Audit Manual March 2016 - Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Audit Group - North West Clinical Senates

 
Audit Manual March 2016 - Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Audit Group - North West Clinical Senates
Cheshire and Merseyside
Palliative and End of Life Care
     Network Audit Group
          Audit Group

     Audit Manual
      March 2016
Cheshire and Merseyside Palliative and End of Life Care
                     Network Audit Group
                                Audit Manual 2016

                                          CONTENTS
         Acknowledgements                                                                  4
1.       Introduction                                                                      5
         1.1    Background.                                                                5
         1.2    Aims of the Audit Manual.                                                  6
         1.3    Overview of the Network Audit Programme.                                   6
         1.4    Definitions of Clinical Audit.                                             6
         1.5    Roles and Responsibilities for Members of the Guideline                    8
                Development Group.
         1.6    The StR Audit Co-ordinator.                                                9
2.       Key Steps in Delivering A Successful Audit                                        11
         2.1    What Kind of Audit?                                                        11
         2.2    Planning the Audit.                                                        12
         2.3    Membership of the Guideline Development Group.                             12
                2.3.1 Defining the Scope of the Guideline and Audit.                       12
                2.3.2 The Systematic Literature Review.                                    12
                2.3.3 The Invited Expert.                                                  13
                2.3.4 Managing the Process and Support.                                    13
         2.4    Survey and Audit Form Design.                                              14
         2.5    Data Collection.                                                           16
         2.6    Analysis of Data.                                                          16
         2.7    Producing Localised Reports.                                               17
3.       The Audit Presentation                                                            18
4.       Developing the Standards and Guidelines                                           19
5.       How to Access Support                                                             20
6.       Dissemination                                                                     22
7.       The Standards and Guidelines Book and Website                                     23
8.       References and Resources                                                          24

2     Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

      Production Date: March 2016                Review Date: March 2018
CONTENTS (continued)
9.      Appendices                                                                          25-41
        Appendix 1    NICE Accreditation Process.                                           25-28
        Appendix 2    Overview of Network Audit Structures.                                  29
        Appendix 3     Job Description for StR Audit Co-ordinator                           30-32
        Appendix 4     Specialist Palliative Care Units / Teams participating in Regional   33-35
                      and Supra regional Audits
        Appendix 5    Example of a Gantt Chart.                                              36
        Appendix 6    One Page Protocol for Marie Curie Palliative Care Institute           37-38
        Appendix 7    The Marie Curie Hospice Liverpool and Marie Curie Palliative           39
                      Care Institute Liverpool.
        Appendix 8    Audit Topics to Date.( January 2016)                                  40-41

3    Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

     Production Date: March 2016                Review Date: March 2018
ACKNOWLEDGEMENTS

Clinical audit has the potential to make a significant impact on the quality of care that
patients and those important to them experience. This manual aims to encourage
healthcare professionals to get involved with audit and make a difference. I hope that
readers of this second edition of the Audit Manual will find it a useful and interesting
resource.

The audit programme and this manual would not exist without the input and support
of many colleagues. I would like to acknowledge the huge contributions from
members of the Audit Group over the past 18 years. They have helped the audit
process to develop and strengthen through their hard work and commitment.

Special thanks go to Dr Andrew Khodabukus, Dr Sarah Fradsham and
Dr Aileen Scott for their drive, enthusiasm and hard work in creating the first edition
of the audit manual. Thanks now also go to Dr Daniel Monnery for his help with this
second edition.

Thank you to all the members of the Audit Subgroup for their leadership of the audit
programme.

Thank you once again to Dr Helen Bonwick for proof reading the manuscript and
removing all of the grammatical errors.

Thank you to the Cheshire and Merseyside Strategic Clinical Network for their
financial support of the group which has helped us to develop and improve the
quality of our audit programme.

Finally a huge thank you to Kath Davies for her administrative support in producing
this new manual, setting up our website and coordinating the audit programme. We
wouldn’t manage without you.

Dr Alison Coackley
Chair of the Audit Subgroup
Cheshire and Merseyside Palliative and End of Life Care Network
March 2016

4   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

    Production Date: March 2016               Review Date: March 2018
INTRODUCTION
    Section 1

Welcome to the Cheshire and Merseyside Palliative and End of Life Care Network
Audit Manual 2nd edition 2016.

This manual has been developed to help you become familiar with the audit process
and hopefully answer some of the questions you may have. Further information is
available on the Network website. (Link) Alternatively please feel free to contact any
member of the Audit Subgroup for further guidance and support. Contact details can
be found on the audit page of the Network website.

1.1 BACKGROUND

The Cheshire and Merseyside Palliative and End of Life Care Network Audit Group
(CMPCNAG) was formed in 1995. One of the main objectives of the group is to use
clinical audit projects to develop standards and guidelines, which can be used to
support specialist palliative care professionals and empower generalists working in
other areas of health care.

The group consists of individuals involved in specialist palliative care across the
Network in community, hospital and hospice settings. The strength of the group lies
in the multidisciplinary representation and the willingness of individuals, units and
services to participate in the audit programme. Over the past twenty years the group
has continued to develop and now holds bimonthly audit meetings throughout the
year. Every spring the whole group plans the audit programme for the next 12 to 18
months, thus helping to maintain ownership of the audit process and enthusiasm for
the projects.

The number and type of audits undertaken each year has varied. Until 2014, five
audit projects were chosen, three of which were identified as regional audits and
based on a previously audited topic. One of these audits was often expanded to
include localities outside the Network as a ‘supra-regional’ audit. A further two new
audit topics were also chosen one of which was designated as non-symptom control.

Since 2014/2015 four regional audits are undertaken each year. This was in
recognition of the need to maintain quality with the more complex and intensive
guideline development process that the group adopted. Implementation of the
robust process will allow the group to apply for NICE accreditation in 2016. (see
Appendix 1)

Each audit meeting attracts approximately 60 health care professionals from across
the Network. The meeting begins with the presentation of a literature review of the
designated topic, followed by results from the audit. Proposed standards and
guidelines, or suggested amendments to existing guidelines, are then presented.
This is followed by an open discussion to further develop and refine the proposed
standards and guidelines. An invited expert is also asked to contribute to both the
presentation and discussion. The guidelines are developed following the process
outlined in the Guideline Development Manual.1[Link] The guidelines are not
standard protocols and are by no means prescriptive.

5    Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

     Production Date: March 2016              Review Date: March 2018
INTRODUCTION
Section 1

Regional audits complete the audit cycle by assessing the group’s performance
against previously developed standards. Dissemination of results from the audit
projects has been achieved by presentations and publications at national and
international level. Examples of publications can be found on the Network website.1
[Link]

Following the meeting, the draft standards and guidelines are sent to members of the
audit subgroup for comment and then to an external reviewer. At the end of the
process the standards and guidelines are finalized and published on the Network
website.[Link] A full description of the review process may be found in the Guideline
Development Manual.1 [Link]
In 2015 the group began a process of localized reporting for clinical audits and for
teams which had submitted a specific level of data. This is usually set as a minimum
of 10 clinical cases but will vary between the different audits. This initiative will
continue to develop over the next 18 months and will allow units to focus on quality
improvements to their delivery of care.

In 2013, following consultation with group members it was decided to apply for NICE
accreditation of the Standards and Guidelines. This process has included a rigorous
development of a new Guideline Development Manual to meet all of the 23 criteria
specified by NICE. We have been unable to submit an application until we have at
least two guidelines which had completed the entirety of the new process. We are
now in that position and the application for NICE accreditation will be submitted in
spring 2016 (see Appendix 1).

1.2 AIMS OF THE AUDIT MANUAL

This audit manual is designed to provide you with information about the audit
programme and how to participate in an audit project. It describes the different
phases of an audit project including planning, survey design, data collection,
analysis, presentation of results and dissemination. It is designed to be used in
conjunction with the Guideline Development Manual.1[Link]

1.3 OVERVIEW OF THE NETWORK AUDIT PROGRAMME

The Audit Subgroup oversees the audit programme for the Network and the
production of standards and guidelines. The Subgroup is responsible for ensuring
guidelines are produced according to the agreed process and disseminated in a
timely manner to appropriate stakeholders. This group has representatives from
each of the localities within the Network and holds four formal meetings per year.
The Chair of the Audit Group provides quarterly reports to the Network Steering
Group. Appendix 2 gives an overview of the Network structure. Terms of reference
and membership for the Audit Subgroup can be found on the Network website. [Link]

6   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

    Production Date: March 2016              Review Date: March 2018
INTRODUCTION
 Section 1

1.4 DEFINITIONS OF CLINICAL AUDIT

Clinical audit is a quality improvement process that seeks to improve patient care
and outcomes through the systematic review of care against explicit criteria and the
implementation of change. (see Figure 1) Aspects of the structure, processes and
outcomes of care are selected and systematically evaluated against explicit criteria.

Where indicated, changes are implemented at an individual team or service level
and further monitoring is used to confirm improvement in healthcare delivery. 3

Research, service evaluation and audit can sometime be confused. Table 1.1
highlights the differences in ethos, aims, components, data and organisation.

Table 1.1 Key Differences between Research, Service Evaluation and Audit
          (adapted from Harris 4 )

Elements                Audit           Service Evaluation            Research

                Are we doing what       What are we doing?       What should we do?
                we should be doing?
Ethos           Are we doing what
                we said we would be
                doing?
                Assesses current        Describes current        Identifies new
                practice against a      practice                 knowledge to
Aims
                standard                                         influence clinical
                                                                 practice
           Measures or                  Measures or              Observational
           describes activity           describes activity but   studies or
Components
           against agreed               not against a            experiments testing
           standards                    particular standard      hypotheses
           Examines standard            Examines standard        Often need to get
           collected data (e.g.         collected data – (e.g.   new data
Data       case note analysis)          National Council for
                                        Palliative Care
                                        Minimum Data Set)
                Proforma used to        Proforma used to         Study protocols.
                assess standard         assess standard
                collected data          collected data           Must comply with
                                                                 Good Clinical
             NHS research ethics        NHS research ethics      Practice for
Organisation approval not               approval not             Research
             needed.                    needed.
                                                                 Almost invariably
                Likely to need local    Likely to need local     needs NHS research
                clinical governance     clinical governance      ethics approval
                or audit approval       or audit approval

7   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

    Production Date: March 2016              Review Date: March 2018
.

                    INTRODUCTION
    Section 1

    Figure 1: The Audit Cycle

1.5 ROLES AND RESPONSIBILITIES FOR MEMBERS OF THE GUIDELINE
    DEVELOPMENT GROUP

A number of professionals will volunteer to deliver the audit project and develop the
standards and guidelines for that topic. They will be known as the Guideline
Development Group. (GDG) The group will include a range of healthcare
professionals from specialist palliative care. Members of a GDG may not necessarily
work with other members on a day to day basis. Being involved in an audit is often a
good way of getting to know other colleagues from across the Network.

The group will include a clinical lead with overall responsibility for keeping the audit
project on track and ensuring that standards and guidelines are completed according
to the NICE process in a timely fashion. Historically this has usually been a
Consultant in Palliative Medicine but it is open to all professionals within the group
who have appropriate audit, leadership and supervision experience.

The group will include at least one specialty registrar and two registrars where
possible. Specialty registrars (StRs) are undertaking a four year training programme
in Palliative Medicine which will equip them to take on a Consultant role in the
specialty. All registrars have to complete audits as part of their training. If they are
nearing the end of their training they will be tasked with co-ordination of the GDG
and will do much of the organisation. If they are a more junior registrar they will have
a supporting role giving them opportunity to develop skills both in clinical audit and
project management. Individual StRs need to consider how they meet the curriculum
competencies required for audit. 5, 6 [Link]

8     Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

      Production Date: March 2016              Review Date: March 2018
INTRODUCTION
    Section 1

It is equally important that specialty doctors working across the network have
adequate experience in clinical audit. They should be encouraged to participate in
the programme and where possible, be an active member of one of the GDGs.
Doctors hoping to submit a CESR application will need to provide extensive
evidence of participation in audit and quality improvement projects. It may be
appropriate for the specialty doctor to take the place of one of the registrars
depending on numbers and availability.

Membership of a GDG should include professionals with a variety of backgrounds
and experience as the project will benefit from diverse and shared input.
Participation in a GDG can support revalidation for doctors and nurses and provide
evidence for Agenda for Change/Knowledge and Skills Framework Appraisal (KSF)
for allied health professionals.

It is important that everyone in a GDG is prepared to contribute to the work as each
audit involves a significant amount of time and effort. At the first planning meeting it
is important to consider the roles and responsibilities of different members. Certain
aspects of the project may be unfamiliar to some members of the group depending
on previous experience. Participation should be seen as an opportunity to develop
skills, and help and support will be available from other members of the group.

It is important that where possible everyone attends the group meetings in order to
keep the project on track. Group members should do their best to arrange release
from the workplace. This can be difficult and should be discussed with their Line
Manager as soon as possible. It is also helpful if meetings are scheduled at the initial
planning discussion so that everyone can have dates, times and locations in their
diary. Where possible the location for the meetings should be rotated so that travel is
shared equally between members.

Table 1.2 provides an overview of key responsibilities for the GDG and an optimum
timescale for project management.

1.6 THE StR AUDIT CO-ORDINATOR

The Audit Co-ordinator is a senior StR within the training programme. The trainee
group nominates the most appropriate person to take on the role, usually for 12
months. The Audit Co-ordinator is a member of the Audit Subgroup and is
responsible for coordinating the bimonthly meetings and supporting other registrars
involved in audit projects. They may be a very useful source of advice and help.
Details of how to contact them are available on the website.2 [Link] A job description
for this role can be found in Appendix 3

You are encouraged to keep the Audit Co-ordinator up to date with the progress of
your audit to ensure you are meeting appropriate time frames and also to let them
know if you are encountering any specific problems with your audit.

9   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

    Production Date: March 2016               Review Date: March 2018
INTRODUCTION
 Section 1

Table 1.2 Roles and Responsibilities of the GDG
Responsibility                                                         Suggested Timescale
1.     To follow the NICE agreed process for production of the Throughout the process
       standards and guidelines using the information in the
       Guideline Development Manual.
2.     To define the clinical question(s) for the audit topic.          At the beginning of the
                                                                        process
3.     To conduct a systematic literature review.                       Complete 4 weeks before
                                                                        presentation
4.     To design an audit tool/ data collection form.                   Complete,       design    and
                                                                        submit for approval at least
                                                                        4 weeks before start of data
                                                                        collection
5.     To communicate arrangements and guidance for data Discuss with Co-ordinator
       collection with all localities, teams and units participating in soon after first GDG
       the audit.                                                       meeting.
                                                                        Approved materials to be
                                                                        with Coordinator 2 weeks
                                                                        before data collection starts
6.     To keep the Audit Co-ordinator informed about the progress Throughout the process
       of the audit and guideline production.
7.     To collate the data returns and analyse the information.          4 weeks before
                                                                        presentation
8.     To invite an expert to the audit presentation.                   At start of process

9.     To deliver an audit presentation to the Network Group.       On set date. Copy of
                                                                    presentation to be sent to
                                                                    Co-ordinator 1 week in
                                                                    advance of the meeting.
10.    To develop updated or original standards and guidelines for 8     weeks     after  initial
       that topic according to the process and present them to the presentation. Date set in
       Network Group as timetabled.                                 audit programme
11.    To submit the final draft of the standards and guidelines to 4 months from the date of
       the Audit Subgroup Chair ready to start the external review presentation
       process
12.    To take feedback from the external reviewer as part of the Complete whole process
       guideline development process and adjust documentation within 6-8 months of
       as appropriate. Produce finalized guidelines.                presentation date
13.    To ensure dissemination of the work e.g. abstracts, posters As soon as audit project
       presentations, articles. This may be local, national or complete.         Be aware of
       international.                                               submission deadlines for
                                                                    conferences.
14.    To contribute to the production of any supporting material Complete        within   6-12
       for the standards and guideline.                             months        from      the
                                                                    presentation date
15.    To assist with reviewing and updating the standards and As required
       guidelines as appropriate

10    Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

      Production Date: March 2016                  Review Date: March 2018
KEY STEPS TO DELIVERING A SUCCESSFUL
Section 2
                  AUDIT

  2.1 WHAT KIND OF AUDIT?

  The audit may be either local or regional.

  Regional audits are designed to look at standards and guidelines which have
  previously been developed. If it is a regional audit it will involve data collection from
  all areas across the Network.

  In each locality there are generally three care settings i.e. community, hospice, and
  hospital. Where possible all three settings in each locality should be included in data
  collection for a regional audit. The Audit Coordinator will have details for each of the
  different areas in the Cheshire and Merseyside Network. A list is also available in
  Appendix 4.

  It may be appropriate to use a previously designed audit tool / proforma or the group
  may want to develop a new tool. Examples used in previous audits can be found on
  the website. [Link] It is essential that the group audit against the existing standards
  and guidelines.

  A local audit may look at either one or two localities. It may not necessarily include
  all care settings although it is usually helpful to try and do so. This will be a new audit
  so no standards or guidelines will exist and there will be no local audit tool /
  proforma.

  Table 2 highlights the key differences between a local and regional audit. Note: A
  junior StR would not be expected to lead a regional audit .This would be the
  responsibility of a more senior trainee. The less experienced StR would be expected
  to play a supporting role allowing development of the necessary knowledge and
  skills.

  Sometimes partners from organizations outside the Cheshire and Merseyside
  Cancer Network wish to participate in an audit. This then becomes a supra regional
  audit. Details of teams and units who may wish to participate can be found in
  Appendix 4.

  The annual review meeting held in the spring determines the timetable and topics for
  audit for the following year (see Guideline Development Manual 1).[Link]

  Table 2     Key differences between a CMPCNAG local and regional audit
                                              Local Audit                Regional Audit
  Existing standards and guidelines      No                           Yes
  Local Audit tool / form in existence   No                           May be available
  Extent of data collection              May be one        or   two   Will involve all localities
                                         localities only              across the Network

 11   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

      Production Date: March 2016                  Review Date: March 2018
KEY STEPS TO DELIVERING A SUCCESSFUL
Section 2
                     AUDIT

2.2 PLANNING THE AUDIT

This is a crucial stage. Following the annual spring review meeting and allocation of
the Lead clinician(s) and StRs/ specialty doctors, a planning meeting should be
organised. This is usually the responsibility of the senior StR. It is strongly advised
that everyone in the group attends. The group will then be known as the Guideline
Development Group (GDG). The audit project forms part of the Guideline
Development process. Everyone in the group should read both this Audit Manual
and the Guideline Development Manual1 thoroughly.[Link] These two documents
provide important information about how the process should be undertaken and the
key steps along the way. In order for the final standards and guidelines to be NICE
accredited it is essential that they are produced by following the clearly outlined
process. There is specific paperwork that needs to be completed and declarations
regarding Conflicts of Interests for each member need to be submitted.1 [Link] Any
concerns should be communicated to the Chair of the Audit Subgroup as soon as
possible.

2.3 MEMBERSHIP OF THE GUIDELINE DEVELOPMENT GROUP

Firstly it is important that the group has representation from a range of settings and
professionals, and that the members are committed to the project. If there is a
problem with membership the lead clinician should contact the Chair of the Audit
Subgroup as soon as possible. It is also very important that patient, carer or public
involvement is considered at an early stage. Further guidance about this is found in
the Guideline Development Manual. 1[Link]

.       2.3.1 Defining the Scope of the Guideline and Audit
        The group needs to define a clinical question(s). This process will have started
        at the review meeting but now needs to be developed. There is more
        information on how to do this in the Guideline Development Manual.1 [Link] if
        your group has problems with this it is important you contact the Chair of the
        Audit Subgroup who will be able to assist.

        If this is a local (new) audit then you will need to determine your draft standards
        prior to developing your data collection proforma. A regional re-audit will have
        existing standards as a basis for the data collection.

     Tips
     Know what type of audit is expected so that you can plan accordingly i.e.
     Local audits – one/two localities.

     Regional – open to all localities in the Network.

     Supra-regional – open to all localities in the Network and other invited localities.

12    Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

      Production Date: March 2016                   Review Date: March 2018
KEY STEPS TO DELIVERING A SUCCESSFUL
Section 2
                 AUDIT

      2.3.2 The Systematic Literature Review
      A literature search is a key step in the audit process and the Guideline
      Manual.[Link] gives extensive information on how to do this.1 It is important that
      when planning your project you allow sufficient time for this stage. It should
      involve the majority of the GDG membership.

      There needs to be a relevant and concise summary of the literature review
      presented at the audit meeting.

      2.3.3 The Invited Expert
      Audit projects and the presentation benefit from the input of an invited expert. It
      is important to think about this at an early stage and approach the professional
      who would be most appropriate to help with your topic.

      2.3.4 Managing the Process and Accessing Support
      Draw up a Gantt chart6 to plan the audit project. This helps you meet all the
      required deadlines. Appendix 5 contains an example of an audit project Gantt
      chart.

      It may be that you would benefit from additional support for your audit. This
      may take the form of general advice; help with the literature review, advice on
      survey design or data analysis. Support and help may be accessed in several
      ways. Please see section 6 for more details.

      Figure 2 illustrates the important components of the planning phase.

13   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

     Production Date: March 2016               Review Date: March 2018
KEY STEPS TO DELIVERING A SUCCESSFUL
Section 2
                 AUDIT

      Figure 2 The Planning Phase

                                      Membership
                                      and allocated
                                          roles
                     Timing of data                         Think about
                       collection                            additional
                                                              support/
                                                             resources

             Think about              Key elements
              the invited             in planning a                 Understanding
             expert early               successful                  of the process
                                          audit

                        Form/
                     questionnaire                          Gantt Chart.
                        design                              Plan meetings
                                       Define the
                                        clinical
                                       questions

  2.4 SURVEY AND AUDIT FORM DESIGN

  The audit form / survey is key for collecting the data and needs to be designed with
  great care. If there are existing standards these should be used in the design. The
  form should include some basic demographic questions. It is important that the
  locality and the care setting are identified. It may also be important to know the role
  of the professional responding to the survey.

  GDGs may use an electronic method e.g. Survey Monkey or paper. The Audit
  subgroup has access to an enhanced Survey Monkey account. This allows you to
  design a questionnaire with more than 10 questions and use the upgraded facilities.
  If you wish to use this account you should contact the Audit Subgroup Chair for log in
  details.

 14    Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

       Production Date: March 2016                    Review Date: March 2018
KEY STEPS TO DELIVERING A SUCCESSFUL
Section 2
                 AUDIT

 Questionnaires need to be simple, easy to read and unambiguous as data may be
 collected by individuals not directly involved in the GDG. Clinical data collection
 forms must be straightforward. Better response rates are usually obtained from
 shorter forms. We would strongly advise that you avoid using paper forms as this
 adds to the workload when inputting/analysing data. They should only be made
 available in exceptional circumstances. If using paper the form should ideally be no
 more than two sides of A4.

 Examples of forms that have been designed for previous audits are available on the
 Network website.[Link] As each set of standards and guidelines goes through the
 NICE process the website will add the audit data collection form as supporting
 evidence.

 Decide who you will send the questionnaire out to, which settings and how many
 responses you would want from each area. You will also need to determine how
 many responses are required for a team or unit to receive a localized report (see
 section 2.7 for further details).

 To prevent the overlap of multiple data collection periods for the different audits you
 should inform the StR Audit coordinator of the proposed time scale for data collection
 at the earliest opportunity. They can then ensure this does not overlap with other
 projects. On some occasions it may be necessary to alter timings slightly to avoid
 any clashes.

 Once the whole GDG has reviewed the form, it is recommended that you pilot the
 form with someone outside the project group before submitting it for review by the
 Chair of the Audit Subgroup (see below).

 If it is a regional audit you will need to draft a covering letter to the Leads of all the
 Integrated Clinical Networks and to the Audit subgroup member from each locality.
 Both of these people are responsible for encouraging teams and units within their
 locality to actively participate in the audit data collection and so they need to be well
 informed about your project.

 If it is a local audit there will be a need to be a letter to the Lead of the Integrated
 Clinical Network and subgroup members for the areas involved in data collection.

 This letter should give clear instructions about:-

     The audit project e.g. title / topic/ clinical question(s)
     The data collection period with the deadline for returning all forms
     How many submissions you are expecting as a minimum and the number
      required to receive a localized report
     Who you want to complete the form i.e. which healthcare professionals
     If using a paper form where these should be returned to
     You should also include a contact name and email address in case there are
      any questions or problems
15   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

     Production Date: March 2016                Review Date: March 2018
KEY STEPS TO DELIVERING A SUCCESSFUL
Section 2
                  AUDIT

Once you have the final draft of both the form and the covering letter you should
send to the Chair of the Audit Subgroup and StR Audit Coordinator along with the
completed proposal form and all of the Conflict of Interest statements (see Guideline
Development Manual1). [Link]

Drafts should be sent at least 4 weeks before the start of the proposed data
collection period to give time for review and amendments.

If registering with the Marie Curie Palliative Care Institute Liverpool you will need to
complete the one page Institute protocol (See Appendix 6) and submit to the
Research/Development Administrator and the Research/ Development Lead for
review. Please see guidance in section 5 on which audits to register with the Institute
and how to do this

 Top Tips
 Plan effectively – a Gantt chart may help with this.

 Questions included on the audit form should help answer the overall question “are we
 doing what we should be doing?” Don’t collect too much data!

 Pilot your form – preferably using someone not involved in its creation.

 Send your form to the Audit Coordinator 4 weeks before your data collection period
 to allow review and comments by the Audit Sub Group.

 Factor in time to get any local Clinical Audit/Governance approval prior to data
 collection.

 Factor in time to get any local Clinical Audit/Governance approval prior to data   2.5
       DATA COLLECTION
 collection
When approval has been given by the Audit Subgroup Chair, send the approved
form or questionnaire link and the covering letter to the Audit Coordinator who will
then arrange for it to be circulated to the appropriate people.

Individual units/teams participating in an audit will sometimes need to get agreement
from their Trust/ Audit committee before they can go ahead. Different audit
departments will have differing stipulations about data collection. The lead StR, with
support from the lead clinician, should discuss with the individual units/teams about
how this issue is best managed. It is important that the GDG helps with advice on
completing the relevant local form(s) so that all the information is included. You need
to factor in the time required for this when planning your project.

16   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

     Production Date: March 2016                 Review Date: March 2018
KEY STEPS TO DELIVERING A SUCCESSFUL
Section 2
                    AUDIT

It is important to keep track of the number of responses received from each
individual unit /team. This is easily done by logging into the Survey Monkey account.
A reminder email should be sent halfway through the data collection period and
again two weeks from the final submission deadline. You should forward the draft
reminder emails to the StR Audit Co-ordinator for circulation.

2.6     ANALYSIS OF DATA

Try and avoid using paper data collection forms. They tend to simply increase the
workload. You should only issue paper forms to units/teams in exceptional
circumstances. Data from paper forms will need to be recorded using an appropriate
software package e.g. SPSS or Excel. Survey Monkey has its own analysis section,
but data may be downloaded and inputted into other software if needed.

The type of analysis to be used should be identified at an early stage as it influences
both the type and amount of data collected. Descriptive analysis is the most
commonly used approach.

There may be useful qualitative information collected and this should be analysed
thematically. Using comment boxes for free text on the form is one way of collecting
this kind of data.

The results should be summarized in the final audit presentation. It is important to
think about the key messages that the audience need to be aware of. Not all of the
graphs produced will need to be included in the final presentation although they may
well be of use in future abstracts, articles or presentations and will of course be
available in the final localized reports.

2.7     PRODUCING LOCALISED REPORTS

Individual units are increasingly being asked to demonstrate their results from a
regional audit. In 2015 we conducted a pilot of localized reporting with two of the
regional audits and this process will be further developed in 2016. A minimum
number of returns will be required. The exact figure will be different for each audit
and will be determined by the GDG. Further details of how this will be delivered will
be made available on the Network website and at the bimonthly meetings during the
year. GDGs will not need to produce the localized reports. This will be done by the
Audit Subgroup. However GDGs will need to organize their data collection so that it
is possible to produce meaningful reports. Advice on this can be obtained through
the StR Audit Co-ordinator.

17    Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

      Production Date: March 2016              Review Date: March 2018
THE AUDIT PRESENTATION
    Section 3

The audit presentation meeting is held at the Marie Curie Hospice in Liverpool.
Details of the location can be found in Appendix 7.

The date for the presentation of the audit will have been decided at the preceding
spring review meeting. Ideally all members of the group should contribute to the
presentation so it is worth thinking about which areas of the work different members
would like to present. An electronic copy of the presentation and any files containing
hand-outs for the meeting should be sent to the StR Audit Coordinator seven days
before the audit meeting.

The presentation is usually 40-45 minutes followed by 30 minutes for discussion.
The presentation should include:-

       Summary of the clinical questions.
       Outline of the current standards and guidelines (if they exist).
       Summary of the systematic literature review. There needs to be a relevant and
        concise summary of the review presented at the meeting.
       Description of the method(s) used.
       Summary of patient and public involvement.
       Audit results.
       Proposed new standards and guidelines.
       Comments/ overview from invited expert.

Following the presentation the GDG are invited to help with answering any questions
from the audience and contribute to the discussion.

At the end of the presentation and discussion the group will be asked to take all of
the comments away to produce a final draft of the standards and guidelines to
present at the next audit meeting i.e. in 2 months. If this is not possible the lead StR
should discuss with the Audit Co-ordinator about rescheduling. GDGs should note
that the revised standards and guidelines do not need to be completely
formatted in order to be presented. Full details about the development of the
standards and guidelines can be found in the Guideline Development Manual.[Link]1

    Tips
    When planning the questions for your audit form always think “how am I going to analyse this”
    to help guide the kind of question you will use.

    Results presented at the meeting should support your assessment in whether we are meeting
    the standards or not.
    Try and involve everyone in the presentation.
    Make sure you send the presentation to the Audit Co-ordinator before the big day!
    Try and finalise your standards and guidelines as soon after the presentation as you can whilst
    the memory remains fresh.

18     Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

       Production Date: March 2016                      Review Date: March 2018
DEVELOPING THE STANDARDS AND
    Section 4
                    GUIDELINES

A clinical guideline has been defined by NICE as “recommendations on the
appropriate treatment and care of people with specific diseases and conditions within
the NHS. Clinical guidelines are based on the best available evidence. Guidelines
help professionals in their work, but they do not replace their knowledge and skills” 7.

Good clinical guidelines aim to improve the quality of healthcare. They can change
the process of healthcare and improve peoples’ chances of getting as well as
possible. Clinical guidelines can:-7

     Provide recommendations for the treatment and care of people by health
      professionals
     Be used to develop standards to assess the clinical practice of individual health
      professionals
     Be used in the education and training of health professionals
     Help patients make informed decisions
     Improve communication between patient and health professional

The methodology for the production of clinical guidelines has evolved over the past
decade. The Guideline Development Manual located on the Network website 1 [Link]
details the production and review of the standards and guidelines in line with current
best methodologies and aims to meet the NICE criteria for guideline production.

Information in the manual includes:-

     Defining the scope of the guideline
     Establishing the evidence
     Reviewing and grading of evidence
     Development and grading of recommendations
     Consultation and external review
     Format and content
     Dissemination and Implementation
     Comprehensive list of resources and supporting documentation

Tips
Read the Network Guideline Development Manual 1 in conjunction with this guide. It
contains valuable information.

Electronic versions of the various forms are available on the Network website.

19   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

     Production Date: March 2016                Review Date: March 2018
HOW TO ACCESS SUPPORT
          Section 5

      5.1 SUPPORT FOR REGISTRARS

      For Specialty Registrars (StRs) leading audits whilst resident at the Marie Curie
      Hospice and the Royal Liverpool and Broadgreen University Hospital (RLBUHT)
      Palliative Care Team, the Marie Curie Palliative Care Institute( MCPCIL) will offer
      support in the design, development and analysis phases of the audit project.
      The StR must complete a one page protocol (See Appendix 6) and subsequently a
      full protocol - indicating the support required and expected outputs (e.g. abstracts
      and publications).

      If a StR is leading an audit and would like support but working outside the Marie
      Curie Hospice and the RLUBHT Palliative Care Team they should submit a one
      page protocol to the MCPCIL R&D lead for consideration (See Appendix 6). If
      accepted, a full protocol should be developed, identifying expected outputs (e.g.
      abstracts and publications).

      For a StR leading an audit and working in units other than the Marie Curie Hospice /
      Palliative Care Team and the RLUBHT, and who does not wish to have support,
      there is no obligation to register the project. Support, advice and signposting may be
      accessed through the Audit Subgroup Chair and StR Audit Co-ordinator. See Figure
      5.1 for an overview of the process.

      5.2 ANNUAL TRAINING PROGRAMME

      The Audit Subgroup has developed an annual training programme to help members
      participate in the work and to deliver the regional audits and guidelines. All members
      of the group are encouraged to attend the different sessions. StRs should do their
      best to ensure they attend all of the sessions during their training (see Table 5.1).
      There may be additional ad hoc sessions throughout the year including an
      Introduction to the Audit programme delivered in September. Further details will be
      made available on the Audit website. CPD accreditation points have been applied
      for.

      Table 5.1 Details of Annual Training Programme
      May                   Essential Skills 1: Literature Searching
      July                  Essential Skills 2: Sifting through the evidence - refining
                            search results
      September             Essential Skills 3: Grading the evidence - making
                            recommendations from the best available evidence
      November              How to audit effectively and analyse with Survey
                            Monkey/Localized reporting

Tips
If unsure – seek help early, there are many people that can either help or know someone who can.

     20   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

          Production Date: March 2016                 Review Date: March 2018
21   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

     Production Date: March 2016              Review Date: March 2018
HOW TO ACCESS SUPPORT
     Section 5

Figure 5.1 Support Offered by Marie Curie Palliative Care Institute Liverpool for Audit Projects

                                                      StR leading on Audit

        StR based at either                                                                      StR NOT based at either
       MCHL or Palliative Care                                                                   MCHL or Palliative Care
         Team @ RLBUHT                                                                              Team @ RLBUHT

                                                                              Support Required                      Support NOT Required
        Complete MCPCIL one page
    protocol and full protocol indicating
      support required and expected         If accepted
       outcomes. This should also be
    copied to the Audit Subgroup Chair                    Submit MCPCIL one             Book appointment                   No action needed,
                                                           page protocol to               with ‘support                     and there is no
                                                             R&D lead for               surgery’ to obtain                  expectation of
     Support offered by MCPCIL:                             consideration              advice on all aspects                 support from
       Audit design                                                                         of audit                           MCPCIL
       Audit development
       Audit Analysis
       Poster production
DISSEMINATION
     Section 6

Following the presentation remember to write and thank your invited expert for
his/her help and attendance. This is usually the responsibility of the lead StR in the
GDG.

Copies of the presentation will be made available on the Network website so that
other units may use as a teaching aid when disseminating the results from the audit
and implementing change. The website presentation will not include the actual audit
results. These can be accessed by contacting Kath Davies. The presentation on the
website will include the clinical question, methodology, literature review and the
draft standards and guidelines.

GDGs are strongly encouraged to disseminate the results of their work as widely as
possible. This may include abstracts/ posters for local, national and international
conferences. It may be appropriate to submit abstracts to non-palliative care
conferences. GDGs should also consider writing articles for both palliative and non-
palliative care journals.

Any posters or publications arising from the work should acknowledge the
contribution of the Cheshire and Merseyside Palliative and End of Life Care
Network Audit Group. For poster format, this is usually by including the Network
group logo which can be obtained from the StR Audit Coordinator.

Details of successful abstracts, presentations or articles should be sent to the Chair
of the Audit Subgroup and will be made available on the website.

 Tips
 Identify your conference early.

 Write the abstract once data analysis is concluded – conference abstracts follow a
 similar structure.

 The Guideline Development Manual has suggestions of other ways to help dissemination
 and implementation of your work.
ACCESSING THE STANDARDS AND
 Section 7
                    GUIDELINES

Every three years between 1998 and 2010 the group produced a book which
collated the standards and guidelines It was designed both for the purposes of
education and to facilitate the production of other standards and guidelines. It
aimed to encourage the setting and monitoring of standards and promote clinical
excellence in end of life care. It was intended as an information resource for
qualified medical staff and other health professionals caring for patients where
palliative care is appropriate. The content was applicable to patients with cancer
and other types of advanced disease. The guidelines are not standard protocols
and are not intended to be prescriptive.

The fourth edition of the book was produced in 2010. Each chapter had been
extensively reviewed by members of the group and experts from across the United
Kingdom. Six new chapters were included: drugs at the end of life, interventional
pain techniques, major haemorrhage, spiritual care, substance misuse and urinary
incontinence. Standards and guidelines which had not been re-audited since the
3rd edition were updated and reviewed. There are levels of evidence throughout the
guidelines and grades of recommendation for all of the standards in each of the 43
chapters.

The fourth edition was the last paper copy produced. At the moment there are no
plans to produce a further paper edition. However all of the standards and
guidelines are available on the audit website. [Link] Professionals are able to sign
up for email alerts.These will notify you when new guidelines are uploaded or
changes made to the website. [Link]

The website has four main areas:-

1.    Introduction to the Audit Group.
2.    Standards and Guidelines.
3.    Details of annual programme and meetings.
4.    Manuals for Audit and Guideline Development plus educational resources.

Appendix 8 contains a list of all the audit topics that have been undertaken by the
group.

Copies of the 2010 book can be obtained through the Marie Curie Palliative Care
Institute Liverpool website [Link]

Details of each of the annual audit programmes since 2010 can be found on the
network website.[Link]

     24   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

          Production Date: March 2016              Review Date: March 2017
REFERENCES & RESOURCES
     Section 8
       [Link]

                                       REFERENCES

1.     Cheshire and Merseyside Palliative and End of Life Care Network Audit
       Group. Guideline Development Manual. March 2014. Available from:
       www.cmscsenate.nhs.uk. [Last accessed 05 February 2016]. [Link]

2.     Cheshire and Merseyside Palliative and End of Life Care Network Audit
       Group. Website. Available from www.cmscsenate.nhs.uk [Last accessed 05
       February 2016].[Link]

3.     Health Quality Improvement Partnership Criteria and Indicators of Best
       Practice in Clinical Audit 2012. Available from:
       http://www.hqip.org.uk/public/cms/253/625/19/186/HQIP-
       Criteria%20and%20indicators%20of%20best%20practice%20in%20clinical%2
       0audit-March%202012.pdf?realName=JlO6ff.pdf [Last accessed 05 February
       2016] [Link]

4.     Harris D. Differentiating clinical audit from service evaluation and research.
       Eur J Palliat Care 2013: 20(3):133-135.

5.     Joint Royal Colleges of Physicians Training Board. Specialty Training
       Curriculum for Palliative Medicine. August 2010. (Amendments August 2012).
       Available from: www.jrcptb.org.uk/trainingandcert/ST3
       SpR/Documents/2010Palliativemedicinecurriculum(AMENDMENTS2012).pdf
       [Last accessed 5 February 2016].[Link]

6.     Joint Royal Colleges of Physicians Training Board. 2010 Palliative Medicine
       ARCP Decision Aid. Available from: www.jrcptb.org.uk/trainingandcert/ST3-
       SpR/Documents/2010PalliativeMedicineARCPDecisionAid.pdf [Last accessed
       05 February 2016].[Link]

7.     Department of Health: National Clinical Audit Advisory Group Gantt Charts.
       Available from:
       www.improhealth.org/fileadmin/Documents/Improvement_Tools/Gantt_Chart.p
       df [Last accessed 05 February 2016].[Link]

8.     National Institute for Health and Care Excellence. Clinical guidelines. Available
       from:www.nice.org.uk/CG Updated 28 October 2011. [Last accessed 05
       February 2016].[Link]

      25   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

           Production Date: March 2016              Review Date: March 2017
REFERENCES & RESOURCES
 Section 8

              ADDITIONAL RESOURCES YOU MAY FIND USEFUL

Note. New resources are also available on the audit webpages and will be
updated regularly [Link]

Royal College of Paediatrics and Child Health. Clinical Audit and e learning.
Available from:
http://www.rcpch.ac.uk/training-examinations/education/clinical-audit-e-learning.
[Last accessed1 6th February 2016] [Link]

Clinical Audit Support Centre. www.clinicalauditsupport.com
[Last accessed 16 February 2016]. [Link]

NHS England . Clinical Audit, Available
from:https://www.england.nhs.uk/ourwork/qual-clin-lead/clinaudit/[Last accessed
16th February 2016] [Link]

Royal College of Physicians. Quality improvement for revalidation. Available from:
https://www.rcplondon.ac.uk/education-practice/advice/quality-improvement-
revalidation-p-cat-tool [Last accessed 16th February 2016] [Link]

Clinical Audit Teaching Toolkit. Available from:
http://www.hqip.org.uk/downloadable-learning-resources/
[Last accessed 16 February 2016]. [Link]

    26   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

         Production Date: March 2016              Review Date: March 2017
APPENDIX 1

                       NICE ACCREDITATION PROCESS

Accreditation helps health and social care professionals identify the most robustly
produced guidance available, enabling them to deliver high quality care. Since 2009
the National Institute for Health and Care Excellence have accredited 60 guidance
development processes.

What is accreditation?

The accreditation programme assesses the processes used to produce guidance
and advice. This will, in turn, help raise standards in guidance production.

What are the benefits of accreditation?

   To help health and social care professionals identify the most trusted sources of
    guidance developed using critically evaluated high quality processes.
   To drive up the quality of information used by health and social care
    professionals in decision making.
   To improve patient outcomes through providing robust evidence for NICE
    quality standards.

Why apply for accreditation?

   To Increase the visibility of guidance and advice.
   To attain accreditation for guidance, making it eligible to be considered for the
    development of NICE quality standards.
   To promote the guideline development processes as being robust and
    transparent.
   To use the NICE Accreditation Mark as an indication of high standard, good
    quality information.

The following table outlines the 6 domains and criteria required for a guideline
development process to be NICE accredited. The process must meet all of the
criteria. Further information can be found on the NICE website
http://www.nice.org.uk/accreditation.

    27   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

         Production Date: March 2016              Review Date: March 2017
APPENDIX 1

                          ACCREDITATION DOMAINS AND CRITERIA

                   DOMAIN                                                     CRITERIA
1. Scope and purpose is concerned with          These criteria consider whether the guidance producer has a
the overall aim of the guidance, the specific   policy in place and adhered to that requires them to explicitly
health questions and the target population.     detail:

                                                   1.1 The overall objective of the guidance.
                                                   1.2 The clinical, healthcare or social questions covered
                                                          by the guidance.
                                                   1.3 The population and/or target audience to whom the
                                                          guidance applies.
                                                   1.4 That the producer ensures guidance includes clear
                                                          recommendations in reference to specific clinical,
                                                          healthcare or social circumstances.
2. Stakeholder involvement focuses on           These criteria consider whether the guidance producer has a
the extent to which the guidance represents     policy in place and adhered to that means it includes:
the views of its intended users and those
                                                   2.1 Individuals from all relevant stakeholder groups including
affected by the guidance (patients and
                                                          patients groups in developing guidance.
service users).
                                                   2.2 Patient and service user representatives and seeks
                                                          patients views and preferences in developing
                                                          guidance.
                                                   2.3 Representative intended users in developing
                                                          guidance.
3. Rigour of development relates to the         These criteria consider whether the guidance producer has a
process used to gather and synthesise           clear policy in place and adhered to that:
information and the methods used to
                                                   3.1 Requires the guidance producer to use systematic
formulate recommendations and update
                                                          methods to search for evidence and provide details
them.
                                                          of the search strategy.
                                                   3.2 Requires the guidance producers to state the criteria
                                                          and reasons for inclusion or exclusion of evidence
                                                          identified by the evidence review.
                                                   3.3 Describes the strengths and limitations of the body
                                                          of evidence and acknowledges any areas of
                                                          uncertainty.
                                                   3.4 Describes the method used to arrive at
                                                          recommendations (for example, a voting system or
                                                          formal consensus techniques like Delphi
                                                          consensus).

         28       Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

                  Production Date: March 2016                         Review Date: March 2017
APPENDIX 1

                   DOMAIN                                                      CRITERIA
                                                     3.5 Requires the guidance producers to consider the
                                                          health benefits, side effects and risks in formulating
                                                          recommendation.
                                                     3.6 Describes the processes of external peer review.
                                                     3.7 Describes the process of updating guidance and
                                                          maintaining and improving guidance quality.

4. Clarity and presentation deals with the        These criteria consider whether the guidance producer ensures
language and format of the guidance.              that:
                                                     4.1 The recommendations are specific, unambiguous
                                                          and clearly identifiable.
                                                     4.2 The different options for management of the condition
                                                          or options for intervention are clearly presented.
                                                     4.3 The date of search, the date of publication or last
                                                          update and the proposed date for review are clearly
                                                          stated.
                                                     4.4 The content and style of the guidance is suitable for
                                                          the specified target audience. If the public, patients
                                                          or service users are part of this audience, the
                                                          language should be appropriate.

5. Applicability deals with the likely            These criteria consider whether the guidance producer routinely
organisational, behavioural and cost              consider:
implications of applying the guidance.
                                                     5.1 Publishing support tools to aid implementation of
                                                          guidance.
                                                     5.2 Discussion of potential organisational and financial
                                                          barriers in applying its recommendations.
                                                     5.3 Review criteria for monitoring and/or audit purposes
                                                          within each product.

6. Editorial Independence is concerned            These criteria consider whether the guidance producer:
with the independence of the
                                                     6.1 Ensures editorial independence from the funding body.
recommendations, acknowledgement of
                                                     6.2 Is transparent about the funding mechanisms for its
possible conflicts of interest, the credibility
                                                          guidance.
of the guidance in general and their
                                                     6.3 Records and states any potential conflicts of interest of
recommendations in particular.
                                                          individuals involved in developing the recommendations.
                                                     6.4 Takes account of any potential for bias in the conclusions
                                                          of recommendations of the guidance.

          29     Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

                 Production Date: March 2016                          Review Date: March 2017
APPENDIX 2

     OVERVIEW OF CHESHIRE AND MERSEYSIDE PALLIATIVE AND END OF LIFE CARE NETWORK STRUCTURE

30   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

     Production Date: March 2016              Review Date: March 2017
APPENDIX 3

      JOB DESCRIPTION FOR STR AUDIT CO-ORDINATOR ROLE

 Outline of Role

 There are four main aspects to the role:-

     1. Co-ordination of the annual regional audit programme.

     2. Organizing the bi-monthly regional clinical audit meetings.

     3. Membership of the Audit Subgroup.

     4. Liaison with specialty registrars.

 Details of Responsibilities

 1. Coordination of the annual regional audit programme

 You will need to have a record of who is leading each Guideline Development
 Group (GDG) and the membership of each. This information should be forwarded
 to Kath Davies so the website can be updated. Traditionally this has been recorded
 as ‘the matrix’, but with the website we have tried to improve the formatting. Lists
 for 2014/15 onwards are on the memory stick.

 You will also need to know where each GDG is up to in their process, and in
 particular when they are planning to data collect. We would suggest emailing
 each StR Lead once a month to get an update.

 The StR leads should send their data collection tool to you along with a draft of their
 covering letter. You should check both for any obvious errors or omissions. You
 should make sure that all of the different units and teams are included.

 Then send data collection form to the Chair of Audit Subgroup for approval.

 Return the data collection form to the StR lead with clear guidance on any changes
 required.
 It finally comes back to you along with the covering letter. You then send out to the
 ICN Lead and Audit Subgroup representative for each locality. The list of email
 addresses is on the audit stick in the folder.

 At the same time as submitting their data collection tool, the GDGs should also
 submit their proposal form. This should be reviewed by you, then forwarded to the
 Chair of the Audit Subgroup, who will then circulate to members of the subgroup for
 comment and approval

31   Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Manual

     Production Date: March 2016               Review Date: March 2017
You can also read
Next slide ... Cancel