Good medical practice (3rd ed, 2001, paragraph 12): Maintaining your performance
12. You must work with colleagues to monitor and maintain the quality
of the care you provide and maintain a high awareness of patient safety.
In particular, you must:
- take part in regular and systematic medical and clinical audit, recording
data honestly. Where necessary you must respond to the results of audit
to improve your practice, for example by undertaking further training;
- respond constructively to the outcome of reviews, assessments or appraisals
of your performance;
- take part in confidential enquiries and adverse event recognition
and reporting to help reduce risk to patients;
Confidentiality: Protecting and Providing Information (April 2004, paragraphs 13-15): Disclosing information for clinical audit
13. Clinical audit is essential to the provision of good care. All
doctors in clinical practice have a duty to participate in clinical audit1.
Where an audit is to be undertaken by the team which provided care, or
those working to support them, such as clinical audit staff, you may
disclose identifiable information, provided you are satisfied that
patients:
- have been informed that their data may be disclosed for clinical
audit, and their right to object to the disclosure; and
- have not objected.
14. If a patient does object you should explain why information is
needed and how this may benefit their care. If it is not possible to
provide safe care without disclosing information for audit, you should
explain this to the patient and the options open to them.
15. Where clinical audit is to be undertaken by another organisation,
information should be anonymised wherever that is practicable. In any case
where it is not practicable to anonymise data, or anonymised data will not
fulfil the requirements of the audit, express consent must be obtained
before identifiable data is disclosed.
Glossary
- Anonymised data
Data
from which the patient cannot be identified by the recipient of the
information. The name, address, and full post code must be removed
together with any other information which, in conjunction with other
data held by or disclosed to the recipient, could identify the patient.
Unique numbers may be included only if recipients of the data do not
have access to the ‘key’ to trace the identity of the patient.
- Clinical Audit
Evaluation
of clinical performance against standards or through comparative
analysis, to inform the management of services. Studies that aim to derive, scientifically confirm and publish
generalisable knowledge constitute research and are not encompassed within the definition of
clinical audit in this document.