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Gloucestershire PCCAG
Clinical Audit and the Audit Cycle
Gloucestershire PCCAG
What we are going to cover today
• The audit cycle
Gloucestershire PCCAG
What we are going to cover today
• The audit cycle
• Criteria and standards
Gloucestershire PCCAG
What we are going to cover today
• The audit cycle
• Criteria and standards
• Structure, process and outcome
Gloucestershire PCCAG
What we are going to cover today
• The audit cycle
• Criteria and standards
• Structure, process and outcome
• An audit example
Gloucestershire PCCAG
What we are going to cover today
• The audit cycle
• Criteria and standards
• Structure, process and outcome
• An audit example
• Problems with audit
Gloucestershire PCCAG
What we are going to cover today
• The audit cycle
• Criteria and standards
• Structure, process and outcome
• An audit example
• Problems with audit
• How audit fits into ‘Clinical Governance’
Gloucestershire PCCAG
A definition of audit
“The systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient”
Working for Patients 1989
Gloucestershire PCCAG
Reactions to audit
• Enthusiasm
• Cynicism
• Obligation
• Doubt
• Exhaustion
Gloucestershire PCCAG
Types of audit
• Managerial
Gloucestershire PCCAG
Types of audit
• Managerial
• Financial
Gloucestershire PCCAG
Types of audit
• Managerial
• Financial
• Clinical
Gloucestershire PCCAG
Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
Gloucestershire PCCAG
Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
Cross boundary
Gloucestershire PCCAG
Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
Cross boundary
Cohort based
Gloucestershire PCCAG
Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
Cross boundary
Cohort based
Comparative
Gloucestershire PCCAG
Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
Cross boundary
Cohort based
Comparative
Significant event based
Gloucestershire PCCAG
Effective audit
• An educational activity
Gloucestershire PCCAG
Effective audit
• An educational activity
• Promotes understanding
Gloucestershire PCCAG
Effective audit
• An educational activity
• Promotes understanding
• Resource effective
Gloucestershire PCCAG
Effective audit
• An educational activity
• Promotes understanding
• Resource effective
• Raises standards
Gloucestershire PCCAG
Effective audit
• An educational activity
• Promotes understanding
• Resource effective
• Raises standards
• Promotes change
Gloucestershire PCCAG
Effective audit
• An educational activity
• Promotes understanding
• Resource effective
• Raises standards
• Promotes change
• Source of information
Gloucestershire PCCAG
Effective audit
• An educational activity
• Promotes understanding
• Resource effective
• Raises standards
• Promotes change
• Source of information
• Peer led
Gloucestershire PCCAG
Effective audit• An educational activity• Promotes understanding• Resource effective• Raises standards• Promotes change• Source of information• Peer led• Involves patients
Gloucestershire PCCAG
The audit cycleProblem or objective identified
Gloucestershire PCCAG
The audit cycleProblem or objective identified
Criteria agreed and standards set
Gloucestershire PCCAG
The audit cycleProblem or objective identified
Criteria agreed and standards set
Audit (Data collected)
Gloucestershire PCCAG
The audit cycleProblem or objective identified
Criteria agreed and standards set
Audit (Data collected)
Identify areas for improvement
Gloucestershire PCCAG
The audit cycleProblem or objective identified
Criteria agreed and standards set
Audit (Data collected)
Identify areas for improvement
Make necessary changes
Gloucestershire PCCAG
The audit cycleProblem or objective identified
Criteria agreed and standards set
Audit (Data collected)
Identify areas for improvement
Make necessary changes
Re-audit
Gloucestershire PCCAG
The audit cycleProblem or objective identified
Criteria agreed and standards set
Audit (Data collected)
Identify areas for improvement
Make necessary changes
Re-audit
Gloucestershire PCCAG
Another way of expressing the audit cycle
Gloucestershire PCCAG
Another way of expressing the audit cycle
• Determine which aspects of current work are to be considered
Gloucestershire PCCAG
Another way of expressing the audit cycle
• Determine which aspects of current work are to be considered
• Describe and measure present performance
Gloucestershire PCCAG
Another way of expressing the audit cycle
• Determine which aspects of current work are to be considered
• Describe and measure present performance• Develop explicit standards
Gloucestershire PCCAG
Another way of expressing the audit cycle
• Determine which aspects of current work are to be considered
• Describe and measure present performance• Develop explicit standards• Decide what needs to be changed
Gloucestershire PCCAG
Another way of expressing the audit cycle
• Determine which aspects of current work are to be considered
• Describe and measure present performance• Develop explicit standards• Decide what needs to be changed• Negotiate change
Gloucestershire PCCAG
Another way of expressing the audit cycle
• Determine which aspects of current work are to be considered
• Describe and measure present performance• Develop explicit standards• Decide what needs to be changed• Negotiate change• Mobilise resources for change
Gloucestershire PCCAG
Another way of expressing the audit cycle
• Determine which aspects of current work are to be considered
• Describe and measure present performance• Develop explicit standards• Decide what needs to be changed• Negotiate change• Mobilise resources for change• Review and renew the process
Gloucestershire PCCAG
Criteria and standards
Gloucestershire PCCAG
Criteria and standards
• Criteria are those aspects of care that you wish to examine
Gloucestershire PCCAG
Criteria and standards
• Criteria are those aspects of care that you wish to examine
• Standards are the pre-stated or implicit levels of success that you wish to achieve
Gloucestershire PCCAG
Structure, process and outcome
Gloucestershire PCCAG
Structure, process and outcome
• Structure refers to resources you have available (including current knowledge, skills and attitudes)
Gloucestershire PCCAG
Structure, process and outcome
• Structure refers to resources you have available (including current knowledge, skills and attitudes)
• Process refers to what you actually do, e.g. a protocol
Gloucestershire PCCAG
Structure, process and outcome
• Structure refers to resources you have available (including current knowledge, skills and attitudes)
• Process refers to what you actually do, e.g. a protocol
• Outcome refers to the health benefits, cost effectiveness or patient satisfaction
Gloucestershire PCCAG
The great coffee audit
Gloucestershire PCCAG
The great coffee audit
Problem The doctors feel that their coffee isn’t hot enough after slogging through morning surgery
Gloucestershire PCCAG
The great coffee audit
Problem
Criteria
The doctors feel that their coffee isn’t hot enough after slogging through morning surgery
The coffee shall be hot and satisfying to the hard pressed docs
Gloucestershire PCCAG
The great coffee audit
Problem
Criteria
Standards
The doctors feel that their coffee isn’t hot enough after slogging through morning surgery
The coffee shall be hot and satisfying to the hard pressed docs
The coffee shall be served at a temperature of 85-90C on 80% of occasions and there will be 90% satisfaction level expressed by the docs
Gloucestershire PCCAG
The great coffee audit
Methods The junior receptionist shall check the temperature of the coffee daily for two weeks and circulate a questionnaire to the partners asking them to score a coffee satisfaction level between 1 and 10. The practice manager shall visit Tesco’s and interview the manager about the availability, costs, quality and sell-by dates of the coffee brands available
Gloucestershire PCCAG
The great coffee audit
Review After a rather tense audit team meeting it was found that the coffee temperature fell below 37C on at least 33% of occasions and reached the standard on only 10% of occasions. The doctors scored the coffee at an average 3/10 and two expressed it undrinkable. The practice manager reported the results of her Tesco’s visit.
Gloucestershire PCCAG
The great coffee audit
Change It was agreed to replace the aged coffee maker ( after agreeing suitable redundancy terms for the senior receptionist) with a shiny new machine from Argos. As an additional ‘quality initiative’, cream cakes would be served after surgery. The coffee contract would be switched from the corner shop to Tesco PLC Trust
Gloucestershire PCCAG
The great coffee audit
Re-audit For a further two weeks it was agreed to measure the coffee temperature and re-circulate the questionnaire. It was gratifying to find 100% correlation with agreed standards with the exception of one partner who didn’t like coffee anyway.
Gloucestershire PCCAG
The great coffee audit
Re-audit
Future audit
For a further two weeks it was agreed to measure the coffee temperature and re-circulate the questionnaire. It was gratifying to find 100% correlation with agreed standards with the exception of one partner who didn’t like coffee anyway.
• Cost implications of standard maintenance• Cholesterol assays for partners
Gloucestershire PCCAG
Contents of an audit
Gloucestershire PCCAG
Contents of an audit
• Background
Gloucestershire PCCAG
Contents of an audit
• Background
• Literature review
Gloucestershire PCCAG
Contents of an audit
• Background
• Literature review
• Criteria and standards
Gloucestershire PCCAG
Contents of an audit
• Background
• Literature review
• Criteria and standards
• Methods or protocol
Gloucestershire PCCAG
Contents of an audit
• Background
• Literature review
• Criteria and standards
• Methods or protocol
• Results
Gloucestershire PCCAG
Contents of an audit
• Background
• Literature review
• Criteria and standards
• Methods or protocol
• Results
• Recommendations for change
Gloucestershire PCCAG
Contents of an audit
• Background
• Literature review
• Criteria and standards
• Methods or protocol
• Results
• Recommendations for change
• Recommendations for further audit
Gloucestershire PCCAG
Why audit
Gloucestershire PCCAG
Why audit
• Useful clinically
Gloucestershire PCCAG
Why audit
• Useful clinically
• Encourages teamwork
Gloucestershire PCCAG
Why audit
• Useful clinically
• Encourages teamwork
• Improves patient care
Gloucestershire PCCAG
Why audit
• Useful clinically
• Encourages teamwork
• Improves patient care
• Financial benefits (sometimes!)
Gloucestershire PCCAG
Why audit
• Useful clinically
• Encourages teamwork
• Improves patient care
• Financial benefits (sometimes!)
• Becoming contracturally an obligation with the arrival of PCG’s
Gloucestershire PCCAG
Problems with audit
Gloucestershire PCCAG
Problems with audit
• Audit and research
Gloucestershire PCCAG
Problems with audit
• Audit and research
• Statistical verification
Gloucestershire PCCAG
Problems with audit
• Audit and research
• Statistical verification
• Outcome measures and proxies
Gloucestershire PCCAG
Problems with audit
• Audit and research
• Statistical verification
• Outcome measures and proxies
• Protocols
Gloucestershire PCCAG
Problems with audit
• Audit and research
• Statistical verification
• Outcome measures and proxies
• Protocols
• Closing the loop - introducing change and re-audit
Gloucestershire PCCAG
A word about clinical governance
Gloucestershire PCCAG
A word about clinical governance
“A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards by creating an environment in which excellence in clinical care will flourish”
A First Class Service 1998
Gloucestershire PCCAG
‘Clinical Governance’
Gloucestershire PCCAG
‘Clinical Governance’
Gloucestershire PCCAG
‘Clinical Governance’
Research
Gloucestershire PCCAG
‘Clinical Governance’
Research
Audit
Gloucestershire PCCAG
‘Clinical Governance’
Research
Audit Evidence based
medicine
Gloucestershire PCCAG
‘Clinical Governance’
Research
Audit Evidence based
medicineDissemination of
guidelines
Gloucestershire PCCAG
‘Clinical Governance’
Research Practice development plans
Audit Evidence based
medicineDissemination of
guidelines
Gloucestershire PCCAG
‘Clinical Governance’
Research Practice development plans
Audit Evidence based
medicineDissemination of
guidelines
Personal development
plans
Gloucestershire PCCAG
‘Clinical Governance’
Research Practice development plans Postgraduate
medical education
Audit Evidence based
medicineDissemination of
guidelines
Personal development
plans
Gloucestershire PCCAG
‘Clinical Governance’
Research Practice development plans Postgraduate
medical education
Audit Evidence based
medicineDissemination of
guidelines
Personal development
plans
Practice accreditation
Gloucestershire PCCAG
‘Clinical Governance’
Research Practice development plans Postgraduate
medical education
Audit Evidence based
medicineDissemination of
guidelines
Personal development
plans
Practice accreditation
Special interest groups
Gloucestershire PCCAG
‘Clinical Governance’
Accountability