IntroductionIntroductiontoto

Clinical AuditClinical Audit

Bachchu Kaini; (Cert in Clinical Audit, MBA, PGDHM, LLB, Bcom)

'about finding out if we 'about finding out if we areare doing what we doing what we shouldshould be doing' be doing'

Every One’s Business Every One’s Business ….......….......

What is Clinical Audit?What is Clinical Audit?

“Clinical audit is a quality improvement process that seeks to improve patient care & outcomes through a systematic review of care against explicit criteria and the implementation of change”.

(NICE, 2002)

More SimplyMore Simply

Actual Practice Best Practice

Clinical Audit Measures & Bridges

the Gap

Mind the Gap!

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Clinical Governance

Clinical Governance and Clinical Clinical Governance and Clinical AuditAudit

Why Clinical Audit & Why Clinical Audit & Effectiveness Important?Effectiveness Important? Patient Reason

› Better healthcare, less complaints & complications, more satisfaction

Professional Reason› Lifelong learning, enhance

accountability, reflective activity

Political Reason› Annual health check, meeting

national standards & guidance

Clinical Research & Clinical Clinical Research & Clinical AuditAudit

Characteristic

Clinical Research

Clinical Audit

Purpose To prove To improve

Character Scientific Inquiry Systematic Measurement

Function Suggests Standards Compares Practice with Standards

Sample Size Sufficient for Statistical Significance

Sufficient for Commitment to Act

Bases for Measurement

Testing Hypothesis Standard of good Practice

Methods New Treatment No New Treatment

Outcome Increased Knowledge Improved Practice & Quality of Care

Clinical Research & Clinical Clinical Research & Clinical AuditAudit

Research

GuidelinesProtocol

Clinical Audit

What is the best way?

This is the best way.

Does your clinical practice match the best way?

Clinical Audit & Clinical Clinical Audit & Clinical ResearchResearch

Podiatrists in a clinic surveyed healing rates in their patients with planter warts to compare results of different treatments.

Clinical Audit Clinical Researchor

Clinical Audit & Clinical Clinical Audit & Clinical ResearchResearch

General surgeon adopted a recommendation from pharmacists that an expensive antibiotic should have restricted clinical use. This led to a 90% reduction in use.Clinical Audit Clinical Researchor

Significant Event Significant Event AuditAudit

SEA is a form of audit Focus on particular incidents

considered significant, to learn and improve. e.g.› Drug errors› High infection rate in a certain

case› Patient complaints

Significant Event Significant Event AuditAudit

Inter-professional team activity Regular meeting to discuss

events (both positive and negative aspects)

Focus on system improvement rather than individuals

Development of a ‘no blame’ culture

SurveySurvey

Describes a group – how many, when, where, who? (Audit describes and investigates the problems)

Aims to give you a big picture (Audit measures compliance of standards)

Could be an audit if practices are measured against standards.

Types of AuditTypes of Audit

Structural Audit (staff, equipment, resources)

Process Audit (treatment, procedures, service delivery)

Outcome Audit (result of intervention, treatment, mobility, quality of life)

Stages of Clinical AuditStages of Clinical Audit

Stage One

Preparing for Audit

Using the Methods

Creating Environment

Stage Two

Selecting Criteria

Stage Three

Measuring Performance

Stage Four

Making Improvements

Stage One

Preparing for Audit

Using the Methods

Creating Environment

Stage Two

Selecting Criteria

Stage Three

Measuring Performance

Stage Four

Making Improvements

Stage Five

Sustaining Improvements

The Clinical Audit CycleThe Clinical Audit Cycle

Identify Topic

Change Mgmt

Report & Action Plan

SettingStandard

Planning Project

Piloting Project

Collecting Data

AnalysingData

Project Team

Setting Aim

Step 1: Identify TopicStep 1: Identify Topic

Local concern Patient’s concern Wide variation Trust priorities Areas of high volume, risk or

cost Risk, complaints and litigation Mandatory audits Annual programme

Step 2: Project Team Step 2: Project Team FormulationFormulation

Consider for…………….. Audit Lead/Supervisor Audit Owner Singular or multi-

disciplinary team Team members

Step 3: Setting Aims and Step 3: Setting Aims and ObjectivesObjectives

AimExactly what you want to achieve in performing this audit

ObjectivesSpecificMeasurableAchievableRelevantTimely

Useful verbs› To improve, enhance, increase, change, ensure

etc.

Step 4: Setting Step 4: Setting StandardsStandards

Criteria, Targets and Standards: Criteria a basis for comparison or a reference

point against which other things are assessed Standards are known levels of best practice Targets are the pre-stated or implicit levels of

success that you wish to achieve

While setting standards use: National Guidance e.g. NICE Local Guidance Guidance prepared by professional bodies Literature review Evidence based practice NSFs

Standards for Clinical Standards for Clinical AuditAudit

NSF Diabetes Standard

Standard Target Exceptions Data Collection

3 Empowering people with diabetes to enhance day to day management of their diabetes. (This is a ‘general’ statement, so, what are the standards that will allow us to measure this?)

e.g. Patient attends Diabetes Group Ed sessions for Type 2 (for new patients)

100% Pts with Type 1 Diabetes and existing type 2 patients

Patient asked via the data collection proforma / questionnaire

e.g. Personal care plans to help empower people with diabetes

100% None Copy of personal care plan in notes

Step 5: Planning the ProjectStep 5: Planning the Project ‘No one sets out to fail, they just

fail to plan’ Stakeholder involvement Proposal Sample

› Census Vs sample› Sample frame › Sampling method› Size› Time

Methodology Data source Time frame

Step 5: Planning the Step 5: Planning the ProjectProjectAsk Questions…………….. What are we going to audit? Why are we going to audit? Who are we going to audit? Who is going to be involved? When are we going to audit? How are we going to audit?

Step 5: Planning the Step 5: Planning the ProjectProjectQuestionnaire Design Visual impact, layout Explanations Covering letter Question phrasing Open Vs Close Cost implication Approval

Step 6: Piloting the Step 6: Piloting the ProjectProject

Consider for….. Testing audit tool Sampling Consistency Validity & reliability of the

tool Re-design the audit tool or

project if necessary

Step 7: Data CollectionStep 7: Data Collection

  Activity Logs Written documentation of clinic attendance, episodes of diagnosis tests, examinations

Good for what and how many questions

Document/ Data review

Review of written documents such as Patient notes, PAS records, Indicators

Good for what and how many questions

Focus groups Moderated discussions on a particular topic or issue

Good for what, how, and why questions

Interviews Data collection through oral conversations

Good for what and why questions

ObservationWatching people engaged in activities and recording what occurs

Good for how, what, and how many questions

Questionnaires Written responses to clearly defined questions

Good for what and how many questions

Step 7: Data CollectionStep 7: Data Collection

DO NOTDO NOT record anything and everything !

DO NOT collect data unless you actually need it !› KKeep IIt SSimple &SSpecific› Standardization (follow

instruction, collect data in the same way for all)

› Respect confidentiality› Optional participation

Step 8 : Data AnalysisStep 8 : Data Analysis

AnalysisFormic software for scanning the

responseExcel spread sheet

• Quicker• More accurate• Evidence for queries

SPSS/Statistical tools

Evaluation Link findings with objectives Compare actual practice with the best

practice Identify problems & analyse

inconsistencies Look potential for change

Step 9: Report and Action Step 9: Report and Action PlanPlan Report &

Presentation Anonymity Clarity Simplicity Action Plan Presentation forum Confidentiality No blames

Contents of Audit Report Background/

Introduction Aim/Objective Standards, criteria Methods Results Recommendations Action plan Recommendation for

further audit Appendix

Step 9: Report and Action Step 9: Report and Action PlanPlan

Propose solutions for improvements

Propose change in policies & procedures if necessary

Convert solutions into action plan

› Issue› Action plan› Responsible person› Time scale› Review plan

Step 10: Change Step 10: Change ManagementManagement

Stakeholder involvement Commitment Impact assessment if

necessary Dealing with emotional

aspect ‘Change resistant’ culture Sustain the improvement

Step 10: Change Step 10: Change ManagementManagement

Re-audit • Make sure the change makes things better• Change is improvement – not always the case• Don’t do it too soon• Let change ‘bed down’ in the organization• Not always done – poor practice

Share the success Share the learning Publicise results Give where credit is due

Celebrate the Success!!Celebrate the Success!!

An educational activity Raises standards Promotes understanding Resource effective Promotes change Sources of information Peer led Involves patients

An Effective Clinical AuditAn Effective Clinical Audit