Clinical Audit Relating to Falls

Jeannette Kamar

Quality, Safety & Risk Unit; Northern Health

Jeanette.kamar@nh.org.au

Using Clinical Audit to Support Quality Improvement Seminar

Monash University, School of Public Health and Preventive Medicine

The Alfred Medical Research and Education Precinct, Melbourne

Friday 26th February 2016

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.

Today’s Presentation

Clinical Audit Relating to Falls

1. Identify problem or issue

2. Set criteria & standards

3. Observe practice / data collection

4. Compare performance with criteria & standards

5. Implementing change

Identify the Problem or Issue

Stage 1:

• Determine the issue / problem / audit topic₋ Focus on areas with greatest need to improve

₋ Include government or regulatory requirements

• Involve stakeholders₋ Staff & Patients delivering or receiving the care

₋ Staff with authority to support change

• Plan the delivery₋ Who will conduct the audit

₋ Who will collate / monitor progress

Falls - Identify the Problem

• Patient falls:

- World wide problem

- Common cause of harm in hospitals

• NSQHS Standards 10 - falls prevention: - National government regulatory requirements

• Currently: - An absence of high-quality evidence showing

the effectiveness of falls prevention strategies

across acute hospital wards

National Safety and Quality Health Service Standards, September 2012

Barker A, Morello R, Wolfe R et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial ,

BMJ 2016;352:h6781

Falls - Identify the Problem

• Currently:- There is evidence suggesting that some locally

developed hospital falls prevention programs have

been effective in the setting where is was developed

• Local programs are:- Developed, using local data

- Aim to address local issues

• Clinical audit:

- Assess local issues to improve patient care

Barker A, Kamar J, Morton A, et al. Bridging the gap between research and practice: review of a targeted hospital inpatient fall

prevention programme. Quality & safety in health care 2009;18(6):467-72.

A Barker, J Kamar, M Graco, V Lawlor, K Hill. Adding value to the Stratify falls risk assessment in acute hospitals. JAN volume 67, Issue

2, pages 450–457, February 2011.

Clinical Audit within a Service

• Helps to identify and measure areas of risk

• Creates a culture of quality improvement

• Is educational for the participants

• Offers an opportunity for increased job satisfaction

• Is increasingly seen as an essential component of

professional practice.

• Can improve the quality and effectiveness of care

Set Standards & Criteria

Stage 2:

• Identify related National Standard- Local committee

• Set the criteria₋ Measurable statements of what should happen

in line with National Standard and local policy

• Set targets & agree acceptable exceptions - Include expected performance levels and

action to be taken if level is not achieved

Set Standards & Criteria

Setting Targets

• Indicator Description

• Indicator Formula / Measurement Unit

Examples:

a) Number of Patient Falls by 1000 bed-days per month

- Falls per 1,000 occupied bed days: Divide the number of falls by the number

of occupied bed days for the month; then multiply this by 1,000

b) Percentage Risk Assessment Tools (RAT) completed within 24

hours for each patient admitted to a general inpatient Ward

- Number of RAT completed (within relevant time-frame) divided by number

of patient admissions (to relevant wards); then multiply this by 100

Set Standards & Criteria

Setting Targets

• Data Source, (i.e. Riskman / Clinical Audit)

• Baseline Measure

• Current Measure

• Target Measure: by percentage or rate and identify

expected performance levels, i.e.:

₋ Target / Good >=98%

₋ Moderate >=80%

₋ Poor <80

Set Standards & Criteria

Setting Targets

• Determine action required if below Target

• Primary Responsibilities:

₋ Conducting the audit

₋ Collating the data

₋ Accountable process owner

₋ Reporting cycle

₋ Governance Committee

Observe Practice / Data Collection

Stage 3:

• Audit Tool

₋ Data collected should be in relevant order and

relevant to the objectives / criteria

₋ Use clearly worded closed questions

₋ Limit free text or open questions: these are difficult

to code / analysis is very time consuming

₋ Include definition of terms

₋ Include space for comments to record exceptions

Audit Tool - Sample

• Purpose

• Instructions

• Tool:

- Yes / No questions

- Observing documentation

- Observing practice

- Includes question to

measure overarching aim

- Option to provide comment

PURPOSE

This audit is intended as an educational tool to help ensure:

• Documentation on the Patient Care Plan or Clinical Pathway is

correct, complete and complies with the 6-Pack Falls

Prevention Program

• Falls prevention strategies are implemented as indicated on

the documentation

• Issues are discussed and addresses at ward level

The tool may also be used following a fall to investigate the

circumstances of the fall and thus provide a basis for feedback to

staff.

Audit Tool - Sample

INSTRUCTIONS

• Audits are best undertaken towards the end of the shift to

ensure documentation is completed.

• Circle responses as appropriate and discuss issues arising

with the nurse caring for the patient.

• Note comments in the space provided in order to clarify

issues identified and suggestions for improvements.

• Forward completed audits to: (insert name and location).

Audit Tool - Sample

Observe Practice / Data Collection

Stage 3:

• Data collection₋ Collection of relevant data about current practice in

order to facilitate comparison

• Data analysis₋ Convert the facts / data into useful information in

order to identify the level of compliance with the

agreed standard

• Draw conclusions₋ Identify the reasons why the standard was not met

Compare with Standard / Criteria

Stage 4: - Present and discuss results

‘No further action required’• If target achieved, there should be an explicit

statement saying ‘no further action required’

‘Further action required’• If Moderate or Poor, identify areas for improvement

₋ Target / Good i.e. >=98%

₋ Moderate i.e. >=80%

₋ Poor i.e. <80

Compare with Standard / Criteria

‘Further action required’

• Change is often the most difficult part of the audit.

• When the audit team have developed the

recommendations, decisions should be made on how

changes can be introduced and monitored.

• Results should be used in conjunction with feedback and

local consensus to change clinical practice and to

improve standards.

• Priorities for action should be identified and these

should be clearly documented.

Implement Change

Stage 5:

• All audits should be accompanied by a quality

improvement plan in order to achieve the required

improvements in practice.

• Monitor implementation of changes

• Report on progress of implementation as required

• Re-audit to ensure changes have improved practice and

decide if further audit procedures are required

Overview

Summary

• Keep audits simple

• Get everyone involved

• Determine the topic

• Have a plan

• Do not collect needless data

• Take care with statistics

• Close all clinical audit loops

• Share learning

• Re-audit to ensure improvement in clinical care

Clinical Audit Relating to Falls

Jeannette Kamar

Quality, Safety & Risk Unit; Northern Health

Jeanette.kamar@nh.org.au

Questions?