AUDIT CLINICO - · PDF fileAUDIT CLINICO 1. Definizione 2. Struttura 3. Pianificazione e conduzione 4. Report 5. Barriere e fattori facilitanti Audit Clinico “Audit is the

AUDIT CLINICO

1. Definizione

2. Struttura

3. Pianificazione e conduzione

4. Report

5. Barriere e fattori facilitanti

Audit Clinico

“Audit is the systematic and critical analysis of the quality of medical care including the procedures

used for diagnosis, treatment and care, the associate use of resources and the resulting

outcome and quality of life for the patient”

Secretaries of State for Health, England, Wales Northern Ireland and Scotland,1989

“Audit is the process of reviewing the delivery of health care to identify

deficiencies so that they may be remedied”

Crombie IK, et al. 1993

“Clinical audit is the process by which the doctors, nurses and other health professionals regularly and

systematically review, and where necessarychange, their clinical practice”

Primary Health Care Clinical Audit Working Group, 1995

From “Medical” to “Clinical” Audit

Clinical Governance Tools & Skills

• Evidence-based Practice

• Information & Data Management

• Practice Guidelines • Care Pathways

• Health Technology Assessment

• Clinical Audit

• Clinical Risk Management

• CME, professional training and accreditation

• Staff management

Evid

en

ce-b

as

ed

Heal t

hC

are

• Consumer InvolvementModificata da:

Cartabellotta A, et alSanità & Management

Novembre 2002

• Research & Development

Audit di sistema*

Audit puntuale**

Audit clinico

Contenuti professionali

Revisionetra pari

Sistematicità

NO

SI’

NO

NO

SI’SI’

SI’SI’

SI’

* Accreditamento, certificazione

**Discussione di casi clinici, significative event audit (SEA)

1. Definizione

2. Struttura


4. Report


Audit Clinico

• Clinical audit can be described as a cyclical or spiral systematic process, with the ultimate aim of improving care.

• The spiral suggests that as the process continues, each cycle aspires to a higher level of quality.

2. Struttura dell’audit clinico

Benjamin A. BMJ 2008


1. Identifytopic

3. Measure practiceagainst standard

4. Identify areaswhich need to

be changed

5. Implement changein practice

6. Re-audit to ensurechange has been

effective2. Set standard

1. Definizione

2. Struttura


4. Report


Audit Clinico

1. Identify topic

2. Set standard

3. Measure practice against standard

4. Identify areas which need to be changed

5. Implement change in practice

6. Re-audit to ensure change has been effective


- High frequence- High risk- High variability- High cost- High anxiety

Department of Health, 1994

1. Identify topic

Presentazioni cliniche - Dispepsia Diagnostic pathways

- Dolore toracico anteriore

Test diagnostici - Gastroscopia Technology assessment

- Coronarografia

Malattie, sindromi - Ulcera peptica Care pathways

- Infarto del miocardio

Trattamenti - Linezolid Technology assessment

- NIV

Prevenzione primaria - Prev. infezioni post-chirurgia Preventive care

- Screening

1. Identify topic

Presentazioni cliniche - Dispepsia Diagnostic pathways

- Dolore toracico anteriore

Test diagnostici - Gastroscopia Technology assessment

- Coronarografia

Malattie, sindromi - Ulcera peptica Care pathways

- Infarto del miocardio

Trattamenti - Linezolid Technology assessment

- NIV

Prevenzione primaria - Prev. infezioni post-chirurgia Preventive care

- Screening

1. Identify topic

Livello Macro: Azienda

- Riferimento organizzativo: Collegio di Direzione

- Numero limitato di progetti di GC: 2-3 per anno,

spesso su committment regionale

Livello Meso: Dipartimento, Distretto

- Riferimento organizzativo: Comitato di Dipartimento,

Comitato di Distretto

- Coinvolgere tutti i dipartimenti in almeno un progetto

(mono o interdipartimentale), ma evitare che un singolo

dipartimento sia coinvolto in oltre 2-3 progetti/anno

1. Identify topic

CHI

• Collegio di Direzione/GC (priorità aziendali)

• Comitato di Dipartimento (priorità dipartimentali)

COME

• Processo di consenso formale (metodo Delphi modificato)

QUANDO

• Prima della definizione del budget

1. Identify topic

1. Identify topic

2. Set standard






• Gli standard (di processo e di esito) possono essere

derivati da:

- Evidenze scientifiche à Linee guida à Percorsi

assistenziali

- Normative

- Benchmarking

- Processo di consenso locale

2. Set standard

Criteri di definizioneAppropriatezza Professionale

Revisioni sistematicheTrials randomizzatiStudi osservazionali

2. Processi di consenso formale (RAND)

Evidence-basedGuidelines

Care Pathways

1. Evidenze scientifiche

3. Normative nazionali (note AIFA) o regionali

Criteri di definizioneAppropriatezza Organizzativa

2. Benchmarking

3. Evidenze scientifiche (health service research)

1. Normative nazionali (LEA) e regionali (requisiti accreditamento, direttive specifiche)

• Per massimizzare la probabilità

dell’implementazione, uno standard dovrebbe avere

le seguenti caratteristiche:

- Evidence-based

- Condiviso tra tutti i professionisti

- Adattato al contesto locale

2. Set standard

• Gli indicatori di processo, ed eventualmente di esito,

vengono definiti utilizzando un formato standard:

- Tipo indicatore

- Categoria indicatore

- Denominazione indicatore

- Numeratore/Denominatore

- Fonte dei dati

- Target

- Eccellenza (max)

- Accettabile (min)

2. Set standard

Fase 1 Definizione Priorità

Fase 2 Costituzione G.L.A.M.

Fase 3 F.A.I.A.U.

Fase 4 D.I.E

Framework GIMBE

1. Finding Ricerca delle LG

2. Appraising Valutazione critica delle LG (e scelta della LG di riferimento)

3. Integrating Integrazione della LG

4. Adapting Adattamento locale e costruzione dei PA

5. Updating Aggiornamento

FASE 3: F.A.I.A.U.

FASE 4: D.I.E.

1. Disseminating Disseminazione del PA

2. Implementing Implementazione del PA

3. Evaluating Valutazione dell’impatto del PA

1. Identify topic

2. Set standard






Dove cercare i dati?

• Documentazione sanitaria (cartelle cliniche, relazioni, etc)

• Archivi/database aziendali, regionali o nazionali

(eventualmente integrati)

• Database clinico ad hoc


Come organizzare il data entry?

1. CC tradizionale • Scheda cartacea • Scheda elettronica • DB

2. CC tradizionale • • Scheda elettronica • DB

3. CC elettronica • • • • • DB

CC= Cartella Clinica

DB= Database




Come selezionare un campione rappresentativo e casuale?

1. Definire l’unità temporale di riferimento e il denominatore

2. Calcolare il campione rappresentativo

3. Scegliere le cartelle cliniche

• Campione consecutivo (errore random?)

• Randomizzazione semplice

• Randomizzazione stratificata (stagionalità)


WARNING!

• Un audit dipartimentale (o di U.O.) richiede un

campionamento ad hoc


1. Identify topic

2. Set standard






• In questa fase vengono identificate, rispetto agli standard

definiti, le inappropriatezze, sia in difetto, sia in eccesso


La visione “strabica” dell’inappropriatezza

Inappropriatezza

in eccesso

Risparmio

Tagli

InappropriatezzaDallo “strabismo” alla visione bidimensionale

Appropriato

Inappropriato

Erogato Non erogato

OK

OK

NO

NO

€

Inappropriatezza

in eccesso

Risparmio

Tagli

InappropriatezzaDallo “strabismo” alla visione bidimensionale

Inappropriatezza

in difetto

Spesa

Incremento utilizzo

Inappropriatezza in difetto• 30-45% of patients are not receiving

care according to scientific evidence

Inappropriatezza in eccesso• 20-25% of the care provided is not

needed or could potentially cause harm

Stime dell’inappropriatezza

Schuster et al. Milbank Q, 1998Grol R. Med Care, 2001

Merlani P, Garnerin P, Diby M, Ferring M, Ricou B.

Linking guideline to regular feedback to increase appropriate

requests for clinical tests: blood gas analysis in intensive care.

BMJ 2001;323:620-4

Merlani P, et al. BMJ 2001

The problem• In our surgical intensive care unit, 46 000 arterialblood gas analyses were performed each year.

• A one week prospective study showed that over half of these tests could not be justified clinically.

• In addition, 96% of requests were left to the discretion of the nursing staff,while clinical signs such as respiratory rate or altered pattern of breathing were seldom taken into account in deciding whether the test was necessary.

• Values of percutaneous oxygen saturation from pulse oximetry were rarely used, even though they match arterial measurements.

Copyright © - GIMBE

Merlani P, et al. BMJ 2001

Wolff AM, Taylor SA, McCabe JF.

Using checklists and reminders in clinical pathways to improve hospital

inpatient care

Med J Aust 2004;181:428-31


Wolff AM et al. Med J Aust, 2002

Wolff AM et al. Med J Aust, 2002

1. Identify topic

2. Set standard






• In questa fase vengono attuate le strategie di

implementazione con l’obiettivo di modificare i

comportamenti professionali e migliorare l’appropriatezza


Cabana MD, Rand CS, Powe NR, et al.

Why don't physicians follow clinical practice guidelines?

A framework for improvement

JAMA 1999;282:1458-65

Perché i clinici non seguono le linee guida?

1. Internal Barriers

• Lack of Awareness • Lack of Familiarity

• Lack of Agreement • Lack of Self-efficacy • Lack of Outcome Expectancy • Inertia of Previous Practice

2. External Barriers

• Guideline-Related Barriers

• Patient-Related Barriers

• Environmental-Related BarriersCabana MD, et al. JAMA 1999

Conoscenze

Attitudini

Comportamenti

Interventions to promote behaviouralchange among health professionals

Consistently effective

Bero L, et al. BMJ 1998SIGN 50. April, 2002Grol, et al. Lancet 2003

• Educational outreach visits (drugs)• Reminders• Interactive educational workshops• Multifaced interventions

Variable effectiveness

Little or no effect

No conclusive evidence

• Audit and feedback • Local opinion leaders• Local consensus processes• Patient mediated interventions

• Educational materials• Traditional lectures

• Financial incentives• Policy, regulation


1. Identify topic

2. Set standard






• In questa fase viene ripetuto l’audit per verificare il

miglioramento dell’appropriatezza


1. Definizione

2. Struttura


4. Report


Audit Clinico

How to write…

an audit report

1. Definizione

2. Struttura


4. Report


Audit Clinico

G Johnston, IK Crombie, HTO Davies, et al.

Reviewing audit

Barriers and facilitating factors

for effective clinical audit

Qual Health Care 2000;9:23-36

To review the literature on the benefits and disadvantages

of clinical and medical audit, and to assess the main

facilitators and barriers to conducting the audit process.

Johnston J, et al. Quality Health Care 2000

Objective

A comprehensive literature review was undertaken

through a thorough review of Medline and CINAHL

databases using the keywords of “audit”, “audit of

audits”, and “evaluation of audits” and a handsearch

of the indexes of relevant journals for key papers.

Design


• 93 publications were reviewed

• These ranged from single case studies of individual audit

projects through retrospective reviews of departmental audit

programmes to studies of interface projects between primary

and secondary care.

• The studies reviewed incorporated the experiences of a

wide variety of clinicians

Results (1)


The literature review identified 4 main themes

1. Importance of clinicians’ perceptions of the benefits of audit

2. Importance of clinicians’ perceptions of the disadvantages

of audit

3. Barriers which block its success

4. Facilitating factors which promote its success

Results (2)


• Professional benefits

• Patient care and service delivery

1. Benefits of Audit


• Increased workload

• Restriction of clinical freedom

• Professional threat

2. Disadvantages of Audit


3. Barriers to successful audit

• Lack of resources

• Lack of expertise in project design and analysis

• Lack of an overall plan for audit

• Relationship problems

• Organizational impediments


4. Facilitating factors to successful audit

• Quantifying success

• Factors which promote success


1. Clinical audit should assess structure, process, or

outcomes of care

2. The audit should be part of a structured programme and

should have a local lead

3. Audit should ideally be multidisciplinary

4. Patients should ideally be part of the audit

5. Choose audit topics based on high risk, high volume, or

high cost problems or on national clinical guidelines

Summary of elements of effective clinical audit


6. Derive standards from good quality guidelines

7. Use action plans to overcome the local barriers to change,

and identify those responsible for service improvement

8. Repeat the audit to find out whether improvements in care

have been implemented as a result of clinical audit

9. Develop specific mechanisms and systems to monitor and

sustain service improvements once the audit cycle has

been completed

Summary of elements of effective clinical audit




Documents

AUDIT CLINICO - · PDF fileAUDIT CLINICO 1. Definizione 2. Struttura 3. Pianificazione e conduzione 4. Report 5. Barriere e fattori facilitanti Audit Clinico “Audit is the