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This online session will look at the essential role of robust data and learning from audit in helping identify risks, prevent harm, and build safer systems of care. Drawing on practical examples, the session will explore how data from audits and registries can be used to detect safety signals, understand where harm is occurring, and support action to reduce risk and improve patient safety. This session includes: Welcome from the Chair: Dr Jacqueline Andrews, Executive Medical Director, Harrogate and District NHS Foundation Trust and HQIP Trustee Using data for safety – A perspective from the Patient Safety Commissioner: Professor Henrietta Hughes OBE, Patient Safety Commissioner The role of the National Joint Registry in patient safety: Chris Boulton, Director of Operations, National Joint Registry Using national maternity data to drive patient safety improvement: Faith Sheils, Director of Midwifery, Northern Care Alliance NHS Foundation Trust From incident to improvement: using Epilepsy12 data to commission a safer first seizure pathway: Dr Colin Dunkley, Consultant Paediatrician, Sherwood Forest Hospitals, Epillepsy12 Clinical Lead Update from Patient Safety Learning: Clare Wade, Director, Patient Safety Learning Register here.

Stefan Peil summarises a pilot study he has done to see whether a structured systems model can support the preparation of a morbidity and mortality (M&M) conference discussion. The example used is a coronary angiography risk scenario to explore whether a model-based representation of patient safety knowledge could serve as a reliable basis for an artificial intelligence (AI)-assisted decision template. The work was produced to address a practical problem in patient safety: relevant information for M&M preparation is often spread across diagrams, reports and team knowledge, which can slow and make shared understanding less consistent. The pilot study, therefore, examined whether systems modelling could help organise, make transparent and reuse safety relevant information in a more structured way. The full study is attached at the end of this page. The challenge The identified challenge was the lack of a structured, reusable approach to preparing patient safety discussions for M&M conferences. The aim was not to automate clinical judgement, but to test whether a model-based risk analysis derived from team knowledge could serve as a structured input for drafting an M&M decision template. M&M preparation often relies on fragmented information and informal interpretation. In complex clinical environments, such as coronary angiography, risks do not arise from a single isolated factor. They emerge from the interaction between tasks, people, technology, information flow and organisational conditions. In this specific pilot example, the safety concern was a risk scenario in coronary angiography in which cognitive overload during real-time decision-making and escalation could contribute to complications not being detected in time. This formed the basis for testing whether a structured model could provide a clearer and more traceable starting point for discussion. Method and measures To explore this, a systems model based on Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 was created in Systems Modeling Language (SysML) using SPARX Enterprise Architect. The objective was to represent the work system, the contributory task factor, the resulting risk and the proposed measures in a traceable form. The model focused on one coronary angiography scenario. The critical task factor was described as cognitive density in real-time decision-making and potential escalation. In the model, this contributed to the risk that complications would not be detected in time. The text states an impact on quality of care, an occurrence rating described as relevant and an overall risk class of moderate. The proposed measures were: pre-procedure briefing risk-adapted staffing standardised laboratory layout regular simulation drills. The intended achievement was a more structured, transparent and reusable basis for M&M preparation and discussion. Outcomes and lessons learned The pilot showed that a structured model can be a useful way to organise safety-relevant knowledge. Because the model linked work system elements, risks and measures in a traceable way, it provided a clearer starting point for discussion than unstructured text alone. The practical process tested in this pilot was: defining a relevant patient safety scenario in coronary angiography modelling the work system and the contributory task factor linking this to a patient safety risk documenting possible mitigating measures using the model as the basis for an AI-assisted one-page decision template. One important observation was that the AI-generated output reflected the underlying model's content. This suggests that a structured model can support more consistent synthesis than relying only on memory or informal interpretation. The text does not describe multiple alternative technical approaches in detail, so it cannot be stated from the source whether other options were formally compared or ruled out. It also does not state direct patient involvement. Staff involvement is referenced indirectly by using team knowledge as an input to the model. The text does not report formal measurement tools, outcome metrics, time savings, patient safety indicators or model costs. Therefore, no validated impact measurement can be claimed from the source. A key lesson learnt was that AI can assist with drafting and synthesis, but cannot replace clinical judgement, governance or safety review. Any output generated from the model still needs to be checked against the source material and reviewed by responsible clinical and patient safety leads. Impact This work is only a prototype, not as a formal effectiveness study. As a result, the impact that can be claimed is limited. The main result was that the structured model appeared to support: clearer organisation of safety-relevant knowledge better traceability between work system factors, risks and proposed measures a more consistent starting point for multidisciplinary discussion reuse of modelled information for drafting a one-page M&M decision template. At the same time, the the study is explicit about what was not demonstrated. The pilot did not test whether the approach: improved patient outcomes reduced harm shortened preparation time in routine practice improved care delivery in a measurable way. A further limitation was that only a single, limited example was used, and some information was withheld for data protection reasons. This means the results were narrower than would be needed for broader implementation decisions. What worked was the structured linkage between the work system, contributory factors, risks and measures. What remains uncertain is whether this translates into measurable operational benefit in routine clinical governance. A likely barrier to improvement is the need for continued expert review, because AI-generated output cannot be used without clinical validation and governance oversight. If repeated, the next stage would need a clearer evaluation design, including defined measures of clarity, consistency, usability and possibly preparation time. Next steps The next step is a practical pilot in real clinical governance settings. A suitable next-stage comparison would be conventional M&M preparation versus model-supported preparation in a small, clearly defined pilot. The proposed questions for the next phase are: Does the approach improve clarity and shared understanding? Does it help teams identify contributory factors more systematically? Does it support consistency and traceability of measures related to patient safety? The study does not provide evidence of long-term organisational change, staff reaction, patient impact statistics or system-wide implementation results. Therefore, those elements cannot yet be stated as outcomes. However, based on insights from the pilot study, the anticipated longer-term value would be to make patient safety knowledge: more structured more reusable easier to discuss across professional groups more clearly linked to the wider work system rather than to isolated errors. A sensible next step would, therefore, be a controlled local test with defined governance, clinical review and evaluation criteria before any broader adoption.

Join us for an exciting webinar where Buckinghamshire Healthcare NHS Trust share their journey to next-generation quality management. Discover how their partnership with Quantium created a Quality Audit Tool that's revolutionising compliance monitoring and quality assurance across the Trust. Learn how Buckinghamshire managed to: Streamline quality auditing and save 60-80% of audit completion time: Digital workflows replace paper-based processes and legacy solutions, with automated action plan generation ensuring immediate response to quality issues. Achieve compliance excellence and reduce quality risks: Real-time monitoring with proactive reminders drives audit completion rates, while intelligent analytics identify quality issues before they escalate into patient safety concerns. Future-proof by establishing AI-driven audits: data capture and simple workflows are supported by AI to provide intelligent automation and predictive quality insights. Realise benefits in weeks, not months: Deployment through the Federated Data Platform (FDP) provides a tried-and-tested user experience with rapid implementation. Who should attend: Chief Nurses / Deputy Chief Nurses Medical Directors / Chief Medical Officers Associate Directors of Quality, Governance, Patient Safety, and Risk Management Quality Audit Coordinators and Managers Clinical Audit Leads Ward Managers and Matrons responsible for quality standards CQC Compliance Leads Quality Improvement Teams Register

In this blog, Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, shares with the hub what appreciative clinical auditing could look like in health and care I recently hosted a 'learn at lunch' with the amazing Clinical Audit Support Centre to broach the subject of what appreciative clinical audit could look like in health and care. Although I had arrived with some preconceived ideas (as everyone does), I hadn’t foreseen the engagement that would happen in the room when we started to talk about the potential for clinical audit processes that are recognised and built to seek the good. Clinical audit is described as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria" (Principles of Best Practice in Clinical Audit, 2011), but how often is that explicit criteria set to seek exemplary care? And what do we do with that information when it is witnessed and audited? My clinical audit colleagues shared that they are often viewed negatively when approached. That people deem audit to be a punitive experience. But my experience of clinical audit has been anything but that. One of the most meaningful pieces of work I had undertaken in the past few years was a clinical audit to review the care an Accident and Emergency department had delivered in a time of critical incident. Using the constructionist principle of appreciative inquiry that describes that there are multiple interpretations of what is real, I knew that "words create worlds" and if only the harm was sought, only the harm would be found. By leaning towards my senior clinical audit colleagues, we were able to design a clinical audit with a mandatory field that asked "what went well?". The auditor could not bypass or work round it, they HAD to seek for the good, and it was found… often. So, what could this look like in a day-to-day practice of clinical audit, and how could that affect senior leader decision making when receiving the data? The learn at lunch was a great place to start to dream, and the participants (who would know much more than me regarding what an appreciative clinical audit process could look like) dreamed big. Existing positive processes were identified and acknowledged. Questions were asked of what a future could look like "when not practicing in anxiety of what could go wrong". Ideas grew when picturing where appreciative inquiry could sit within a clinical audit process and setting, and thoughts considered what it could be like "if we spend time looking at compliance as well as non-compliance". But I want us to dream even bigger. I want senior leaders to consider how the data you are receiving is scoped from the very beginning. Is it that the data you are reviewing is focussing solely on the substandard and prioritising the ‘red’ on your RAG charts? Alternatively, are clinical audit output reports focussing on best practice and exemplary care? Could the future of clinical audit mean that the data your amazing audit teams are collecting and analysing could point towards your strategic vision and direction? I think health and care could be evidenced to be a lot brighter through audit that seeks and documents the magic and dedication that happens every day. Further blogs from Katy: Appreciative inquiry case study What could Appreciative Governance start to look like in the NHS? A blog by Katy Fisher

This webinar will look at how we can collaboratively and effectively utilise clinical audit to continuously improve patient safety, prevent avoidable harm and work together within our patient safety systems. The Clinical Audit Hero Award for Patient Safety will be announced and there will be the opportunity to hear the winner present their project for wider learning for us all. The event is hosted by the National Quality Improvement (inc. Clinical Audit) Network (N-QI-CAN) and the Healthcare Quality Improvement Partnership (HQIP). Register for the event

The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key Learning Outcomes: Why clinical audit is an integral element of PSIRF Why clinical audit staff have a vital role to play in PSIRF How clinical audit data can help raise red flags and spot risks Using clinical audit to better understand your incidents Ensuring your safety actions are working Using audit to assess your patient safety incident investigations Register hub members get a 20% discount. Email [email protected] for discount code.

The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key Learning Outcomes: Why clinical audit is an integral element of PSIRF Why clinical audit staff have a vital role to play in PSIRF How clinical audit data can help raise red flags and spot risks Using clinical audit to better understand your incidents Ensuring your safety actions are working Using audit to assess your patient safety incident investigations Register hub members get a 20% discount. Email [email protected] for discount code.

The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members receive a 20% discount. Email [email protected] for discount code.

The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register

The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register

The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members receive a 20% discount. Email [email protected] for discount code.

Clinical Audit for Improvement 2024 is now in its 24th year and brings together clinicians, senior/middle managers and leading local and national clinical audit and improvement experts. Over the last two decades this event has become the ‘must-attend’ annual conference for clinical audit and QI professionals. Historically this one-day virtual conference has featured national updates with leaders providing information on relevant current and future policy. However, in 2024 the focus will change slightly with more emphasis on practical skills and techniques needed by those involved in delivering clinical audit projects at a local and/or national level. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/clinical-audit-improvement-summit or email [email protected] hub members receive a 20% discount. Email [email protected] for the discount code. Follow on Twitter @HCUK_Clare #ClinicalAudit2024

In this blog, Susan Martin, a Tissue Viability Specialist Nurse at East Sussex, describes how she implemented the aSSKINg model (assess risk; skin assessment and skin care; surface; keep moving; incontinence and moisture; nutrition and hydration; and giving information or getting help) for pressure ulcer prevention into her Trust. The incidence and prevalence of pressure ulcers continues to rise in England despite national and international guidance. When I was considering what to do for my MSc dissertation as part of the Wound Healing and Tissue Repair programme at Cardiff University, I wanted to explore how we were doing as an organisation. As a Tissue Viability Nurse Specialist, I was familiar with aSSKINg, which is a pressure ulcer care bundle, although we had yet to implement it within our organisation. Data collection A clinical audit to determine the organisation's compliance against the aSSKINg framework for pressure ulcers seemed like a good place to start. I completed the required clinical audit paperwork and started collecting data from adult community nursing caseloads in the East locality. The Trust is large and, as I was a single auditor, one locality was chosen to determine our compliance. I adapted a data collection tool from another clinical audit undertaken in acute trusts for a community setting. The audit covered the period July to December 2021 and I had access to 3000 patient records alongside clinical incident reports. Overall, 418 patients were identified as having a pressure ulcer in the audit period. Pre-audit work to determine if the data collection would be successful involved removing 20 patients and checking the data collection tool. I subsequently completed a pilot audit in another locality (West) and further amendments were made to the data collection too. Of the remaining 398 patients in East, they were randomised using a number generator app and 150 patients were randomised to audit. Baseline data and aSSKINg pilot The baseline data from the audit highlighted a need for improvement and I made the recommendation that an aSSKINg template was required in the electronic patient record to reduce the variations in care and improve documentation. A digital nurse specialist, a digital configuration analyst and I built the initial template. I identified six community nursing teams Tust-wide who wanted to participate in the pilot and the pilot started on the 6 February 2023. Alongside the pilot sites we made adjustments to the template. Due to the overwhelming success of the pilot, I closed it on the 15 April. This is demonstrated in the table below. The feedback from the pilot site was that they found it helpful in that everything relating to pressure ulcers was in one place and they knew they had documented everything correctly. The Operational Leads fed back that they found it easier to locate information when completing clinical incident reports. Next steps Following success of the pilot, the aSSKINg template has started to be rolled out Trust-wide. I decided, in discussion with other clinicians, that the roll out would be done gradually. The reason for this was to allow staff time to digest the changes and feel supported by the Practice Development Nurses, the digital team, their local tissue viability team and myself. Overall, the rollout is successful and teams are engaging with the change. There is a noted improvement in the overall documentation and early evidence that the variations in care are reducing. My advice to anyone thinking about doing something similar is to have good stakeholders involved, and to roll out a programme like the aSSKINg template care plan slowly as that has helped us to iron out any issues early on. Have you implemented a new initiative in your organisation? Have you improved patient safety where you work? We would love to hear from you and share on the hub your journey. If you are a member, you can share directly on the hub or please contact [email protected] to discuss further.