Clinical audit for the enlightened ian callanan hslg conference 2013
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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)
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