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Using clinical audit findings to ensure improvements in patient care

Yvonne Murray Head of Clinical Audit Central Manchester University Hospitals NHS Foundation Trust discusses using clinical audit findings to ensure improvements in patient care on day one of today’s Clinical Audit for Improvement 2015 conference.  Yvonne looks in depth at:

  • supporting and enabling clinicians to implement action plans quickly and re-audit for improvement
  • developing the clinical audit assurance framework
  • how do you identify audits where patient care activities require immediate improvement? Working with risk registers

Yvonne Murray’s full presentation is available for download at the end of this page.


CMFT has approximately 600 audits registered in any one year. All these audits have action plans which are monitored by the clinical audit team via the clinical audit database. This is an onerous task and once an audit had been completed there was reluctance on the part of some clinicians to undertake a re-audit. This meant that in some instances improvement in patient care was not being achieved in a timely fashion

The purpose of this clinical audit management project was to allow Clinicians Divisions and the Board of Directors to identify easily and quickly those audits where agreed standards for quality care for patients were not being met and to enable and support the clinicians to implement their action plans quickly and re-audit for improvement within an agreed timescale.


A clinical audit quality assurance framework was developed in 2012 using a RAG rating system which allowed the results of a clinical audit to be assigned one of the following categories:

  • Full assurance
  • Significant Assurance
  • Limited assurance
  • Very limited assurance

This assurance level is put onto the front cover of each audit project and reported to the Divisional and Trust Clinical Audit and Clinical Effectiveness Committees. It is also included on each Divisions clinical audit dashboard.

The lead clinician who has an audit resulting in  limited or very limited assurance is required to complete their action plan and re-audit [either all the standards or just those standards which  were rated ‘RED’] within a 3-6 month period depending upon the impact those standards would have on patient safety and clinical effectiveness.

These re-audits are added to the Forward Plan for each Division and the audit cycle continued until Full or Significant assurance is achieved.

Any audits of services with limited or very limited assurance are considered by the relevant Divisional clinical audit Committee for addition to the local Risk Register


All clinicians and managers are able to identify from the audits those patient care activities requiring immediate improvement. The action plans of those audits with limited or very limited assurance are kept under close review to ensure that targets are being met and any actions requiring input from the Division or Board can be fast tracked.

The audit is not removed from the Forward Plan and the audit cycle continues until full or significant assurance has been achieved.

Clinical risk are highlighted on the Risk Register and only removed when the service delivery has improved [i.e. Full or significant assurance has been reached] or the risk has been accepted by Divisional managers or the Board as something that cannot be immediately resolved.

There is a clear mechanism, understood by all clinicians for re-audit and clinical audit resources are deployed to assist.


Audits resulting in limited and very limited assurance are discussed at Divisional and Trust clinical effectiveness committees

Action plans are actively managed and there has been a huge reduction in ‘overdue’ actions

There has been an increase in appropriate re-audit rate.

Quality improvement can be measured and assured.

Yvonne Murray Biography:

Yvonne is a nurse by background, is currently Head of Clinical Audit for Central Manchester University Hospitals NHS Trust [CMFT]. This is a role that she took up in 2004. Prior to that she was involved in operational management, research, clinical audit and quality improvement within the NHS.

Forthcoming events of interest:

Root Cause Analysis: 2 Day Intensive Training Course
Monday 16 - Tuesday 17 March 2015, London

Wednesday 22 - Thursday 23 April 2015, London

Monday 11 - Tuesday 12 May 2015, London

Monday 22 - Tuesday 23 June 2015, London

Thursday 9 - Friday 10 July 2015, London

Clinical Audit Masterclass
Thursday 7 May 2015, London

Improving Patient Experience & Efficiencies using Lean 6 Sigma: Two Day Intensive & Interactive Workshop
Wednesday 22 — Thursday 23 April 2015, London

Tuesday 7 — Wednesday 8 July 2015, London

Tuesday 20 — Wednesday 21 October 2015, London

Tuesday 8 — Wednesday 9 December 2015, London

Download: Yvonne Murray"s Presentation

3 March 2015


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