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P85 Developing audit in a hospice
  1. Amanda Gregory and
  2. Laura Myers
  1. St. Catherine’s Hospice, Crawley, West Sussex

Abstract

The clinical audit group (CAG) at an independent hospice aims to motivate and encourage staff to undertake audit and to provide support and education for this activity. Many clinical staff have audit included in their job description. It was, however, observed that, while some staff regularly and competently carry out audit, some have not participated in audit and others find it difficult to conduct audit and report on their work, with variable knowledge of the theory and practice of audit. The CAG have, therefore, sought to implement a more robust audit registration and approval system alongside a programme of education to develop audit skills across the hospice in order to be able to produce credible and appropriate audit that demonstrates quality and areas for improvement. A set of resources to support audit was produced and made accessible to hospice staff electronically. A local step by step guide to registering an audit was produced. This included ensuring that CAG members review all audit registrations and recommendations for refinements are made before an audit is approved to start. The education team provides support to plan audits, including survey design, analysis and presentation of data. An audit of audits revealed that the quality of audits had improved (following implementation of some of these steps), while highlighting the a need to strengthen audit reporting, action plans and re-audit planning. A regular newsletter, highlighting audit activity within the organisation has been produced and audit activity has been reported in the general hospice newsletter. More recently, a questionnaire issued to the CAG members demonstrated gaps in knowledge and understanding, suggesting the need for further training to enable them to support their colleagues in undertaking audit. A programme of education has been designed to meet this need. The structure and membership of CAG is also being reviewed.

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