Clinical Audit for the

Ian Callanan MB FRCSI MBAGroup Clinical Audit Co-ordinatorSt Vincent’s Healthcare

Medical DirectorAviva Healthcare Insurance

PCC Committee Medical Council of Ireland

uninitiatedtroubledconfusedharriedenlightened

Clinical Audit for the

Ian Callanan MB FRCSI MBAGroup Clinical Audit Co-ordinatorSt Vincent’s Healthcare

Medical DirectorAviva Healthcare Insurance

PCC Committee Medical Council of Ireland

uninitiatedtroubledconfusedharriedenlightened

What does it mean for health staff?

CPD50 points per year

Clinical audit1 per year(12 hrs suggested)

CPD?

AccreditationHIQAJCI etc

Clinical auditHealthstatKPIs

Life, according to Librarians…..?

What is quality?

Clinical AuditClinical Audit

Systematic review and evaluation

of current practice with reference to research

based standards with a view to improving patient care

Clinical AuditClinical AuditIt

does exactly as it says

on the tin

“Ronseal”

Clinical Audit

Identify and eliminate waste

Identify and promote

good practice

Identify and stopbad practice

Promote MDT working

Improve professional practice

Improve patient outcomes

Release money to provide

better patient care

Select & support highest quality

care Professional education

Identify StandardMeasure activity

Validate against standardMake appropriate changes

Standard and

Criterion

What should happen–98% of female population at risk should be immunised against rubella

–100% of children needing attention for acute problems will be seen on the same day

–All patients Rxed with statins should have an LFT carried out

Criterion:

a definable and measurable item

of health care

Standard:

a statement of expectation

PDCA

ACT

Example of wrist bands

0 printed

428 handwritten

21 ABSENT

54 printed

360 handwritten

10 ABSENT

165 printed

214 handwritten

15 ABSENT

339 printed

55 handwritten

34 ABSENT

368 printed

10 handwritten

31 ABSENTAug 2006 Aug 2010 Oct 2010 April 2011 Sept 2012

Audit and Feedback

0%

+70%

-16%

Change in practice after clinical audit– measured by adherence to specific guideline

Jamtvedt et al 2006, Cochrane Database of Systematic Reviews

Plan

Do

Do

CHeck

Do

CHeckACT

Plan

CHeckACT Plan

ACT

SourceProfessional directionsResearchBenchmarksGuidelines

Level of complianceIs 100% achievableIs 80% good enough

Progressive improvementThe First Rule of Aviation

More than my jobsworth

Source of Standards• Pubmed• Cochrane• BMJ• SIGN• Clinical Evidence• EBM online• School of York reviews• Best BETS • Bandolier• Centre for Clinical Effectiveness • Centre for Evidence-Based Medicine • Centre for Evidence-Based Mental Health • Centres for Health Evidence • Clinical Assessment of the Reliability of the

Examination • Clinical Decision Rules, The Samuel Bronfman

Department of Medicine • Clinical Examination Research Interest Group • Clinical Resources, Clindx Update Listserv &

Bibliography • Netting the Evidence • NHS Centre for Reviews and Dissemination • Ovid EBM • Physiotherapy Evidence Database (PEDro) • Resources for Practicing Evidence-Based

Medicine • Department of Family & Community Medicine • Trip Database

• EPIQ (Effective Practice, Informatics & Quality Improvement)

• Evidence-Based Mental Health • Evidence based Nursing• Evidence-Based Paediatrics • Evidence-Based Practice Centers • McMaster Health Information Research Unit • National Library of Medicine's Health

Services/Technology Assessment Text (HSTAT)

+ Google

Research is probably

the nemesis of clinical audit

Information for researchDetailed, focussed and minutiaeInfo not usually collectedEXCITES doctors

Information for monitoring / accountabilityTechnical dataExternally used (Lot of energy in getting agreement)Not illuminating how outcomes achieved or processes managed

Information for quality improvementQuickly gatheredRapid cycleIdentify problems / get baseline / measure improvements

1

2

3

After Solberg et alJt Comm J Qual Improv. 1997 Mar;23(3):135-47.

Who does audit?

1. Self-audit

2. Peer audit

3. External audit

Part of professional’s regular questioningCan be difficult to sustain (time, space, skills….Private

Adv: Frank discussionDisadv: Collusion, avoid the awkward

“It takes one to know one”Likely to be

Appropriate to context Acceptable to

colleaguesPrincipal risk

May become collusive

Most rigorousMost threateningRequire resources

• Numbers needed

• Clarity of gathering the right data

• Using databases– Paper tots– Excel

• Analyses / Stats!!!!

Gathering the data

Framework for clinical audit

Structure

Process

Outcome

Physical attributes of health care•Tangible, easily counted•Presence increases the chance of good quality care but does not ensure it (appropriate use…..)•Examples: equipment; medical records

Care given by a practitioner / service•Health professionals identify process with quality

–It describes what they do–Reflects their attitudes, knowledge & skills

•Examples: prescribing habits, hospital referral rates, lab & x-ray use

Changes in patient’s current & future health status as result of intervention•Describe effectiveness of care•Difficult to measure……•Example – lower incidence of specific disease; lower mortality; improvement of level of function, patient satisfaction

Criteria and Standards

Criterion Standard

Structure Patient records will include hard copy results (NHO audit)

Should apply to 80% records

Process Patients aged 20-65 will have their BP recorded at least once in last 5 years

Should apply to:

50% records in Y 1

75% in Y 2;

95% in Y 3.

Outcome Patients with BP aged u 40 will have diastolic < 90mm Hg within 1st yr of treatment

Will be achieved in 80% cases

Gap models of service quality (SERVQUAL)

Expected service

Perceived service

Service delivery

Service standards

External communications

Company perceptions of customer expectations

Gap 1

Gap 4

Gap 2

Gap 3

Gap 5

Good audit.....• Topic is a priority

– Reflects local services

– Agreed by all as priority • Measured against

standards– Best available evidence

• Supported by organisation– Time and planning

• Engages with all– Ownership– Through to completion

• Patient involvement– Patient priorities

• Target sample appropriate– Generates meaningful

results• Data collection

robust– Clarity on criteria

• Action plan– Ownership– Accountability

• Repetition

Performance

Davidoff, Ann Int Med 2011

Reflection

Hands on experience

Reflective observation

Abstract conceptualisation

Endless performance

1. I am Clinical Audit….thou shall not wave a Research Idea at me

2. Thou shall close all clinical audit loops… unclosed loops are an abomination

3. Keep thine audits simple

4. Thou shall have a plan

5. Thou shall not bear false witness to statistics

6. Thou shall not collect needless data

7. Thou shall tell everyone about your audit

8. Tell “The Organisation” about your audit

9. Keep to thee all the data only for as long as it is needed…the God of Information shall visit all manner of plagues upon ye

10. Re-audit, in the name of all that is good and right in clinical care

Any questions?

Now…..

Later…..

clinicalaudit@svuh.ie