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Clinical AuditClinical Audit
Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine
Presented by: Dr. Zekeriya Aktü[email protected]
www.aile.net
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Clinical Audit and the Audit Cycle
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What we are going to cover today
• The audit cycle
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What we are going to cover today
• The audit cycle
• Criteria and standards
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What we are going to cover today
• The audit cycle
• Criteria and standards
• Structure, process and outcome
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What we are going to cover today
• The audit cycle
• Criteria and standards
• Structure, process and outcome
• An audit example
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What we are going to cover today
• The audit cycle
• Criteria and standards
• Structure, process and outcome
• An audit example
• Problems with audit
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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’
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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
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Reactions to audit
• Enthusiasm
• Cynicism
• Obligation
• Doubt
• Exhaustion
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Types of audit
• Managerial
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Types of audit
• Managerial
• Financial
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Types of audit
• Managerial
• Financial
• Clinical
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Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
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Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
Cross boundary
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Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
Cross boundary
Cohort based
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Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
Cross boundary
Cohort based
Comparative
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Types of audit
• Managerial
• Financial
• Clinical Multi-disciplinary
Cross boundary
Cohort based
Comparative
Significant event based
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Effective audit
• An educational activity
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Effective audit
• An educational activity
• Promotes understanding
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Effective audit
• An educational activity
• Promotes understanding
• Resource effective
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Effective audit
• An educational activity
• Promotes understanding
• Resource effective
• Raises standards
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Effective audit
• An educational activity
• Promotes understanding
• Resource effective
• Raises standards
• Promotes change
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Effective audit
• An educational activity
• Promotes understanding
• Resource effective
• Raises standards
• Promotes change
• Source of information
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Effective audit
• An educational activity
• Promotes understanding
• Resource effective
• Raises standards
• Promotes change
• Source of information
• Peer led
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Effective audit
• An educational activity• Promotes understanding• Resource effective• Raises standards• Promotes change• Source of information• Peer led• Involves patients
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The audit cycle
Problem or objective identified
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The audit cycle
Problem or objective identified
Criteria agreed and standards set
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The audit cycle
Problem or objective identified
Criteria agreed and standards set
Audit (Data collected)
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The audit cycle
Problem or objective identified
Criteria agreed and standards set
Audit (Data collected)
Identify areas for improvement
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The audit cycle
Problem or objective identified
Criteria agreed and standards set
Audit (Data collected)
Identify areas for improvement
Make necessary changes
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The audit cycle
Problem or objective identified
Criteria agreed and standards set
Audit (Data collected)
Identify areas for improvement
Make necessary changes
Re-audit
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The audit cycle
Problem or objective identified
Criteria agreed and standards set
Audit (Data collected)
Identify areas for improvement
Make necessary changes
Re-audit
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Another way of expressing the audit cycle
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Another way of expressing the audit cycle
• Determine which aspects of current work are to be considered
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Another way of expressing the audit cycle
• Determine which aspects of current work are to be considered
• Describe and measure present performance
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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
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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
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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
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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
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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
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Criteria and standards
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Criteria and standards
• Criteria are those aspects of care that you wish to examine
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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
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Structure, process and outcome
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Structure, process and outcome
• Structure refers to resources you have available (including current knowledge, skills and attitudes)
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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
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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
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The great coffee audit
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The great coffee audit
Problem The doctors feel that their coffee isn’t hot enough after slogging through morning surgery
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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
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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
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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
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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.
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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
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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.
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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
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Contents of an audit
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Contents of an audit
• Background
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Contents of an audit
• Background
• Literature review
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Contents of an audit
• Background
• Literature review
• Criteria and standards
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Contents of an audit
• Background
• Literature review
• Criteria and standards
• Methods or protocol
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Contents of an audit
• Background
• Literature review
• Criteria and standards
• Methods or protocol
• Results
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Contents of an audit
• Background
• Literature review
• Criteria and standards
• Methods or protocol
• Results
• Recommendations for change
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Contents of an audit
• Background
• Literature review
• Criteria and standards
• Methods or protocol
• Results
• Recommendations for change
• Recommendations for further audit
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Why audit
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Why audit
• Useful clinically
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Why audit
• Useful clinically
• Encourages teamwork
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Why audit
• Useful clinically
• Encourages teamwork
• Improves patient care
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Why audit
• Useful clinically
• Encourages teamwork
• Improves patient care
• Financial benefits (sometimes!)
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Why audit
• Useful clinically
• Encourages teamwork
• Improves patient care
• Financial benefits (sometimes!)
• Becoming contracturally an obligation with the arrival of PCG’s
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Problems with audit
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Problems with audit
• Audit and research
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Problems with audit
• Audit and research
• Statistical verification
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Problems with audit
• Audit and research
• Statistical verification
• Outcome measures and proxies
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Problems with audit
• Audit and research
• Statistical verification
• Outcome measures and proxies
• Protocols
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Problems with audit
• Audit and research
• Statistical verification
• Outcome measures and proxies
• Protocols
• Closing the loop - introducing change and re-audit
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A word about clinical governance
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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
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‘Clinical Governance’
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‘Clinical Governance’
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‘Clinical Governance’
Research
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‘Clinical Governance’
Research
Audit
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‘Clinical Governance’
Research
Audit Evidence based
medicine
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‘Clinical Governance’
Research
Audit Evidence based
medicineDissemination of
guidelines
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‘Clinical Governance’
Research Practice development plans
Audit Evidence based
medicineDissemination of
guidelines
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‘Clinical Governance’
Research Practice development plans
Audit Evidence based
medicineDissemination of
guidelines
Personal development
plans
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‘Clinical Governance’
Research Practice development plans Postgraduate
medical education
Audit Evidence based
medicineDissemination of
guidelines
Personal development
plans
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‘Clinical Governance’
Research Practice development plans Postgraduate
medical education
Audit Evidence based
medicineDissemination of
guidelines
Personal development
plans
Practice accreditation
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‘Clinical Governance’
Research Practice development plans Postgraduate
medical education
Audit Evidence based
medicineDissemination of
guidelines
Personal development
plans
Practice accreditation
Special interest groups
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‘Clinical Governance’
Accountability
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Clinical Audit: Tools and Techniques
Helen Betts
Head of School
Chair of CHIRAD
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What is Audit?
A systematic and critical appraisal of the planning, delivery and evaluation of service/s
in terms of efficiency, effectiveness and quality, within given resources.
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Research is concerned with discovering the right thing to do; audit with ensuring that it is done
right.
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Research or Audit into Nutrition?
• Determination of the population’s consumption of fatty acids
• identification of actions to reduce fatty acid levels in local population
• investigation of the interaction between the effects of fatty acid and obesity
• implementation of actions to reduce coronary heart disease
• quantification of the level of fatty acid in prepared foods
• communication exercise to inform “at risk” patients of beneficial lifestyle changes
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“Clinical audit involves systematically looking at the
procedures used for diagnosis, care and treatment, examining how
associated resources are used and investigating the effect care has on the outcomes and quality of life for
the patient”.Department of Health
Clinical Audit: Meeting and Improving Standards in Healthcare (1993).
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Care is audited against defined standards derived from research
findings, professional expertise and information about patient needs and
expectations.
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In concurrent audit, care is evaluated at the time it is taking place. In retrospective audit, care
is evaluated after it has been completed.
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Reliability refers to the ability of an instrument to measure the area of interest consistently, in the same
way across time and with different assessors.
Validity refers to the ability of an instrument to measure what it is
intended to measure.
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Audits of the quality of care are normally undertaken through a
process of peer review: the review of a professional’s practice by someone of the same profession, against professionally defined
standards.
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The main methods used in audit of the quality of care are:
• Direct observation
• Checklists
• Documentation audit
• Questionnaires
• Interviews
• Case review
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You are a general practitioner organising an audit of the home care
for cardiac rehabilitation patients. List all the professions who
contribute to this care, including those from other organisations who input to the holistic programme of
home support.How could you receive their
observations?
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Items that would indicate clinical audit is developing successfully:
• It is undertaken by multi-professional healthcare teams
• it is focused on the patient
• it develops a culture of continuing evaluation and improvement of clinical effectiveness focusing on patient outcomes
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Benefits for professionals from a commitment to quality assurance:
• uphold professional/service standards
• increased job satisfaction
• opportunity for continual improvement
• fewer dissatisfied patients
• recognition/valuing of achievements
• productive use of time/effort
• acquisition of new skills/experience
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Clinical Audit
Julie BoneClinical Governance & Audit Facilitator
Telford & WrekinPrimary Care Trust
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Introduction
• What is clinical audit?
• Audit versus research
• The audit cycle
• Five stages of clinical audit
• Summary
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What is clinical audit?
• A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.
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What is clinical audit?
• Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria.
• Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery.
NICE. Principles for Best Practice in Clinical Audit. Oxford, Radcliffe Medical Press, 2002.
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What is clinical audit?
Clinical audit is at the heart of
clinical governance and clinical effectiveness
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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
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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
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The audit cycle
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Five stages of clinical audit
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Stage 1:Preparing for audit
• Involving users • Selecting a topic
• Defining the purpose • Planning
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Involving users
• The focus of any audit project must be those receiving care. Users can be genuine collaborators, rather than merely sources of data (Balogh et al., 1995).
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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?
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Selecting a topic
• High cost/volume/risk
• Area of local clinical concern
• Potential for improvement
• National priority
• Organisational priority
• Evidence based
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Defining the purpose
The 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
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Planning
• Involve ALL the right people
• Time and resources
• Access the evidence
• Methodology
• Pilot
• Report and Action
• Re-audit
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Stage 2:Selecting criteria
• Defining criteria• Sources of evidence
• Appraising the evidence
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Defining criteria
Criteria:
• are explicit statements that define what is being measured
• represent elements of care that can be measured objectively.
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Sources of evidence
• NeLH /Cochrane/WISH
• NICE
• Official Websites
• NSFs
• Local or regional guidelines/policy
• Royal College or Professional Body
• Recognised journals
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Appraising the evidence
• Aim /objectives
• Methodology
• Results /conclusions
• Applicable to your patient group
• Bias/ causes for concern
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Stage 3: Measuring level of performance
• Planning data collection• Methods of data collection
• Handling data
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Planning data collection
Need 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.
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Methods of data collection
• Computer stored data• Case notes/Medical Records• Surveys • Questionnaires• Interviews• Focus Groups• Prospective recording of specific data
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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.
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Stage 4: Making improvements
• Identifying barriers to change
• Implementing change
• External relationships
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Identifying barriers to change
• Fear of change
• Lack of understanding
• Low morale
• Poor communication
• Culture
• Pushing too hard
• Consensus not gained
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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
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Stage 5: Sustaining improvement
• Monitoring and evaluation• Re-audit
• Maintaining and reinforcing improvement
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Monitoring and evaluation
Although 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).
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Re-audit
• Close the loop
• Review evidence
• Measure effectiveness
• Decide how often to re-audit
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Maintaining and reinforcing improvement
Common factors:
• reinforcing or motivating factors built in by the management to support the continual cycle of quality improvement
• integration of audit into the organisation’s wider quality improvement systems
• strong leadership.
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Summary
• Defined clinical audit
• Compared audit and research
• The audit cycle.
• Five stages of clinical audit
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Celebrate
• Share learning
• Publicise results
• Give credit where credit is due!
