Clinical Governance - Clinical Audit
Internal
Under the National Minimum Care Standards, all medical practitioners have a duty to supply the hospital with, and make available to the National Care Standards Commission, the following clinical and performance indicators about any patient they have treated:
- Deaths at the hospital
- Unplanned re-admissions to hospital
- Unplanned returns to theatre
- Unplanned transfers to other hospitals
- Adverse clinical incidents
- Post-operative deep vein thrombosis or pulmonary embolisms
- Post operative infections
We encourage all staff and practitioners to report clinical incidents and promote this through a fair and open culture. If you have an incident to report please do so through one of the nurse managers or the Chief Nursing Officer.
This information is collated on a monthly and year on year basis, which then gets reviewed at the Clinical Governance Committee and MAC in turn.
We also collect the following are additional indicators:
- Unplanned admissions to ITU/HDU
- Extended Length of Stay
- Drug Errors
- Blood related incidents
- Wound related incidents
- Cardiac arrests
External
- QIPS - Quality Indicator Project
- Surgical Site Infections
- Inpatient Mortality
- Perioperative mortality
- Unplanned readmission within 31 days
- Unplanned readmission after day-care, Endoscopy or any other procedure
- Unplanned returns to theatre
- Unplanned transfers to the NHS
- NINNS - Nosocomial Infection Monitoring Service
- Surgical site infections for hip and knee arthoroplasty patients
- NCEPOD - Confidential Enquiry into Peri-operative Death
- NCEHSMP - National Confidential Enquiry into Homicide and Suicide by Mentally Ill People
- NJR - National Joint Registry
