Clinical audit registration form 2010/2011

Clinical Audit Registration Form 2010/2011

All services must complete a registration form for a clinical audit as a requirement of the Community Contract. Clinical Audit Lead for Community Contract – Cindy Freeman.

Head of Service Improvement

A registration form must also be completed for any additional audits conducted in the service – return to Sarah Peacock. Clinical Auditor.

1. Project Lead

Name _____________________________________________________

Job Title _____________________________________________________

Department/Service _____________________________________________________

Contact Details _____________________________________________________

2. Audit Title

Target group to be audited:-

Sample size for audit e. g. number of records, staff, patients:-

3. Anticipated start date ________________ Duration __________________

Audit data for Commissioners must be completed at least by Sept 2010 – as time is needed for analysis, report writing, and action planning.

4. Reason for Audit (tick all that apply)

Commissioner audits - must be benchmarking against NICE or other key clinical standard e. g. auditing waiting times is not a clinical audit

NICE guidance (NSF/TA/CG) □ Recurrent/common problem □

Service Level Agreement □ Potential problem □

Evidence based guidance □ Re-audit □

Service development □ Prescribing/medicines □

Provider priority □ High cost/high risk □

NHS Wirral priority □ Complaints □

Care pathway □ Incident reporting □

Compliance □ Variation in practice □

Controls Assurance □ Transforming Community Services □

Policy/guidance □

5. Aims/Objectives

6. Methods

Questionnaire □ Focus Groups □

Use of Survey. monkey (online questionnaire) □ Case/patient notes □

Interviews □

Other (specify) □_____________________________

7. Will the audit involve contact with patients? Yes □ No □

If yes, at what stage:-

Planning and design □

as part of satisfaction – surveys, patient questionnaires □

letter to patients □

8. How do you plan to disseminate the results of the audit to your staff, and wider?

Team meeting □ Provider service meeting □

NHS Wirral meeting □ (please state) ____________________________

Intranet □ Publication in external journal □

Other □ (please state) ____________________________

9. Do you require any help from the clinical audit team? Yes □ No □

If so, please specify: Design/planning stage □

Distribution of questionnaires (paper-based) □

Use of survey. monkey (on-line questionnaire) □

Database design □

Data input (commissioner audits only) □

Analysis of results □

Report writing □

Please return copies of this form : Commissioner audits– Cindy Freeman and Sarah Peacock

(All additional audits to Sarah Peacock)

Cindy Freeman cindy. *****@***nhs. uk Sarah Peacock sarah. *****@***nhs. uk

NHS Wirral, Old Market House, Hamilton Street, Birkenhead CH41 3FL

Clinical audit support will be provided by Sarah Peacock, combined with support from the Service Improvement Unit for survey. monkey (online questionnaire) if this is a suitable requirement for data collection for your clinical audit.