NPHS Primary Care Quality and Information Service

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Audit Training Programme for Care Home Staff

• NPHS Primary Care Quality and Information Service
• Debbie Davies-Quality Nurse Co-ordinator
• Jane Holloway- Quality Audit Facilitator

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• After today you will be able to-
• Understand the basic principles of Clinical
  Audit
• Appreciate links between clinical audit and
  clinical effectiveness
• Undertake audit in your place of work
• Workshop activities
• Audit puzzle
• Select an appropriate audit topic
• Define and apply criteria and standards

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• What is clinical audit?
• 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 implementation of
  change
• (NICE 2002)

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Audit aimTo reduce hospital acquired Infections
amongst injured or ill soldiers changes
implemented stringent standards of hygiene
within the hospital environment and equipment
Outcomemortality rates fell from 40 to 2,
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Types of Audit in Primary Care

• Standards based audit a cycle which involves
  defining standards. Collecting data to measure
  current practice against those standards.
  Implementing changes
• Significant event audit individual episodes are
  analysed
• Peer review audit assessment of quality of care
  provided by the team
• Patient surveys patients views about the quality
  of care they receive.

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Why do audit? - benefits

• It can lead to .
• Improved quality of care .
• A sense of personal and professional achievement
• Improved Team-Working
• Improved communication within an organisation
• A greater understanding of the structure and
  process operating within the organisation

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Attitudes and Criticisms
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Attitudes Criticisms

• Attitudes towards clinical audit are
  influenced by negative experience
• Lack of support and resources
• Lack of Impact
• Failure to change clinical practice
• No time to do audit
• The audit process too time consuming
• Findings rarely seen in practice

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Audit today!

• General Medical Council
• All doctors must take part in regular and
  systematic clinical audit
• Nursing and Midwifery Council
• clinical audit is the business of every
  registered practitioner

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Clinical Governance

• Clinical Governance is an umbrella term for
  everything that helps maintain and improve high
  standards of patient care. It encompasses a range
  of quality improvement activities.
• (RCN 2003)

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The elements of the clinical governance framework
are

• Clear lines of responsibility and accountability
• Quality improvement programmes, including
  clinical audit, evidence-based practice, standard
  setting and monitoring
• Public and patient involvement in Health
• Risk management, learning from incidents, helping
  staff to reflect on and develop their practice.

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What makes a good audit?
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Fundamental steps of the audit cycle

• Choose a Topic
• Agree standards/criteria
• Measure current practice against these standards
• Changing practice where standards are not met
  (Taking action to improve care)
• Re-auditing to check practice has improved and to
  sustain improvement

DEFINE/ REVIEW Criteria and Standards (Based on
the best possible up to date evidence where it
exists
IDENTIFY Need for change Involve everyone
COLLECT Data on Performance Record Analyse
ASSESS Data Performance against criteria
Standards
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Selecting an Audit topic

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A problem may be identified from every day
practice. Problems can be identified in 3 basic
areas Structure The input of care, e.g.
manpower, premises or facilities Process This
refers to the provision of care (looking at what
is done and how it is done) Outcome This
refers to the result of clinical intervention.
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• How to choose your topic
• National Priority
• NICE guidelines
• NSFs
• Royal College
• NPSA
• LHB Priority
• Practice priority

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• Aims
• Why are you doing this project?
• What are you trying to achieve?

Primary Care Quality Information Group
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• Criterion
• an element of care or activity that can be
  measured

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Searching the evidence
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• Try to keep the number of criteria to a maximum
  of 4 or 5
• (It is perfectly acceptable to have only one
  criterion for an audit)
• SMART

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Catheter Maintenance Audit

• Examples of criteria
• All indwelling catheters are connected to a
  sterile closed urinary drainage system or
  catheter valve
• Urinary bags are not in contact with the floor
• CSU Samples are obtained using an aseptic
  technique
• ( Ref Nice 2003)
• Above are aspects of care that can be measured to
  assess quality.

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• Standard describes the level of care to be
  achieved for any particular criterion

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Setting your standards

• Minimum
• Ideal
• Optimum

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• To make the criterion (statement) meaningful a
  standard needs to be ascribed.
• For example - a standard may state
• - 100 of Indwelling catheters will be connected
  to a sterile closed urinary drainage system or
  catheter valve
• - 100 Urinary bags are not in contact with the
  floor
• - 100 CSU Samples are obtained using an aseptic
  technique

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How good is your data?consider

• Relevancy
• Accuracy
• Completeness
• Confidentiality

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Gathering data can be difficult
Its the results that can be exciting
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• Reviewing your data
• Assessing performance against set criteria and
  standards
• (It is at this point you can identify any areas
  of care below the predetermined standard of the
  criteria)

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Analysis of data

• Example
• 100 of Indwelling catheters will be connected to
  a sterile closed urinary drainage system or
  catheter valve.
• However only 45 out of the 50 clients with a
  catheter was connected to a closed urinary
  drainage system.
• Therefore I did not meet my standard of 100
• 45 50x100 90

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Identify need for change

• Discuss share your audit results
• Involve as many people as possible
• Develop an action Plan

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Action Plans

• An action plan must be generated (unless all
  criteria have been met in full during the audit.
  
• An action must be documented for all criteria not
  met

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Making changesConsider your change management
skills

• Leadership, Delegation, Involvement skills

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THE AUDIT CYCLE
DEFINE /REVIEW Criteria and Standards (Based on
the best possible up to date evidence where it
exists)
Design Audit Tool
Implement change
COLLECT Data on Performance
Record Analyse
IDENTIFY Need for change Involve everyone

ASSESS Data Performance against criteria
Standards
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• Group Task

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Group work Activities

• Group Task
• Arrange audit puzzle- (10 min)
• Choose an audit topic- (15 min)
• Select audit Criteria- (10 min)
• Ascribe audit standards- (10 min)
• Overall time allocated 45 mins

• Suggested Audit Topics
• Catheter Maintenance in Care Home
• Eye drops are marked individually for each Pt
  (i.e Rt/Lt eye)
• Infection Control
• Enteral Feeding
• Care of insertion site and enteral feeding tube
• Falls
• Methotrexate monitoring
• Lithium Monitoring

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www.nphs.wales.nhs.ukClick on Primary Care
(Primary Care Quality Information)

• National / Directed Enhanced Services
• Quality Improvement Toolkits 
• The following quality improvement toolkits
  contain the specification requirements of the
  Enhanced Services and contain audit tools and
  Read Codes.
• Access quality improvement toolkit
• Minor Surgery quality improvement toolkit
• Anticoagulation Monitoring quality improvement
  toolkit
• Near Patient Testing - Methotrexate toolkit
• Near Patient Testing - Penicillamine toolkit
• Near Patient Testing - Auranofin toolkit
• Near Patient Testing - Sulphasalazine toolkit
• Near Patient Testing - Sodium Aurothiomalate toolk
  it
• NPT/DMARD resource manual
• Depression quality improvement toolkit
• Violent Patients quality improvement toolkit
• Sexual Health quality improvement toolkit
• Minor Injuries toolkit (coming soon)
• Influenza toolkit (coming soon) 

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Clinical Governance Practice Self Assessment
Tool

• Online Web Version 
• http//nww.nphs-cgtool.wales.nhs.uk/

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Contact Details

• debbie.davies_at_nphs.wales.nhs.uk
• 01495-332313
• jane.holloway_at_nphs.wales.nhs.uk
• 01443-824191
• Primary Care Quality Information Team