Consultant Audit Activity [QSI Ref: XR-703]
Descriptor
Consultant Audit of aspects of his/her own areas of activity or risk.
Background
This audit is worth carrying out because every consultant is required to participate in audit as part of his/her contract [1]. If every consultant carried out one audit a year (within his/her particular area of specialty work) against a departmentally agreed standard, then several areas of work for each consultant would have been assessed. A set of these audits would provide evidence in support of an individual’s revalidation application.
The Cycle
The standard:
• Local Standard
• Each year, every consultant should carry out at least one clinical audit project that is directed at his or her own area of work. For the purpose of revalidation clinical effectiveness audits are of particular value, particularly those pertaining to an area of high (personal) activity or clinical risk
Target:
100%
Assess local practice
Indicators:
For the year being audited, the percentage of consultants who have submitted and reported on, at least one completed audit project.
Data items to be collected:
List of audits and their authors for a 12 month period.
Suggested number:
• All consultants in the department, whether on full-time, part-time or job share contracts
• Any long-term consultant locum (i.e. in the department for over three months) should also be included
Suggestions for change if target not met
Identify clerical help to assist audit activity:
• Alter job plans and identify protected time to enable audit to be carried out
• Improve ease of access to IT
• Present (anonymised) results to the whole consultant group
• The clinical director to emphasise the importance of these particular audits in relation to each consultant’s revalidation folder
• Repeat date for commencing the next audit (following change): 12 months
• Identify staff member responsible for introducing change
• Indicate date for reporting on the repeat audit
Resources
- Clinical director to collect and analyse the submissions in the department’s records and to assess the completion, presentation and introduction of changes
- Two hours per year for the clinical director to make the assessment and to construct a report
References
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Department of Health. Working for patients; medical audit. London: HMSO, 1989.
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General Medical Council. Good Medical Practice. London: GMC, 1995.
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Department of Health. Terms and Conditions of Service of Hospital Medical and Dental Staff (1990). Para 30A and Appendix HC/(90)/6. London: DoH, 1990.
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Godwin R. Audit in clinical radiology - where should we be? RCR Newsletter 1995; 42: 18–20.
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Ritchie J. et al. The report of the enquiry into quality and practice within the National Health Service arising from the actions of Rodney Ledward (Ref. No. 60 IF R9 217411). London: NHS Executive, 2000.
Editor’s comments
Finding time to carry out an audit is a common problem. Nevertheless, it is a requirement that all job plans must include time for audit. The GMC requirements for revalidation stipulate that evidence of participation in quality improvement activity will be required in each individual’s revalidation folder. Completion of one or more Clinical effectiveness audits should satisfy this requirement.
Three recommendations from the Ritchie report [5] are:
– All doctors, including consultants, must participate in clinical audit and co-operate with the demands of audit in the directorate in which they work
– Audit requires thought and deliberation and time should be allowed in every doctor’s contract
– The audit lead should choose appropriate topics, ensure valid data is collected, the results are discussed, deficiencies and changes in practice are clarified and disseminated
Submitted by
Taken from Clinical Governance and Revalidation 2000 RCR, updated by CRAC 2012