aspiration.

10 Core biopsy or fine needle aspiration .. reports for date done.. Single visit means one appointment .. session.. If (a) or (b) or (c) is missing, .. note which was missing and any .. explanation that was in the record.. 3.. Test results are given to the patient <5 working .. 100%.. A. Patient choice .. See outpatient progress notes for date of .. days following investigations triple assessment and date the patient Completed clinical audit forms example .. was given results.. Given means face-to-face contact.. 4.. The breast care nurse is present when test results.