Clinical Audit Practical Guidance

1
Clinical Audit Practical Guidance

• Dr Ranjit Verma
• Consultant Anaesthetist
• Derby City General Hospital
• Uttoxeter Road
• Derby DE22 3NE
• rv3000_at_btinternet.com

2
Scope of this talk

• Definition(s) of Clinical Audit
• Why should I do Clinical Audit
• How do I go about doing it
• Some dos and donts
• Examples of successful audit
• Suggestions for simple audit projects

3
The NHS executives originaldefinition
The systematic critical analysis of the quality
of health care, including the procedures used for
diagnosis, treatment and care, the use of
resources and the resulting outcome and quality
of life for patients. It embraces the work of all
healthcare professionals" The DOH. Working for
Patients. London The Stationery Office, 1989
4
Another definition
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 Principles for Best
Practice in Clinical Audit (2002, NICE)
5
Clinical audit
Theres a lot of it about out there
6
Google search on Audit
7
Google search on Clinical Audit
8
Why should I bother doing clinical audit?

• Things have changed
• Duty of care
• Duty to deliver best quality service
• More accountability for our actions

9
Clinical audit is a part of clinical governance

• Required by
• The Government (our employers)
• The GMC (our regulatory body)
• Our insurers (MPS, MDU)
• Our professional bodies (RCA)

10
The 7 pillars of clinical governance
Use of information
Clinical effectiveness
Education and training
Staff/staff management
Patient/public involvement
Risk management
Clinical audit
11
Why should I bother doing clinical audit?

• Critical analysis of your own skills and ways of
  working (self improvement)
• Critical look at the system that delivers care to
  your patients (i.e. your environment)
• Can make a real difference and change things for
  the better

12
What does clinical audit achieve?

• Best practice
• Best outcome
• Best that we can deliver individually or
  collectively as a group of health professionals

13
What does clinical audit achieve?

• Improved care of patients
• Enhanced professionalism of staff
• Efficient use of resources
• Aids in continuing education
• Aids in administration
• Accountability to those outside the profession

14
Audit versus Research

• Research
• Tries to find out what you should be doing
• Seeks new knowledge
• Confirms validity of existing knowledge
• Audit
• Tells you if what you are doing is what you
  should be doing
• Reviews current practice to stimulate change

15
Do I require ethical committee approval?

• Strictly speaking NO
• However.
• Fine line between the two
• Follow Trust policy
• Departmental audit leads
• Trust audit committee

16
Types of clinical audits

• Standards based audits
• To see if standards are met or are being improved
• Adverse / critical incident
• Screening of such incidents
• Monitoring of such incidents
• Peer review
• Was the quality of care optimal. Case reviews and
  discussions (often multidisciplinary)
• Patient surveys
• Patients point of view of the quality of service

17
Some dos and donts

• Careful planning
• Involve others
• Especially if outcome is likely to affect them
• Anaesthetic colleagues
• Sub-speciality groups
• Surgical colleagues
• ODAs, Nurses, other staff

18
Some dos and donts

• Open and transparent
• Never secretive
• Positive and constructive
• Dont be a defeatist
• Stay focused (dont get distracted)

19
Some dos and donts

• Non confrontational
• Non aggressive
• Not over critical
• Non judgemental
• Dont investigate others

20
What should I audit?

• Anything you like
• Anything of concern
• e.g. departmental as a group
• RCA
• Other sources

21
Royal college of anaesthetists audit recipes
22
NICE CHI - RCN
23
The audit cycle
Select or Re-select Topic
Define criteria Set standards
Evaluate Effects Of Change
Implement Changes
Plan Methodology
Collect Analyze Data
24
Select (re-select) topic
Select or Re-select Topic

• Relevant
• Potential benefit
• To patient or to the organization
• Must have a known standard
• Own area of interest
• Areas you can influence

25
Select (re-select) topic
Select or Re-select Topic

• Local or more widespread
• Own speciality or multidisciplinary
• High risk
• High turnover
• High cost
• High use of resources

26
Define criteria and set standards

• Criterion
• Evidence based (consider literature search)
• State exactly what should be happening
• Terms understandable by all
• Be realistic
• Dont set absurd or unattainable standards
• Occasionally standards can be absolute (e.g. no
  patient should have the wrong operation performed)

Define criteria Set standards
27
Plan methodology

• Plan methodology in detail
• Keep it simple
• Allow sufficient time
• Share ownership, involve others
• Get co-operation from those who might be effected
• Carry your colleagues with you

Plan Methodology
28
Collect and analyze data
Collect Analyze Data

• Retrospective or prospective
• Manual / electronic
• Make data collection as easy as possible
• Do not collect unnecessary data
• Electronic devices may be helpful
• Can be tedious and time consuming
• Get help from the audit department

29
Implement changes
Implement Changes

• Change is never easy
• Often difficult to implement
• However a robust audit with good quality data
  helps in implementing change

30
Repeat the cycle
Select or Re-select Topic
Define criteria Set standards
Evaluate Effects Of Change
Implement Changes
Plan Methodology
Collect Analyze Data
31
Present your work

• Small group meetings
• Departmental meetings
• Trust audit showcase meetings
• Etc.

32
Use of epidural for pain relief in labourNormal
Vaginal Deliveries(a simple telephone audit)

• Time between decision to epidural and epidural
  insertion
• lt 30 minutes 60
• 30 minutes to 1 hour 30
• gt 1 hour 10
• Information given about epidural
• Before admission to hospital 100
• In labour room 100
• Insufficient information given 0
• Was the information given
• Satisfactory 100
• Unsatisfactory 0

33
Use of epidural for pain relief in labourNormal
Vaginal Deliveries(a simple telephone audit)

• While labouring
• Pain free or more comfortable 95
• Delivery
• Entirely/fairly comfortable 92.5
• Uncomfortable 7.5
• Painful 0
• Want epidural in future delivery?
• Yes 95
• No 5

34
Use of epidural for pain relief in labourNormal
Vaginal Deliveries(a simple telephone audit)
Overall experience of the quality of obstetric
anaesthetic service 1 poor, 9 excellent
35
Quality of pain relief in step down unitMajor
Urology vs Major General Surgery

• Noticed pain relief in major urology patients
  much better than major general surgery patients
• All had epidurals for post-op pain relief
• Audit revealed
• Urology lists being done by a few senior
  anaesthetists who consistently put epidurals at
  an appropriate level
• General surgery lists had more variation in
  epiduralists and greater inconsistency of
  appropriate epidural level insertion
• Training issue highlighted
• Steps being taken to correct this

36
Pre-operative fasting in children

• Noticed that some children on paediatric lists
  were dehydrated
• Audit revealed
• Some children were being starved by up to 24
  hours pre-operatively
• Failure in communication to parents
• Failure to follow guidelines
• Guidelines changed
• All children given mandatory drinks up to 12.00
  noon for afternoon lists
• Re-audited
• Problem resolved

37
Late start of elective Caesarean sections

• Noticed persistent delays in starting Caesarean
  sections
• Anaesthetists blamed for delay
• Audit showed
• Not the case
• New sticker introduced with clear timings
• Time decision to C/S
• Time patient sent for
• Time Anaesthetic started
• Time operation started
• Time operation finished
• Misconception dispelled

38
In conclusion

• Clinical audit is
• Desirable
• Self satisfying
• Encourages teamwork
• Can be of benefit to
• Individual undertaking the audit
• The department
• The institution
• The patients

39
References

• Principles For Best Practice in Clinical Audit.
• National Institute of Clinical Excellence (NICE).
  2002.
• A Practical Handbook for Clinical Audit.
• Published in 2005 Endorsed by the Healthcare
  Commission, National Institute for Clinical
  Excellence (NICE), the Clinical Governance
  Support Team (CGST) and the National Audit and
  Governance Group (NAGG).

40
Thank you