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Audit tool: Evaluation of clinical care and services

Details for quality assurance in evaluating clinical care and services can be found below. Please download the audit tool from the bottom of the page.

Part 1A: Data collection from patient records

There is evidence that

  • An appropriate measure is used to evaluate the effect of physiotherapeutic intervention(s)
  • The measure chosen is published, standardised, valid, reliable and responsive
  • The measure used is the most relevant to the service user’s problems to evaluate the change in the service user’s health status
  • The measure is acceptable to the service user
  • The metric is used in an appropriate way for that specific measure (possibly at the start and end of treatment and at appropriate intervals including follow up)
  • Account is taken of the service user’s welfare during the administration of the measure
  • The result of the measurement is recorded
  • Information derived from the evaluation and the use of the outcome measure is shared with the service user and documented
  • Written instructions in the manufacturer’s manual, test designer’s manual or service guidelines are followed during the administration and scoring of the measure if applicable

Part 1B - Data collection from organisational policies and procedures

  • The organisation has effective quality improvement processes in place, which are integrated into existing organisation-wide quality programmes

A structure in place including

  • The opportunity for members to identify and contribute to progressing service improvements
  • A strategy for the implementation of clinical governance, which is linked to the organisation's overall strategy
  • Locally-agreed standards of practice for common conditions developed by multi-professional groups in order to implement national guidance
  • The physiotherapy service produces an annual clinical governance report that contributes to the organisation's overall clinical governance report
  • Support for members to identify and contribute to service improvement processes as an integral part of the process of service improvement 

There is a clinical audit programme to ensure continuous improvement of clinical quality, with clear arrangements for ensuring that clinical audit monitors the implementation of clinical effectiveness which include policies and procedures to facilitate

  • Members participating in a regular and systematic programme of clinical audit
  • Members participating in multi-professional clinical audit, where it is undertaken
  • The clinical audit programme taking account of service user, organisational, service and national priorities
  • The documented results and recommendations from clinical audit made available through the clinical governance process
  • Changes in practice implemented as part of the clinical audit cycle, in order to rectify any deficiencies identified 

There is a clear and responsive procedure for making and dealing with complaints including

  • A process to ensure that all members understand their role within the complaints procedure

Policies in place which ensure

  • service users have access to information about the service’s complaints procedure
  • complaints are managed within a locally defined time-scale
  • complaints are monitored in order to identify trends and to inform the process of service improvement and risk management
  • complaints inform the process of service improvement 

There are procedures in place the ensure the effect of the physiotherapeutic intervention and the treatment plan is evaluated to ensure that it is effective and relevant to the goals including:

A policy

  • to support members in engaging with service improvement initiatives
  • for the use of service user experience surveys
  • for the use of measures to evaluate clinical effectiveness 

A procedure to facilitate the use of an appropriate measure to evaluate the effect of physiotherapeutic intervention(s) such that

  • the measure chosen is published, standardised, valid, reliable and responsive
  • the measure used is the most relevant to the service user’s problems to evaluate the change in the service user’s health status
  • the measure is acceptable to the service user
  • the metric is used in an appropriate way for that specific measure (possibly at the start and end of treatment and at appropriate intervals including follow up)
  • members ensure they have the necessary skill and experience to use, administer and interpret the measure
  • members take account of the service user’s welfare during the administration of the measure
  • the result of the measurement is recorded
  • information derived from the evaluation and the use of the outcome measure is shared with the service user and documented
  • written instructions in the manufacturer’s manual, test designer’s manual or service guidelines are followed during the administration and scoring of the measure if applicable

Part 2: Service user feedback

  • Information was available on how to provide feedback on the physiotherapy service
  • Information was available on the complaints procedure
  • Measurements were taken to assess my progress with physiotherapy

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