Dental Audit: A user guide from application to completion 1. Audit Guidance 2. New Application: Getting Started 3. New Application: The Audit Application Form 4. New Application: Submitting Your Application for Approval 5. Join an Audit: Health Board, National, Template and Infection Control Audits 6. Submitting Your Final Report and Supporting Documents 7. What Happens Next? a. The Review Process b. Amendments c. Completion d. Rejection e. Appeal Process 8. FAQ s 1
1. Audit Guidance Clinical audit activity is a GDS and PDS terms and conditions of service requirement. Most dentists working in the GDS are eligible to claim funding for certified clinical audit activity. All audit applications seeking approval from NES are managed through the NES Dental Portal, so the first step is to make sure that you remember to regularly check the email address linked to your Portal account. We recommend that you use your NHS Mail email address for Portal and that you do not use one of the commercial email providers, some of which divert email sent from the NHS into spam or junk folders. To receive email communications about your audit application, the Portal requires all participants to enable marketing emails in their account. This can be done via account settings in the top left toolbar; scroll down to marketing preferences and choose this option. Don t worry, NES will not disclose your email to third parties so you won t get loads of spam emails. You will only be sent information/reminders about up and coming CPD courses which are run by NES, about audit, and about others matters related to NES education and training. This guide is produced to step you through the process from application to completion of a project using the Portal. Portal is not compatible with Apple word processing software so please remember to only use compatible software, such as Microsoft Office for Mac. Documents should be converted to MS Word or Adobe PDF format. In the ibooklet area of NES Portal, scroll down to and double click to open the area called Dental Audit. This is where you will access everything related to audit activity. The menu structure is shown below and you will find a detailed description of how to use each of the areas listed within this guide. Scroll down and click to select the area you require. 2
Please note: Retrospective approval will not be granted for any audit. Once you have submitted an audit application to NES, you must wait until it is approved before you start work on it. You must submit your final report and supporting documents by the deadline date given at the approval stage. This will be 6 months from the date of approval or from the start date, if later*. NES has no authority to grant extensions and any requests will be refused. *Recent changes in regulations do allow for consideration to be given to an audit completion deadline in excess of 6 months, where this is appropriate and agreed at the outset. All of the participants must be added to your audit project, prior to submitting it on Portal. Later requests to add participants will not be possible. Do not start your audit project until you receive an email advising you that it has been approved or that you have successfully joined one of the projects available in the Join an Audit section. It is possible that you will be asked to make amendments before approval is possible. Poor quality applications will be rejected. If, after Round 1 of any audit, the data collected shows that your practice is already meeting the prescribed standards set for the project you should stop and submit your final report for review at this stage. If satisfactory, the project will be certified for reduced hours. Your report should include reasons why you chose this audit topic, dates and timescales of the audit, your methodology, completed data collection sheets, analysis of your data, a discussion of the reasons how your practice has managed to achieve these results and any suggestions on future improvements. 3
2. New Application: Getting Started This area should be used for submitting your own audit for approval. Selecting a Topic: When selecting a topic, ask yourself the following five questions. If you answer YES to ANY of the five questions, the topic you have chosen should not be selected for audit: 1. I have been a participant in a successful audit of this topic in the last three years (excluding radiology). 2. I have chosen this topic to demonstrate how good this area of my practice is. 3. I have chosen this topic to provide evidence of our current good standards of patient care at the practice. 4. There are no known issues or problems in my practice surrounding this audit topic. 5. I am unlikely to make changes to my practice as a result of findings from this audit. If you answered YES to the any of the above questions, please choose another topic and consider the following two questions. If you answer YES to either of these questions, then the topic is suitable for audit in your practice. 1. A patient complaint or comment was the reason for choosing this audit topic. 2. I have noticed an area of my practice which is performing poorly and this was the reason for choosing the audit topic (for example there has been a Significant Event). Approval must be sought prior to starting an audit. This part is the GP216 form, accessed via New Application. 4
Process Go to Portal, ibooklet, Dental Audit, New Application. You will need to populate all 4 fields to continue. If you wish to abort, simply click the X button at the top right of the window to cancel. Application Title: Pick a suitable title for your audit project. Health Board: Select your Health Board. If you work in more than one, choose where you work most. Application Type: Select Audit. This will determine which form (GP216A for Audit) you see to complete in the next step, so it is important you choose correctly at this stage. The application type you select and save here cannot be changed later. Other clinical audit activities (CAA) can be accessed from this menu. Please see separate guidance for these types of activity. Project Hours: Please see guidance on NES website for how many hours you are likely to be awarded. Hours may be reduced by the review process. http://www.nes.scot.nhs.uk/education-and-training/bydiscipline/dentistry/areas-of-education/professional-development/clinical-audit-activity/audit-steps.aspx Select Continue Application: This will create a record with a status of Draft and will take you to the application form. You now need to complete the application. 5
3. New Application: The Audit Application Form (GP216A) When you click the Continue Application button on the Getting Started page, the record is created in the database and you are ready to provide more detail. The Application Form is based on the old, paper-based Scottish Government GP216A. Tab One: Project Details The content of the form is based on what was required in the old GP216A and all fields are mandatory with the exception of the Additional Information field. The following list will help guide you through the form. Application Title: This will be pre-populated with what you entered on the previous page. Health Board: This will be pre-populated with what you entered on the previous page. Project Hours: This will be pre-populated with what you entered on the previous page. Proposed Start Date: This date must be either the date you submit the application or a date in the future. NES cannot approve clinical audit applications retrospectively. Description: Clearly define what your audit is. Audit should be used as a means of improving something in your practice. Aim of Audit: What do you hope to achieve as a result of the audit or what question do you want the audit to answer? Criteria to be Measured: Criteria are factors which can be measured. For example, the radiographic distance from the end of the root filling to the apex is no more than 1.0mm. Describe the Standards Used: Standards are the threshold of the expected compliance for each criterion or the number of times the criteria are achieved (usually expressed as a percentage). For example, an appropriate standard for the above criterion might be 85% of root fillings should end within 1.0mm of the apex. Describe the Methods Used: How is the audit going to be carried out and by whom? Decide what data you wish to collect and if this will be retrospective or prospective. When will you call a meeting? How long will you leave in between rounds? 6
Collection Sheets & Questionnaires: You will need upload the data collection sheets you intend to use. Sample Size of Each Round of Data (Per Participant): Enter the size of the data collection to be carried out in each round by each participant. Will you collect 2 rounds of data, to assess the effect of change introduced? The normal process is to plan to collect two rounds. Projects with a single round of data collection are not likely to be approved. Additional Information: Add anything you feel that has not been covered above and which will help the reviewer when assessing the project for approval. If you are going to select As a VDP audit or Within a VT practice, you must enter the name of your VT Adviser here. This project is being undertaken by choose one of the four options. Is this project being carried out choose one of the four options. This project involves DCPs choose yes or no. As Lead Participant Please Describe Your Involvement please ensure you tick all the relevant boxes in this section. Once you have completed all the boxes and uploaded your data collection sheets in section 10, press the save button on the top right-hand side of the page and then go to tab 2 (see below). Tab Two: Project Participants As the project Lead, you are responsible for adding any other Dentists who are going to be participating in this project. Participants cannot be added after the application for approval has been submitted: Select +Dentist. Search by GDC number or name. Select the correct user and click +Select user. Portal will assign 0 hours to participants. You need to adjust the participants hours by double clicking on the 0 and changing it to the correct hours (Please see guidance on NES website on how many hours participants are likely to be awarded). Repeat process for any additional participants. Once you have added all participants and altered the hours for everyone, press the save button on the top right hand side of the page. 7
Please note that NES reviewers will review all applications and that the hours you have requested may not necessarily be the same as the hours that you are awarded. This will be communicated to you in the approval email. Tab Three: Final Reports This tab is reserved for uploading project evidence at the end of the process and, until your audit is approved, is disabled. 8
4. Submitting your Application for Approval When you are happy with the contents of the application and have checked that you have added all participant s details, project hours and uploaded the data collection sheets, please press the Submit button on the top right hand side of the page (next to save). Once the application is submitted, you will be unable to make any further changes. Everyone listed as a participant in the audit will be sent an automated email by return advising that the application for approval has been successfully submitted. If you don t receive this automated email, then your audit has not been submitted properly. The Portal system will alert the audit hub that an application has been submitted and the project will be assigned to a reviewer. They will decide whether to approve the audit or to request amendments before it can be accepted, or can decide that it is not suitable for approval. You will receive an email notification of the outcome of the review process. When a project is approved the email confirming this will include a Final Report Deadline date. You will also receive two reminder emails nearer the deadline date. Requests for extensions are not possible and if you do not submit your final report and supporting evidence, including data collection forms by the deadline, the project will be automatically marked as incomplete and you will be unable to submit the audit or be allowed any audit hours for it. 9
Your Audits This area will show you all clinical audit activity you are listed as being involved with. The panel is split into several parts, with Audit first. Click the project title to enter into each project and to see more details. Notes 1. If a project is listed as Draft then it means it has not been submitted to NES for review yet. The lead applicant may decide to complete and submit the project or can delete it if they so wish using the delete button on the form. 2. Once a project is submitted you cannot delete it however the Audit Administrator can do this so please use the Contact Audit Admin button provided on each record to get in touch with them directly. The Audit Administrator is your first port of call for any query. Do not contact NES Portal support line with any questions about audit. 3. Please be aware that the hours listed will differ between participants. The hours are indicative only and subject to change by the review process. When hours are verified you will see a green tick next to them. These hours are now awarded and will appear on your vcpd report. 4. The GP216 Annex 2 form that must accompany the GP217 for payment is only generated on successful completion of a project. It can be generated directly from the Your Audits panel. Access to the GP216 Annex 2 will only be available for up to 6 months from the date of completion. As per the SDR, there is a 6 month time limit for claiming Clinical Audit Allowance. 10
5. Join an Audit: National, Health Board and Template Audits From time to time, NES will publish audit projects which you can choose to join, if they are relevant to your clinical practise. Please note that until you have successfully joined an audit, you do not have approval to carry out the project and that you must not start in advance of receiving the confirmation of approval email. We strongly encourage all members of a practice to collaborate on audit projects and if anyone is else in your practice is intending to carry out the audit, please select a Lead participant who will join the audit and add colleagues as participants. You should not join these audits separately, unless the particular project was designed to be carried out individually. To join a Health Board, National or Template audit: Go to ibooklet and select Join an Audit. Select National Audits. You will then see a list of the audits available for you to join. View the details of those listed and, if you think it is a suitable audit for you to undertake, click the +Join button. Select your Health Board. Click Join Project. A copy of the Master audit is taken and your application form will open pre-populated. The start date will default to today s date and, whilst you can put a date in the future, you cannot put in a retrospective date as, until you finish the joining process, you do not have approval to start the audit. Sections 14, 15 and 16 are in red boxes. You must select as relevant in each box and then press the Save button at the top right hand side of the page. Go to the participants tab (tab 2), Add all the participants here and adjust the hours. As this is a national audit, the hours that can be claimed are detailed in Section 5 (Description) on the GP216a tab. These differ from audit to audit so please check. Once you have added all the participants, press the Save button at the top right hand side of the page again. Press the Submit button which is next to the Save button. You will then receive an automated email advising you that you have successfully joined the project. This email will include the deadline date for submission of your final report and supporting evidence, including your data collection forms. If you do not receive this email, then you have not completed the joining process. 11
Join an Audit: Infection Control Audits You should only attempt to join these Audits if you have already booked a NES Infection Control in-practice training session. You must have returned the list of participants to the IC Administrator, Natalya Zhernakova, before this application can be made. She will email the data collection documents and report template for the IC audit to you. As a result, when you click the +Join button on any Infection Control Audit Project, the system will first check that you have an in-practice training event scheduled. If it does not see this evidence, it will not allow you to proceed. Assuming it does, the system will take a copy of the audit and the application form is opened and prepopulated. You can only change minimal information on Tab One itself but you should add participants in Tab Two if you need to. You are signing up to comply with the details of the Audit. As Lead Applicant for your project group you are responsible for submitting all documentation to attain the audit activity certification on behalf of that group. Submit your application in the same way you would submit an Application for Audit Approval. The first round of data collection should be completed before the in-practice training session. These documents will be reviewed by the trainers at the training session. After the training day, you will undertake Round Two data collection and complete and submit it alongside your Final Report by the deadline date set. See Final Reports section later in this document for further guidance. If you require any help, you should either press the Contact Audit Admin box which is under the title of the audit in the Your Audits section. If you have not yet finished the joining process, you are still the administrator so if you require help at this stage, please email dental.audit@nes.scot.nhs.uk 12
6. Submitting your Final Report and Supporting Evidence 1. When an Audit Application is approved you will be given clear guidance as to when the deadline date for final report submission is due in the email confirming approval. a. The deadline date is 6 months after the approval date. b. Towards the end of that period, the lead applicant will receive two reminder emails of the deadline date. c. Once the deadline date has passed, if you have not submitted the fully completed audit and supporting evidence, including data collection forms, then the status of the project will automatically change to incomplete and you will not be able to submit your audit or claim any hours for the work. NES cannot override this. 2. Infection Control Audits require you to upload Round One data collection evidence before the in-practice training day. 3. What should I submit? a. NES requires a full detailed final report to be submitted. If this is one of the HB/National/Template audits, there may be a template available for you to use. If there is, it will be available in Section 10 of the GP216A. For all other audits, you will find some helpful information available on the NES website. Prior to writing your report, follow the following link for details of what NES expects to be included: http://www.nes.scot.nhs.uk/education-and-training/by-discipline/dentistry/areas-ofeducation/professional-development/clinical-audit-activity/audit-steps.aspx Please make sure, if you use a MAC, to convert the report into a Word or PDF document. b. NES requires data collection sheets for all participants in the audit to be uploaded along with the report. 4. Uploading your final report and supporting evidence, including all data collection forms: To add your final report and other documents you should go to the Your Audits panel and click on the title of the audit to open it. Go to the Final Reports tab (3 rd tab). Select Upload Document (top left of the page). In the box that opens press the Browse button. Search your PC and find your final report. 13
Tick I agree to the above Conditions Press Upload. Repeat the process above for each document you wish to submit. Once all documents are uploaded press the Save button (top right of page). Press the Submit Reports button (next to the Save button): a. This alerts NES to the fact you are ready for the project to be reviewed. b. All participants will receive an email confirming the report and documents have been received and will be reviewed. c. No more reminder emails will be sent. 5. Please note that NES is not able to accept handwritten reports or data collection forms that have been completed by hand and/or scanned/photographed. All reports must be word processed and all data collection forms must be submitted as electronic documents. However, there is nothing to stop you from gathering the data in this way prior to typing it up into an electronic document prior to submission. Projects will be returned for amendment when handwritten and/or scanned/photographed documents are submitted. 6. Do not miss the deadline date. 14
7. What happens next? a) The Review Process When you submit your final report, the audit hub will receive an automated email advising them of the submission. They will check that all the relevant documentation has been submitted and is in the correct format, and if necessary, contact you directly. The audit hub will then assign your audit to a NES Reviewer who will look at your submission and decide whether your submission can be certified as complete or whether amendments are required before it can be certified. b) Amendments Requested: If the NES reviewer feels that with some amendments your audit can be certified as complete, you will be sent an email which will include the Reviewers comments. You will have one week from receipt of the email to submit your amendments as requested. If your amended report is not submitted within 1 week, your project may be marked as incomplete and you will not be awarded any hours. You can reduce the chance of amendments being requested by reading the guidance available on the website before submission. c) Completion: If the NES Reviewer certifies your audit as complete, you will be sent an email advising you that you have successfully completed the audit. The email will include details on how to claim Clinical Audit Allowance if you are eligible for this. You will be directed to go to Portal, ibooklet, Dental Audit, Your Audits to find the GP216A Annex 2 for you to download. This form will only be available to download for up to 6 months from the date of completion. As per the current SDR, you must submit your claim for Clinical Audit Allowance within 6 months of the date of completion of the project. d) Final Report rejected or hours reduced: If your final report has been rejected or the hours awarded are less than you expected, the project will have been reviewed by at least 2 NES Reviewers. The email you receive advising you of the rejection will contain the Reviewers comments giving their reasons for rejection or the reduction in hours. e) Appeal Process: You will be given the opportunity to appeal the decision by replying to the rejection email, detailing your reasons for appealing, however, you will not be able to submit an amended report at this stage. Your reasons, along with the originally submitted report, will then be presented to an external audit appeal panel whose decision is final and binding on both sides. They may agree or disagree with the NES decision and certify some or all of the hours requested, or, in some cases, reduce the hours already awarded. 15
8. Dental Audit: some FAQs 1. I am a Practice Manager - Can I complete the Application Form on behalf of my Principal? No: The Dental Audit area on ibooklet is only open to Dentists. Dentists must complete the application form themselves and logging in under another s credentials breaks our Terms & Conditions. 2. I cannot seem to find a dentist on the system to add to the Project on Tab Two what s wrong? They may not have a Portal account. They must have one to be able to be found. The best way to search is by GDC Number as this is a unique identifier. 3. How do I know I ve submitted the Application ok? Everyone listed on the project will get an email confirmation. The project will also be listed on Your Audits with the status of Application Submitted. 4. What happens after I submit an Application for Audit Approval? The application will be screened and reviewed. The outcome will be to advise that the audit status is either (1) Approved (2) Rejected (3) Further Info required or (4) Ask for a Second Opinion. You will be alerted to any outcome at the appropriate time, and feedback will be given. 5. I do not see much progress who can I call? The best way to contact us is to use the Contact Audit Admin button located in the Your Audits panel underneath each audit. If you have not yet had approval, then you are still the administrator so email dental.audit@nes.scot.nhs.uk Give as much information as possible including your name (as registered on Portal), GDC number and, where possible, the audit project number. 6. My hours are not the same as I remember adding them on the application why is that? The review process has the ability to adjust the hours awarded. What you apply for and what you get might be different. 7. I am not seeing the hours on my vcpd report but they do appear on the Your Audit panel why is that? The project needs to be Completed and processed by the Audit Administrator before that will happen. The hours awarded on the Your Audits panel will show a green tick when this is done. Contact the Audit Administrator if you wish to discuss this. 8. I am ready to upload the Project Report where do I do this? Go to the Submitting Your Final Report and Supporting Evidence section of this guidance document. 16
9. How do I upload Round 1 data? Do not upload Round 1 data. Save all the documents locally until the project is complete and you are ready to upload and submit the final report and supporting evidence. If you do upload and submit, the system assumes this is the final report and the final reports tab will be locked down to you. Only upload documents at the end of the project with the final report. If you do upload too early and have not uploaded all the required document, contact the Audit Administrator who can unlock the tab. 10. I am the Lead Applicant I have asked one of the other project team to upload the final report but they say they cannot do this why is that? The Lead Participant is the only person authorized to upload the report. 11. I have missed the deadline date for submitting my final report. What are the consequences? This should not happen as you will have been sent a number of reminder emails. It is expected the report and all supporting evidence will be submitted on time. If this fails to happen, the Audit is deemed incomplete and you will need to start the process all over again. 12. How do I add participants after submitting the audit? You can only ask an administrator to add a participant if the audit has not yet been approved. Once an audit has been approved you cannot ask for any participants to be added. 13. Can I use another Dentists records for data collection? No, the data used in Audit must be from the Dentists own records. 14. Can I extend the deadline date on my audit? No, the audit regulations require the project to be completed by the deadline set at the outset, which is almost always within 6 months. NES has no authority to extend the deadline date for an audit project. Useful contacts: Dental Audit Hub dental.audit@nes.scot.nhs.uk NES Website (Audit page) - http://www.nes.scot.nhs.uk/education-and-training/by-discipline/dentistry/areas-ofeducation/professional-development/clinical-audit-activity/audit-steps.aspx 17