Clinical Audit

Professor (Dr.) Shamsun NaharMBBS, MSC (LONDON)PhD (Cambridge, UK)

Objectives of the session

At the end of the session the students should• be able to define clinical audit• Importance of clinical audit• Able to discuss the audit cycle• Able to identify the structure, process and outcome indicators• Able to discuss types of clinical audit and methods used in

clinical audit

What is clinical audit?

The systematic critical analysis of the quality of health care, including – the procedures used for diagnosis, treatment and

care, – the use of resources and the resulting outcome

and quality of life for patients. – it embraces the work of all healthcare

professionals"

What we do in clinical audit?What we do in clinical audit?

1. Critical analysis of your own skills and

ways of working for self improvement

2. Critical look at the system that delivers

care to your patients (i.e. your

environment)

What does clinical audit achieve?What does clinical audit achieve?

• Best practiceBest practice

• Best outcomeBest outcome

Planning an audit

• Choose the audit topic• Study the current situation• Analysis and compare with standards• Identify causes for not meeting the standards• Identify the changes to be done• Write a plan for implantation and Implementation of

changes• Re-audit

The audit cycle

The clinical audit process seeks to identify areas for service improvement, develop & carry out action plans to rectify or improve service provision and then to re-audit to ensure that these changes have an effect

Audit topic

“SMART”SpecificMeasureableAchievableRealisticTimely way

What is required for an audit?

• Criteria are those aspects of care that you wish to examine.

• A criterion is a measurable outcome of care

• This should be in the form of a statement.

• Standards are the pre-stated or implicit levels of success that you wish to achieve (Target)

• we usually express it as a percentage

Criterion & Standard

CriterionThis should be in the formof a statemente.g. All patients with

hypertension who smoke should be offered smoking cessation advice.

e.g. The temperature of the refrigerator in the immunization room

StandardWhen the criterion hasbeen defined at a numericallevel, it is referred to as astandard.e,g.100% patients with

hypertension who smoke should be offered smoking cessation advice.

e.g. The temperature of the refrigerator in the immunization room should not exceed + 8ooC

Criteria and standards

Criteria should be Precise Clear Effective Measureable Quality- oriented

Standards should be Comprehensive Practical Scientific Relevant Efficacious Effective Efficient Feasible

WHAT AREAS CAN YOU ‘AUDIT’?

A useful framework has been provided by Donabedian (1966) who classified topics under three headings:

Structure: The availability of resources and personnel of an organization

Process: The activities undertaken, that is what is done with the service’s resources.

Outcome: The effect of the activities on the ‘health/well-being’ of the service user.

• Well trained physicians• Well trained nurse• Health educator• Clinical guidelines• Relevant history• Measuring wt,ht• Measure and recording B.P• Conducting CVS Examination• Conducting Fundi Examination• Conducting Feet Examination• Medical records• Individual diabetic file(POMR)• DM Register• Referral register• Complete data base(including

smoking)• Problems list

• Relevant history• Measuring TC/TG/HDL/LDL• Measuring HbA1C• Health education (diet, exercise,

drugs,fastingfoot care, travelling, complications)

• Assessment of compliance to ( diet, treatment, exercise)

• Health education materials• Well equipped laboratory• Trained lab technician• Appointment system• Action plan for diabetes care• Drugs(Insulin, syringes)• Good control(FBS<126mg/dl)• Poor Control(FBS>140mg/dl)• Overweight• Obesity• Complications• Smokers• Annual Check up

List the indicators under the following headingsSTRUCTURE INDICATORS , PROCESS INDICATORS , OUTCOME INDICATORS

Types of clinical audits

• Standards based audits– To see if standards are met or are being

improved

• Adverse / critical incident– Screening of such incidents

– Monitoring of such incidents

• Peer review– Was the quality of care optimal. Case

reviews and discussions (often multidisciplinary)

• Patient surveys– Patients point of view of the quality of

service

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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

Comparison Between Clinical Research & Clinical Audit

Characteristic

Clinical Research Clinical Audit

Purpose

Character

Function

Sample Size

Bases for Measurement

Methods

Outcome

PROVE IMPROVE

Scientific Inquiry Systematic Measurement

Sets Standards Compares Standards

Statistical Significance Commitment to Act

Testing Hypothesis Standard of Practice

New Treatment No New Treatment

Increased Knowledge Improved Practice

Remember

Clinical audit is not research, but it does make use of research methodology in

order to assess practice.

Analyse & presentation of audit data• Analyse data and write the report• present findings should provide an unbiased picture of

actual practice– Link findings with the objectives and standards– Show overall pattern of actual practice compared to

the measures used in the audit– Information which helps to explain variances

Overview of Self-directed Learning

Objectives of the session

• To define the Self-directed Learning (SDL)

• To identify the characteristics of a Self-directed Learner• To understand the importance of Self-Directed Learning• To describe the Self-Directed Learning Strategies• To understand the importance of Self-directed learning &

Medicine • To find out the Sources of learning

Self-directed learning & Medicine

• Half of what you'll learn in medical school will be shown to be out of date within five years of your graduation; the trouble is that nobody can tell you which half—so the most important thing to learn is how to learn on your own. ---- Dr. Dave Sackett

• Self-directed learning (SDL) has been identified as an important skill for medical graduates.

To meet the challenges in today's healthcare environment, self-directed learning is most essential.

Self-directed learning & Medicine

Before beginning, you might want to read: What is Critical Appraisal? - Critical appraisal is the process of carefully and systematically examining research to judge its trustworthiness, and its value and relevance in a particular context.

• What is Evidence Based Medicine Evidence-based medicine is the meticulous, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

What is Self-directed Learning (SDL)

• Self-directed learning is the method used when a learner, rather than an institution or teacher , controls both the learning objectives and the means of learning.

A process in which students take the initiative. It involves five steps

1. diagnose their learning needs, 2. formulate learning goals,3. identify resources for learning, 4. select and implement learning strategies, 5. evaluate learning outcomes.

Why Self-Directed Learning ?

First reason is that there is convincing evidence that people who take the initiative in learning, learn more things and learn better than people who sit at the feet of teachers passively waiting to be taught.

The second reason is that self-directed learning is more in tune with our natural processes of psychological development; an essential aspect of maturing is developing the ability to take increasing responsibility of our own lives to become increasingly self-directed.

The third reason is that many of the new developments in education put a heavy responsibility on the learners to take a good deal of initiative in their own learning.

Fourth reason is that it can tackle one of the most enduring problems in medical education: the exponential growth in knowledge. It is a fact that the course cannot teach everything that doctors consider relevant, and continued additions can lead to what Abrahamson (1978) describes as "curriculum hypertrophy."

Characteristics of a Self-directed LearnerIndependence• Self-directed learners are fully responsible people who can

independently analyze, plan, execute, and evaluate their own learning activities.

Self-management• Self-directed learners can identify what they need during the

learning process, set individualized learning goals, control their own time and effort for learning, and arrange feedbacks for their work.

Desire for learning• For the purpose of knowledge acquisition, self-directed learners’

motivations for learning are extremely strong. Problem-solving• In order to achieve the best learning outcomes, self-directed

learners make use of existing learning resources and feasible learning strategies to overcome the difficulties which occur in the learning process.

skills help you succeed at being a self-directed learner

'Learning to learn' is a crucial skill.The following skills help you succeed at being a self-directed learner.

• Study them and think of your own abilities. • Are you able to question, inquire and solve problems, • keep an open mind to others' points of view, scan data and quickly choose

relevant resources, • collect data on your performance through self-observation and feedback from

others, • set goals to improve your personal performance, observe and model others'

performance to improve your own, • make a firm commitment to working on your goals, move through the full learning

cycle, • continually motivate yourself ? • Be proactive for SDL• Take note of the skills that you feel comfortable with and also note which ones

you would like to strengthen. • Think of how you can work on them and improve them. Then make a conscious

effort to do it.

Sources of learning

Sources of learning Sources of learning

• Online learning supports the self-directed learner in pursuing individualized, self-paced learning activities.

• Students can visit – libraries, museums and various institutes world-

wide, – talk to professionals, – access recent research, and read newspapers

and peer reviewed scholarly journals online.

Medical Journals in KSA• Saudi Arabia Medical Journal

• The Annals of Saudi Medicine

• KAU (King Abdulaziz Univeristy) Medical Journal

• The Annals of Thoracic Medicine

• Journal of family & community medicine

• Journal of the Saudi Heart association

• Neuro sciences

• Saudi Dental Journal

• Saudi Journal of disability & Rehabilitation

• Saudi Journal of Gastroenterology

• Saudi Journal of Kidney Diseases &Transplantation

• Saudi Journal of Obstetric & Gynecology

• Saudi Journal of Ophthalmology

• Saudi Journal of Sports Medicine Association

• Saudi Journal of Anesthesia

• Journal of Infection and Public Health

• Journal of Parasitology Research

• Saudi Journal of Biological Sciences

Websites for Self directing Learning

Thank you