Javed IqbalJaved IqbalFCPS, FRCSFCPS, FRCS

Professor of Surgery Professor of Surgery

Quaid-e-Azam Medical Quaid-e-Azam Medical College, BahawalpurCollege, Bahawalpur

► CRICKETCRICKET► BattingBatting► BowlingBowling► FieldingFielding► Preparation of pitchPreparation of pitch►Overall fitnessOverall fitness

► SURGERYSURGERY► Basic knowledgeBasic knowledge► Clinical methodsClinical methods► Technical skillTechnical skill► Communication Communication

skillsskills►Ward administrationWard administration► ResearchResearch

There is one thing There is one thing missing in bothmissing in both

Scoring in cricketScoring in cricket

And Audit in And Audit in surgerysurgery

Audit in surgeryAudit in surgery

~~ Keeping the record of Keeping the record of the scores in cricket the scores in cricket

Surgical practice Surgical practice without audit iswithout audit is

Like playing cricket without Like playing cricket without keeping the records of scoreskeeping the records of scores

AUDITAUDIT

Review…Check…Inspection…Review…Check…Inspection…ExaminationExamination

Assessment…InventoryAssessment…Inventory

The main The main responsibility of a responsibility of a

doctordoctor

To provide health careTo provide health care

Knowledge

Training

Experience

OutcomeAudit

History of AuditHistory of Audit

►Personal experiencePersonal experience►Writings………Theodor Billroth in Writings………Theodor Billroth in

18811881►Ward roundsWard rounds►Clinical meetingsClinical meetings►Morbidity and Mortality meetingsMorbidity and Mortality meetings

(INFORMAL AUDIT)(INFORMAL AUDIT)

Informal audit is and use Informal audit is and use to be an activity to be an activity

conducted by someconducted by some

Which are Which are more more enthusiasticenthusiastic

Subjective

Objective

The systemic, critical analysis of the The systemic, critical analysis of the quality of medical care, including the quality of medical care, including the

procedures used for diagnosis, the procedures used for diagnosis, the use of recourses and outcome of the use of recourses and outcome of the

quality of life of the patientquality of life of the patient

Definition

Systemic approach to Systemic approach to the review of clinical the review of clinical care to highlight the care to highlight the

opportunities for opportunities for improvementimprovement

2

Medical AuditMedical Audit

Assessment of the Assessment of the medical care medical care provided by the provided by the doctorsdoctors

Clinical AuditClinical Audit

Assessment of the Assessment of the total caretotal care

Informal audit is and use Informal audit is and use to be an activity to be an activity

conducted by some, conducted by some, which are more which are more

enthusiasticenthusiastic

But now:But now:

The audit is considered to be part of job The audit is considered to be part of job description of all involved in health description of all involved in health carecare

cliniciansclinicians ManagersManagers

Subjective

Objective

This is why, it is now This is why, it is now part of the curriculum of part of the curriculum of

final fellowship final fellowship examinationexamination

WHAT IS THE USE OF AN AUDIT?WHAT IS THE USE OF AN AUDIT?

► It can bring about the change for It can bring about the change for improvementimprovement

► It makes the practice evidence basedIt makes the practice evidence based► It can be used to formulate the It can be used to formulate the

departmental, institutional, national departmental, institutional, national and international policies and protocoland international policies and protocol

To improve the health care

It is also a very It is also a very powerful teaching powerful teaching

tooltool

From where to start?From where to start?

Attitude and Attitude and motivationmotivation

StructureStructureProceduresProceduresOutcomeOutcome

Areas to be audited

StructureStructure

►The quantity and type of resourcesThe quantity and type of resources

Building, equipments, staff and Building, equipments, staff and organization etc.organization etc.

It is easy to measure but is not a very good indicator of the quality of care

ProcedureProcedure

►What is done to the patientWhat is done to the patient

The way operations are performed, The way operations are performed, prescription of medications, prescription of medications, investigations, adequacy of notes, investigations, adequacy of notes, compliance to the set protocols etc.compliance to the set protocols etc.

This area of patient care can be changed by education

Out comeOut come

► It is the result of the clinical It is the result of the clinical intervention and represents the intervention and represents the success or failure success or failure

Hospital stay, complications, Morbidity, Hospital stay, complications, Morbidity, Mortality, return to normal activity and Mortality, return to normal activity and patients satisfaction etc.patients satisfaction etc.

This is the best audit which has potential to bring about change

Collect the data

Feed back the results

Intervene to promote the change

Audit cycle

Choose topic

Set standards

Audit cycleAudit cycle

►What are we tiring to achieve?What are we tiring to achieve?►Are we achieving it?Are we achieving it?►Why are we not achieving it?Why are we not achieving it?►What can we do to make it better?What can we do to make it better?►Have we made it better?Have we made it better?

METHODSMETHODS

An outline

Basic Clinical AuditBasic Clinical Audit

►A report produced by a unit, A report produced by a unit, department, institution after every 3 department, institution after every 3 monthsmonths

►Type of patients, Diagnosis, Type of patients, Diagnosis, Management offered, Complications, Management offered, Complications, Mortality, Patients satisfaction etc.Mortality, Patients satisfaction etc.The results are compared

with previous period, other departments or institution

1

Incidence reviewIncidence review

►Selection of a criteria or clinical Selection of a criteria or clinical scenario.scenario.

All incidences are reported and then All incidences are reported and then their frequency is matched with their frequency is matched with already available standardsalready available standards

2

Clinical record reviewClinical record review

A team of other unit reviews the A team of other unit reviews the randomly selected record of the randomly selected record of the patients.patients.

3

There might be more emphasis on record keeping skills than

actual quality of the care of the patient

Criterion auditCriterion audit

► It is more advanced and structured form of It is more advanced and structured form of incident audit.incident audit.

► A standard criterion of an aspect of patient A standard criterion of an aspect of patient care is selected. The criterion should be care is selected. The criterion should be such that even a non-technical auditor can such that even a non-technical auditor can get an unambiguous assessment from the get an unambiguous assessment from the patients chart.patients chart.

► If the criterion is not met, then further If the criterion is not met, then further review is conductedreview is conducted

► This has a potential to assess all aspects of This has a potential to assess all aspects of patients carepatients care

4

Adverse occurrence Adverse occurrence screeningscreening

►The auditors decide to shortlist the The auditors decide to shortlist the adverse happenings which should not adverse happenings which should not take place and needs to avoided. e.g. take place and needs to avoided. e.g. Wound infections, burst abdomen, Wound infections, burst abdomen, readmission within 24 hours of readmission within 24 hours of discharge, unplanned blood discharge, unplanned blood transfusions etc.transfusions etc.

►The frequency of them are than The frequency of them are than matched with standards.matched with standards.

5

Focused audit studyFocused audit study

►This is conducted on the basis of the This is conducted on the basis of the outcome of another audit to find out outcome of another audit to find out the finer details.the finer details.

►This is closer to clinical research but it This is closer to clinical research but it not intended to find new knowledge. not intended to find new knowledge.

6

Research finds “right thing to do”Research finds “right thing to do”Audit finds “whether right thing has Audit finds “whether right thing has

been done or not”been done or not”

Global auditGlobal audit

►Comparison of the data across Comparison of the data across different units, hospitals and regions.different units, hospitals and regions.

7

Out come studiesOut come studies

8

National studiesNational studies

9

1.1. Basic Clinical AuditBasic Clinical Audit

2.2. Incidence reviewIncidence review

3.3. Clinical record reviewClinical record review

4.4. Criterion auditCriterion audit

5.5. Adverse occurrence screeningAdverse occurrence screening

6.6. Focused audit studyFocused audit study

7.7. Global auditGlobal audit

8.8. Out come studiesOut come studies

9.9. National studiesNational studies

What minimum we can do?What minimum we can do?

►Personal record keepingPersonal record keeping►Basic surgical auditBasic surgical audit►Out come assessmentOut come assessment

MorbidityMorbidity MortalityMortality Patients satisfactionPatients satisfaction

►Focused studiesFocused studies

Audit is the first stepAudit is the first step

Not an end in itselfNot an end in itself

Surgical practice Surgical practice without audit iswithout audit is

Like playing cricket without Like playing cricket without keeping the records of scoreskeeping the records of scores

Thank you