Clinical Audit Presentation

Clinical Audit

SSU March 2008Contact Session 1

Introduction What is clinical audit?

Audit versus research

The audit cycle

Five stages of clinical audit

Summary

What is clinical 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

Reactions to audit? Enthusiasm Cynicism Obligation Doubt Exhaustion

What is clinical audit? Clinical audit

is at the heart of

clinical governance and clinical effectiveness

Audit:- are we doing the best thing in the best way?

Measures current practice against specific standards

Never experimental

Uses data in existence by virtue of practice

May require ethical approval

Aims to improve delivery of patient care

Research:- What is the best thing to do/the best way to do it?

Provides sound basis for clinical audit

Involves experimental trials

Uses detailed and often sophisticated data collection

Needs ethical approval and registration Aims to add to body of scientific

knowledge

The audit cycleProblem or objective identified


Criteria agreed and standards set



Audit (Data collected)




Identify areas for improvement





Make necessary changes






Re-audit






Re-audit

The audit cycle


Stage 1:Preparing for audit

Selecting a topic Defining the purpose Planning

Suitable topic

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

Selecting a topic There seems little point in trying to

audit a rare condition, with a cheap intervention with a fairly superficial outcome.

Which topic?

Selecting a topic High cost/volume/risk Area of local clinical concern

Mis-diagnosing MIPre elective screen right tests right patient

Potential for improvement National priority Organisational priority Evidence based

Defining the purposeThe following series of verbs may be useful in defining the aims of an audit (Buttery, 1998):

to improve to enhance to increase to change to ensure

Planning Involve ALL the right people Time and resources Access the evidence Methodology Pilot Report and Action Re-audit

Stage 2:Selecting criteria

Defining criteria Sources of evidence Appraising the evidence

Defining criteria

Criteria: are explicit statements that define

what is being measured

represent elements of care that can be measured objectively.

Sources of evidence NeLH /Cochrane/WISH NICE Official Websites NSFs Local or regional guidelines/policy Royal College or Professional Body Recognised journals

Appraising the evidence

Aim /objectives

Methodology

Results /conclusions

Applicable to your patient group

Bias/ causes for concern

Stage 3: Measuring level of performance

Planning data collection Methods of data collection Handling data

Planning data collectionNeed to establish the user group to be included, with

any exceptions noted the healthcare professionals involved

in the users’ care the time period over which the criteria

apply.

Methods of data collection Computer stored data Case notes/Medical Records Surveys Questionnaires Interviews Focus Groups Prospective recording of specific data

Handling data

Health service professionals must be aware of the ethical implications of and their responsibilities under the Data Protection Act (1998) when collecting data and presenting results.

Stage 4: Making improvements

Identifying barriers to change Implementing change External relationships

Identifying barriers to change Fear of change Lack of understanding Low morale Poor communication Culture Pushing too hard Consensus not gained

Implementing Change Discuss the results with those likely to be

affected Agree an Action Plan Clearly define – who is doing what Check progress Produce report and disseminate Share findings and changes in practice

Stage 5: Sustaining improvement

Monitoring and evaluation Re-audit Maintaining and reinforcing improvement

Monitoring and evaluationAlthough improving performance is the primary goal of audit, sustaining that improvement is also essential. Indeed, any systematic approach to changing professional practice should include plans to:

monitor and evaluate the change maintain and reinforce the change (

NHS Centre for Review and Dissemination, 1999).

Re-audit Close the loop Review evidence Measure effectiveness Decide how often to re-audit

The great coffee audit

A case study


Problem The doctors feel that their coffee isn’t hot enough after slogging through morning surgery


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


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


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


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.


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


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.


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

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

‘Clinical Governance’


Research


Research

Audit


Research

Audit Evidence based

medicine


Research


medicineDissemination of

guidelines


Research Practice development plans



guidelines


Research Practice development plans



guidelines

Personal development

plans


Research Practice development plans Postgraduate

medical education



guidelines


plans



medical education



guidelines


plans

Practice accreditation



medical education



guidelines


plans

Practice accreditation

Special interest groups


Accountability

Summary Audit

Defined clinical audit

Compared audit and research

The audit cycle.


Celebrate

Next contact session progress report from you

Final contact session Share learning Publicise results Give credit where credit is due! Work on the assignment and poster

Health & Medicine

Clinical Audit Presentation