Briefing Tutor Clincial Audit 2011

8/3/2019 Briefing Tutor Clincial Audit 2011

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2011

By: Hanevi Djasri, Osman Sianipar, dan Adi Utarini

Centre for Health Service Management, ClinicalEpidemiology & Biostatistics, Hospital Management

Graduate Program, Faculty of Medicine, UGM



Clinical Audit

Preparation for the Practical Sessions

The Practical Sessions





Medical/Clinical committee (Sub-committeeon Clinical Audit)

Clinical Audit Ad-hoc Team (Team work)

Assistant to Clinical Audit (Medical Record)



Select topics

for clinical

audit

Determine

criteria and

standards

Collect data

Analyse data

Make

changes

Re-audit



Topic is selected in a meeting, using the

following information:

◦ Routine data

◦ Patient satisfaction survey

◦ Observation of care delivery

◦ Inputs from stakeholders

◦ Enthusiasm of a certain care groups



Criteria for selecting a topic:◦ Can be improved

◦ High risk, cost, volume, problem

◦ Support or concensus from clinician◦ Clear clinical guidelines

Topics for practical session (2011)◦ Typhoid, ARI, diarrhoea



Topics Risk Volume Cost Problem

1. ARI

2. Diarrhoea

3. Typhoid

...

…

…

…

*already decided for the practical session,but this process will still be conducted

during the practical session. Bring data!



Background

Rationale for the selected topics

(epidemiology, burden of illness, relevance) Clinical guidelines

Problems in case management



Ensure or improve quality Not only to ”measure or examine”

Example:◦

Improve case management of TB ◦ Improve case management of patients with

diabetic ulcer

◦ Improve diagnosis of childhood TB



◦ Appropriateness: Is the treatment

according to guidelines?

◦

Timeliness : Is the treatment given in atimely manner?

◦ Effectiveness : Is the outcome asexpected?



Topics:◦ Breast cancer

Objective:

◦ To improve quality of services for patientswith breast cancer

Specific objective: ◦

Ensure care is provided according toguidelines

◦ Ensure the diagnosis is made timely



Select topics

for clinical

audit

Determine

criteria and

standards

Collect data

Analyse data

Make

changes

Re-audit



What is criteria?

It is an evidence that must be present to

prove that an optimum level of care isprovided

◦ Diagnosis, treatment, interventions, patient reaction

etc. related to topics for clinical audit



Trigger questions to identify auditcriteria:◦ Case management if considered high

quality if.. .... is present

.... is present

.... must not be present

Etc.



Common criteria used: Process criteria: diagnosis, treatment,

intervention, surgery, etc.

Less common criteria used: Input: often linked to budget limitation,

therefore the audit cycle often cannot becompleted

Output/outcome: complex, related to manyfactors (co-morbidity etc), eg: status ondischarge, death, complication, LOS etc.



IMPORTANT MESSAGE!

Concensus toward the criteria from seniorclinicians is important for later improvement

Conduct panel expert or review of criteria andclinical guidelines to be used for the audit



Specific: not ambiguous, value-free

Measureable: can be measured

Agreed: concensus reached

Relevant

Theoretically sound: based on evidence-based clinical guidelines◦

www.sign.co.uk ◦ www.cochrane.org

http://www.sign.co.uk/

http://www.cochrane.org/

http://www.cochrane.org/

http://www.sign.co.uk/



Name of the Criteria◦ Standard

◦ Exception

◦ Instruction for CA assistant/data collectors



Must be present (100%) or must not be

present (0%) for each criteria

Example:◦ Use of prophylactic actibiotics for elective surgery:

standard 100%

◦ Decubitus: standard 0%

Standard is used to evaluate a medical recordwhether a criterion is met or not



Presence of clinical conditions to justify that a

medical record is not meeting the standard

Therefore the exception can be used to explainwhy a standard is not met



Refering to which parts in the medical record

that contains valid and reliable informationneeded to evaluate the criteria

Written in an objective way and all relatedterms need to be listed



Criteria Standard Exception Instruction for

data collector

1. Ulcer in the

vein must be

treated with

multilayer

compressionperiodically

100% ABPI < 0,8

(ankle :

brachial

pressure

index)

MR Form no

002/RM



Criteria Standard Exception Instruction for

data collector

1. …

2. …

3. …

4. …

5.…

…

…

…

…

…

…

…

…

…

…

…

…

…

…

…



Select topics

for clinical

audit

Determine

criteria and

standards

Collect data

Analyse data

Makechanges

Re-audit



Retrospective: data already collected routinelyor available in a certain register

Concurrent/Prospective: data collected duringthe process of care



Code for evaluating the criteria

Code 1: According to standards

Code 2: Not according to standards, butmeeting the exception (justified)

Code 3: Not according to standards and notmeeting the exception (unjustified)



Implementation Data collection can be carried out by CA

assistant (eg medical record staff, nurse,doctor) using the audit instrument

Separate MRs that are not meeting thestandards

Result is recorded using the code system for

audit



Variables are selected to understand certainpatterns or variations

Source of variables: hospital, doctor, nurse,patient characteristics◦ Doctor

◦ Class

◦ Ward

◦ Patient age

◦ Etc.



Take all population if the topic is extremelyimportant (surgery)

Take a sample if the no of patients is large(eg 1000 patients)

Pragmatic approach: 20-50 patients

For scientific purpose: sample size calculation



MR 01 MR 02 MR 03 MR 04 Etc.Variable

Class

Age

Dr.

Criteria

Criteria 1

Criteria 2

Criteria 3

Criteria 4

Criteria 5



Select topics

for clinical

audit

Determine

criteria and

standards

Collect data

Analyse data

Makechanges

Re-audit



1. Re-check: esp for deficiency◦ Ensure that deficiency is correct

2. Identify the sample, if it is represent thepopulation

3. Measure level of compliance

4. Measure pattern of deficiency

5. Identify cause of deficiency using quality

tools



ISTC Standard 2.All patients (adults, adolescents, and children) suspected of having

pulmonary tuberculosis should have at least two sputum specimens obtained for microscopic examination.

SS examination

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8

SS examination





QualityProblem

MachinesMeasurement Human

ProcessEnvironment Materials



Select topics

for clinical

audit

Determine

criteria and

standards

Collect data

Analyse data

Makechanges

Re-audit



Eliminate waste Improve work-flow

Optimize inventory

Change the work environment

Enhance the producer-customer relationship

Manage time

Manage variation

Design systems to avoid mistakes Focus on the product or service



What should be changed

Timeline

Plan of action

Whose responsibility



Follow-up Objective

Measureableindicator

Responsiblepersons

Timeline Cost

1…

2…

3… 4…

5….



Select topics

for clinical

audit

Determine

criteria and

standards

Collect data

Analyse data

Makechanges

Re-audit



See list of groups and audit topics selected

Search references useful as a background forthe topic and exercise for selecting the topic

Search for clinical guidelines for that topics◦ Find and share the guidelines with the group◦ Read the guidelines individually◦ Look for potential criteria individually

Do informal group meeting to discuss topic

selection and criteria (Recommended) Read the recommended readings for the

practical sessions (2 downloadable refs)



•Pre-test (15 min)

•Select topics

•Determine criteria & standard

•Data collection

PS-1

•Data analysis

•Make changes

•Group presentation (in ppt)

PS-2



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Documents

Briefing Tutor Clincial Audit 2011