Clinical Governance & Audit

Box 147

Cambridge University Hospitals NHS Foundation Trust

Hills Road,

Cambridge,

CB2 0QQ

 

Tel: 01223 216 022

 

 

 

The Clinical Governance & Audit Department (CG&AD) is dedicated to promoting and facilitating clinical audit throughout the Trust. The department provides a service to all managers and clinicians undertaking clinical audit projects. This includes advising and supporting staff with any aspect of the audit cycle and often involves direct assistance such as identifying patients, analysing data, producing reports and developing recommendations to maintain high standards of care.

 

There are 7 Audit Coordinators within the department who are all 'patched' to various specialties and are here to help staff with their audit work. The Audit Coordinators are all trained in Clinical Audit and have the necessary IT, problem solving, analytical and report writing skills required for this role.

 

The CG&AD records information about audits undertaken in the Trust on the Trust Audit Database. It's important that all staff register their audits with the department to ensure all audit activity is reported on. The database is a very useful resource which provides a wealth of audit information including details about past and present audits, audit activity per specialty or subject, and information for consultant appraisals. The department also has a resource library which can be used by all staff in the Trust to review completed audit reports/presentations, access audit literature, or to simply use the room to undertake audit work in.

 

Every year an audit plan is produced for each Service Delivery Unit (SDU) within the Trust. The CG&AD has recently introduced an Audit Planning Pathway for SDUs to follow when constructing their annual audit plans. The pathway aims to give the Trust a more organised and planned approach to audit, to allow the Trust to utilise resources more efficiently and to ensure high priority audits are most heavily supported. 

 

 

What is clinical governance?

Clinical audit is a quality improvement process that compares current practice against the ideal, relying wherever possible on evidence based standards of best practice. Clinical audit should be an integral part of clinical practice and is a powerful tool for positive change.

Clinical audit topics can be broadly divided into the following four categories:

• Structure – the use of resources (buildings, equipment, staff)
• Process – the treatment procedure (investigations, treatment, discharges)
• Outcome – the desired result versus what actually occurs
• Patient experience/satisfaction

Audit is a cyclical process, and the full cycle must be followed for the audit to prove effective. The necessary components of an audit project are represented by the audit cycle

 

 

 

Who is responsible for clinical governance?

Clinical governance is not a philosophy for doctors alone but for all those involved in patient care. Governance recognises the importance of both multidisciplinary teams and the involvement of patients in developing effective health care systems.

 

 

 

What is the process by which clinical governance is achieved?

Hospital Trusts and primary care groups are expected to establish local systems for clinical governance, following a framework described in a Department of Health document: A First Class Service (online version). One of the components of the framework include a Clinical Governance Executive Committee, which will oversee all aspects of clinical practice. The focus is on:

• Identifying the right way to do things;

• Measuring the way things are being done;

• identifying areas for improvement.

 

 

 

 

 

Back to top