Dr T SURESH

The Lady with the Lamp

Definition

• Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the review of change.(NICE 2002)

• the word ‘auditing’ has been derived from Latin word “audire” which means “to hear”.

• Clinical Audit is a mandatory element of the Professional Competence Scheme in some countries for all Surgeons / Medical Practitioners according to the Medical Practitioners Act 2007 on 1st May 2011.

Clinical Review

Clinical Review

• A detailed presentation of one or more cases often with certain objectives and around a specific theme.

• e.g. the clinicopathological case presentation)

RESEARCH

RESEARCH

• To derive generalisable new knowledge including studies that aim to generate hypotheses as well as studies that aim to test them.

• Eg: clinical trails

Service evaluation

• Designed and conducted solely to define or judge current care.

measure compare

evaluate

Elements

Elements

• Measurement - Measuring a specific element of clinical practice

• Comparison - Comparing results with the recognized standard

• Evaluation - Reflecting the outcome of audit and where indicated, changing practice accordingly.

Difference between medical audit and that of surgery

• In medical audit usually a pharmaceutical intervention have explicit standards and outcome that can be measurable.

• Most of the guidelines are evidence based.• Eg: diabetes sample audit.

• In surgical audit, it is difficult to set standards and to apply.

• So we need to measure the variations in outcome.

• Eg: mortality rate following radical cystectomy in a centre of international standing will definitely differ from that of a remote area.

Types

• National audits (e.g. in the UK, the National Institute for Health and Clinical Excellence – NICE)

• local/hospital audits.

Audit cycle

• Define the audit question. • Identify the body of evidence and current

standards.• Design the audit to measure performance

against agreed standards.• Measure over an agreed interval.• Analyze results and compare performance

against agreed standards.

• Undertake gap analysis : If all standards are reached, re audit after an agreed interval.

• If there is a need for improvement, identify possible interventions such as training, and agree with the involved parties.

• Re audit.

Determining scope

Common areas in the scope of an audit include:• 30 day mortality and significant morbidity;• length of hospital stay;• positive and negative outcomes• operation-specific complications• use of investigations• justification of management• patient satisfaction.

Select standards

Select standards

• use evidence-based research and guidelines where ever possible(cochrane collaboration);

• adapt existing local guidelines for local relevance;

• use an accessible library for evidence about effective practice and develop new guidelines;

• look to the specialty group to define standards.

Collect data

Collect data

• the information necessary to answer the audit question.

• collect prospectively or retrospectively.• follow up data collected.• Data can be collected from a register, medical

records data, review of referrals, or from previous appointment schedules.

Peer review

Peer review

• The evaluation of work by one or more people of similar competence to the producers of the work (peers).

• It constitutes a form of self-regulation by qualified members of a profession within the relevant field.

morbidity and mortality meetings

Eg: morbidity and mortality meetings• Peers are other surgeons with comparable

training and experience.• It can often also be helpful to include other

non-surgical members of the team in the review group e.g. surgical trainee or senior nursing staff.

• This should be conducted in an atmosphere of confidentiality, of trust and teamwork, and be seen as an evolving process.

Grand rounds

• Grand rounds as the name suggests are hardly confidential peer review - but cases should be presented as an educational exercise.

• They are good opportunities to learn from one or more cases but do not replace formal surgical audit meetings.

Make Changes and Monitor Progress

• Implementation involves not just making changes but ensuring that everyone affected is educated/ informed as to what changes are being made and why.

• It can be at any level from staff to surgeons and instrumentation.

• Then follow up the change achieved and then re audit for better results.

What Resources are Required

Manual systems• paper-based systems with notebooks or card

indexes, often with the help of sticky labels.• As manual data recording and entry can be

tedious and prone to error, it is recommended that advantage be taken where possible, of automated or semiautomated entry, such as bar codes, scanners

Computer systems• It is recommended where ever practicable,

particularly for individuals in private practice.• in addition to surgical audit data can be used

for multiple purposes such as billing, reporting or clinical records

• reduce duplication and facilitate data collection, verification and analysis.

Logbooks• Logbooks used by surgical trainees provide an

opportunity to start a data collection system as part of an ongoing process towards surgical audit.

Privacy

Privacy

• Confidentiality in audit process is essential, both from the point of view of the rights of the individual patient and of the surgeon.

• It is also important to reassure participating surgeons and other team members that peer review discussions constitute confidential professional peer review rather than a ‘witch hunt’.

What Opportunities Arise from Surgical Audit

Educational opportunities• modify attitudes and approaches to clinical

problems• enhancing critical approaches and giving a

rational basis to local changes in clinical practice;

• indicates deficiencies in knowledge and skills, and to develop educational activities to address these;

Systemic improvement opportunities• Clear problems and deficiencies identified in

‘systems’ should lead hospital authorities to re address the issues.

• Similarly individuals and teams can always improve.

• Surgical audit and peer review are essential

components of continuing professional development.

Bibliography

• Bailey and love 26th edition.• A Guide by the ROYAL AUSTRALASIAN COLLEGE OF

SURGEONS- surgical audit and peer review (2008)• Professional competence scheme- guidelines for

surgical audit- RCSI ( NOVEMBER 2012)