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Improving Standards ofPatient Care: Clinical
Audits
Sudigdo Sastroasmoro(Vice Chairman, Medical Committee
Cipto Mangunkusumo Hospital)
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Selected references
Starey N. What is clinical governance? Available at .evidence!based!medicine.co.u".#$$%.
National Prescribing Centre. &he audit cycle.
'epartment of (eneral Practice) *oyal +nited ,ospital. Studyguide - Clinical audit. aris.Christie/ruh!bath.sest.nhs.u"
Allen P. Accountability for clinical governance: developing
collective responsibility for 0uality in primary care. 123 #$$$45#%:6$7!%%.
,alligan A) 'onaldson 8. Implementing clinical governance:turning vision into reality. 123 #$$%4 5##:%9%5!.
National ,ealth Systems. Clinical governance. Available at
.doh.gov.u";pricare;clingov.htmNational Centre for ,ealth
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Value=Quality
Cost
MortalityMorbidityQoL
PatientSatisfact
ion
HealthStatus
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Clinical (overnance
@A frameor" through hich N,Sorganiations are accountable for
continuously improving the 0uality oftheir services and safeguarding high
standards of care) by creating anenvironment in hich e>cellence in
clinical care ill Bourish.@
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Clinical (overnance
A poerful) ne and comprehensivemechanism for ensuring that high
standards of clinical care aremaintained throughout the healthsystems and the 0uality of service is
continuously improvedA system for improving the standardof clinical practice
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Important elements of
clinical governance
=ducation training
Clinical auditClinical eectivenessD=12E
*is" management*esearch anddevelopment
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ClinicalGovernance
Clinicalaudits
Education& Training
Ris !anage!ent
"ccount#ability
Research &develo$!ent
ClinicalE%ective#
ness
EM'F ,&A
F Clinical guideline
F Clin pathaysF AlgorithmsF Protocols
F Procedures
FStanding orders
Patient safety
Clinicalaudits
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Clinical audit
Clinical audit is a 0uality improvementprocess that see"s to improve patientcare and outcomes through systematic
revie of care against e>plicit criteria)folloed by the implementation ofchange. Aspects of the structure)
processes) and outcomes of care areselected and systematically evaluatedagainst e>plicit criteria. Whereindicated) changes are implemented at
an individual) team) or service level and
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Clinical audits
Hormally introduced in %7
Previous name: medicalaudits
2oves from JoptionalK toobligatory
&he heart of clinical
governance
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Clinical indicators
Performance indicators: overallperformance of hospital or department
2ore speciGc: clinical indicators
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=>amples of clinical
indicators ,ospital death
+nplanned re!admission
Compliance to treatmentregimen
Admission for certain healthproblem
Surgery for certain conditions
8ength of hospital stay
!
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Clinical audits refer to 0uality of careevaluation method) a multidisciplinaryprocess of professional team
&he usual approach: standard Devidence!basedE identiGcation) performanceevaluation) compare ith standard)problem identiGcation) recommendations)improvement implementation) re!audit
Audit may involve many hospitals in aregion) but can be implemented in
individual hospital or even department.
Clinical audits
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Audit is not L. *esearch. *esearch attempts to Gnd bestmanagement) audit revies if patient care hasbeen done correctly
1laming action or competition amongindividuals or groups
'iscipline mechanism. &he main purpose ofaudit is improving process and system) not
disciplineComple> statistical or"s. When statistics areneeded) focus is on the comparison tostandards
'atabase collection. 'atabase collects all data
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Clinical audits*evie of clinical performance)the reGning of clinical practice asa result and the measurement ofperformance against agreedstandard
A cyclical process of improving the0uality of care
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What is clinical audit?
Jthe systematic critical analysis of the0uality of clinical care) including theprocedures used for diagnosis andtreatment) the use of resources and theresulting outcome and 0uality of life forthe patientK (Secretaries of State, 1989)
Jthe process of revieing the delivery ofhealth care to identify deGciencies sothat they may be remediedK (Crombie et
al 199)
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Clinical audit is at the heart
of clinical governanceIt provides the mechanisms for revieingthe 0uality of everyday care provided to
patients ith common conditions) li"easthma or diabetes.
It builds on a long history of doctors)nurses and other healthcare professionals
revieing case notes and see"ing ays forbetter service
It addresses 0uality issues systematicallyand e>plicitly) providing reliable
information.
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Stage 1:
Preparing an audit
Stage 2:
Selecting criteria
Stage 3:Measuring performance
Stage 4:
Making improvements
Stage 5:
Sustaining improvements
Creating the
environments
Using the
methods
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Choosing an audit topic
An identiGed problem De.g.) increasedmortality of ',H;'SS patientsE
,igh volume) high ris") or high costareas of practice
Areas ith high variation in practice
=vidence of clinical eectivetreatment
Availability of clinical guidelines
'evelop a matri> to select theriorities
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Choosing an audit topic
opic Molume *is" Cost PP Physyian 2ngmnt Ptsconcern concern Concern
A()*() )+*() )+*() ()*() )+*() ),*() )-*()
$7;%$ $7;%$ %$;%$ $O;%$ $O;%$ $O;%$ $O;%$ 96;
C$O;%$ $O;%$ $O;%$ %$;%$ $6;%$ $7;%$ $7;%$ 9;$
'%$;%$ %$;%$ %$;%$ %$;%$ $O;%$ $O;%$ $$;%$ O$;$
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'eveloping audit team
Select the team leader
Should be multidisciplinary
Involve all area here the patients ourney
Consider patient ; lay!maninvolvement
*emember that you should be sure
that the or" ill be applied to
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State your aims and
obectives
Write the bac"ground of doing audit
Write aims and obective asstatements or 0uestions
Write in brief the methods are goingto use in the audit
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Agree audit standards
'eGne the standards of aspects to bemeasured
&he standard should follo the aimsand obectives
+se local) national) regional) orinternational standards asappropriate
All standards should be evidence!
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Setting standards
=vidence of setting standards canbe
obtained through:
8iterature revies
Comparison ith other hospitals ;
countries ; benchmar"ing
Clinical udgment
Assessment of current practice
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&ypes of standards
E/ternal2edical literatures
World ,ealth
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Compare e>ternal ith
internal standards=>ternal
Imposed
*emote
+sually authoritative
Hi>ed
No eort for local
group8ess incentive for
further improvement
Internal
Negotiated
Sense of onership
Sometimes non!
rigorous
Adaptable
Considerable eort=volve to pursue
higher standard
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&echnical process for health
care standardsClinical practice guideline: *ecommendation for health care based on
current researchClinical pathay: e>pected)multidisciplinary daily plan of treatment
Algorithm: Bo charts of decision grid
Procedures: ho to) step by step instruction
Protocol: management of patient care
Standing orders: a pre!established set of
medical orders
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&ypes of clinical indicators
'eaths in hospital and afterdischarge
=mergency re!admissions to hospitalafter discharge
Admissions to hospital for certain
conditions
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Criteria Standards
riteria: Semua pasien raat inap harusdiperi"sa oleh 'P3P sebelum pu"ul%$.$$ pagi
Standar: $Q
riteria: ematian pada 'SS
Standar: R#Q
riteria: *aat ulang emergenc! setelah pulang raat status
asthmaticus
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Consider ethics
Although not necessarily re0uireethical approval) audit should be
done according to highestprofessional standards
'ata protection and conGdentiality
In any doubt) consult the audit team
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Select an audit sample
2ay be formally estimated by usingsample sie formula) but morepractical sampling methods are
acceptableIn some instances a small number ofsubects is sucient to dra
conclusion and establishrecommendation
2ay be retrospective) prospective)concurrent
A ilot stud ma be necessar to
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'ata analysis
Compare that data you have ith thestandards.
2a"e sure that you compare the correct
data and standardsAll measurements and comparisonsshould refer the aims and obectives of
the auditHormal statistical analysis may beneeded but not a primary concern
2ay as" for consultation to the audit
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'evelop summary and
recommendations*esults of an audit should bepresented to those individuals
re0uired to agree recommendationsand implementation plan
&hen should be presented to other
colleaguesSubmit to the Audit &eam for furtherdeployment
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'raft audit report
Should be ell structuredIntroduction - ustiGcation for doing audit
Aims and obectives - describe in brief butclear
Standards used - should be stated2ethods - detail of data collection) etc
*esults - description and analysis of data
Conclusion - obective statement supportedby Gndings
*ecommendations - based on audit results
Action plan - action that should be
underta"en including time frame for re!audit
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Implementing change
2a"ing change as recommended intimely and appropriate ay
Combine ith feed bac") consensus)opinions
2a"e sure that hat you are going to
change ill improve your practice &he Audit &eam may observe andgives suggestions during the
implementation process
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*e!audit
Hinal stage of audit cycle
Should be carried out at appropriatetime
*epeat every stage of audit cycleusing the same methodology
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*esearch vs. clinical auditAm I singing theright song?
Is T as eectiveas U?
T is alays moreeective than U?
&o investigate
Am I singing thissong right?
Are e doing T)not U?
We did T in OQof cases?
&o improve
i s k S e v e r i t !
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i s k S e v e r i t !
isk
"re#uenc!
$nsignificant Mild Moderate Severe %er! severe
5
4
3
2
1
Certain
%er! likel!
Possi&le
Unlikel!
are
5 1' 15 2' 25
4 ( 12 1) 2'
3 ) * 12 15
2 4 ) ( 1'
1 2 3 4 5
1 2 3 4 5
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Physician1s co!$etence
2alid evidence Patient1s values
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Patient +ith
pro&lem
Search the
evidence
Criticall!appraise
the evidence
"ormulate
in ans+era&le#uestion
,ppl!the evidence
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C- . Committee
• Clinical Practice -uidelines• Standards of Clinical Care /SPM0
• Protocols• Clinical care path+a!s
• ,lgorithms• Standard perating Procedures /SPs0
du ,udit M isk Man
6eadership penness
Commitment Culture