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Dr. CHANDY ABRAHAM. Chief of Med. Staff. Baptist Hospital. Blore. MS. DNB. MRCS. ADHA.
Clinical Audit is
Clinical Audit has many definitions, this is the one above is used by NICE and the Healthcare Commission
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
Clinical Audit
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
1) 2)
From the definition we can extract two key points about Clinical Audit That we need to set explicit criteria That we need to set standards by which to systematically review care And also a third concept that audit should lead to change
Clinical Audit.Criteria
What do we mean by criteria? The criteria (singular criterion) are the things that we are measuring in our audit. A criterion can cover a single event e.g. Did Staff sign the medical record in black ink? or can cover a multitude of separate events within one process e.g. Was the patient assessed and treated within 2 hours of arrival in clinic? The main thing is that the criteria used are objective, unambiguous and should generally be answerable either yes or no. Lets have a look at some possible criteria
Clinical Audit.Criteria
Is the patient seen in a timely manner? NOT an audit criterion timely is ambiguous. Was the patient satisfied with their treatment? NOT an audit criterion satisfaction is not objective. Could very well be an important area to look at, but it is not strictly an audit. Was the patient seen by a specialist within two weeks of referral? Possibly an audit criterion but is referral absolutely unambiguous? does it mean within 2 weeks of the date the referral letter was sent, date referral letter was received or date patient was put on the waiting list? And what exactly does two weeks mean? Was the patient seen by a specialist within 14 working days of their GP appointment? YES an audit criterion we can know the dates of both appointments and unambiguously measure the time between them.
Clinical Audit.Standards
Once we have decided on our criteria we can define our standards. The standard is how many of the cases that we look at do we expect to meet our audit criterion. We could set the standard at 100% e.g. All patients will be seen within 4 hours of arrival at A&E. Or we might consider 100% to be unrealistic and so set the standard at a lower e.g. 95% of children will receive the MMR vaccination. Or we could set more than one standard e.g. 50% of stroke patients should be SALT assessed within 24 hours and 100% within 72 hours.
Clinical Audit.Standards
But how do we decide what the standard should be? Fortunately there are a lot of sources to help us set fair and evidence-based standard for our audits. These include: Nabh guidelines NICE guidelines the Royal Colleges and professional bodies Scientific research papers Local good practice more on this follows
o o o o
Clinical Audit.Standards
NABH GUIDELINES:
The NABH has policies, procedures and guidelines covering many subject areas. It is straight forward to develop an audit based on policy For example let us take Discharge Policy.AAC15: Organisation defines the content of the discharge summary. So the audit tool would be
Criterion a) Is the DS in the disch.patients notes Criterion b) Does the DS have a clear diagnosis Criterion c) Does it contain info on urgent care YES/NO YES/NO YES/NO Standard is 100% YES Standard is 100% YES Standard is 100% YES
Clinical Audit.Standards
Scientific research Of course, the standards suggested by all of the national bodies are based ultimately on the scientific evidence. The National Library for Health website is an excellent portal to a vast array of information on evidence based healthcare. You can find links to Bandolier, Medline, Clinical knowledge Summaries (formerly PRODIGY), and the Cochrane Library.
http://www.library.nhs.uk/Default.aspx
Clinical Audit.Standards
he National Institute for health and Clinical Excellence or NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health (www.nice.org.uk). NICE provide guidance both on treatment methods (known as clinical guidelines) and the use of specific drugs (known as technical appraisal documents). Often these guidelines will come complete with an audit tool to help you monitor your practice. NICE guidance is highly evidence-based and so is regarded as a Gold Standard by external appraisal organisations such as Welsh Risk Pool and Healthcare Inspectorate Wales
Clinical Audit.Standards
The Royal Colleges and other professional bodies have a great interest in promoting professional and service development through the use of audit. It is worth looking at the web sites of the Royal Colleges and other professional bodies to see what audit tools they may have developed.
http://www.rcplondon.ac.uk/news/news.asp?PR_id=354
Clinical Audit.Standards
Local Good Practice
It may be that you wish to audit something that doesnt fall into any of the other categories. The interest here is seeing whether a situation is static or changing. So for example I could do an audit using the criterion a reply is to be sent to any written enquiries received by my office within 2 working days and the standard all written enquiries to be responded to in this way However it could be argued that since I have set both the criteria and the standard myself it may mean I am not working to any agreed best practice. Wherever possible try to base your audit on policy or national guidelines
Clinical Audit.Summary
Remember audit is about two things
a)
An unambiguous criterion ideally one that can be answered yes or no A standard how many of the cases you examine is it reasonable to expect to meet the criterion? This standard should be set using the best available evidence. Gold Standard NABH,Scientific evid. NICE etc. Silver Standard State Policy based on registry etc. Bronze Standard Locally agreed standards Lets do an audit
b)
Ready?
Audit example
Objective audit?
Yes, this can be measured by anyone in the same way
Unambiguous audit?
Yes, as long as I give the results expressed as miles per gallon every one will know what I mean
Evidence a) The Environmental Protection Agency, an impartial government department, suggests I should get 17.2 MPG Evidence b) The Manufacturers, Lamborghini, suggest 18.1 MPG (under ideal conditions in Tuscany) Evidence c) The Royal College of Sport Car Drivers, a respected professional group, suggest 17.5 MPG
I decide that 17 MPG is a fair figure for the criterion and that a fair standard would be that my car always meets this performance target
Audit example
Our audit is ready to go
We have the subject car fuel economy We have the Criterion The car must achieve at least 17 Miles per Gallon We have the Standard The car must achieve this figure 100% of the time. Finally we need to decide if this is a oneoff measurement or a regular audit. In this case lets do a monthly audit
Results
Date May 07 June 07 July 07 Aug 07 Sept 07 Oct 07 Nov 07 result 17.5mpg 17.9mpg 17.1mpg On Holiday 16.8mpg 16.4mpg 15.9mpg standard met? yes yes yes n/a no no no
Results
Clearly my car is falling below an acceptable standard and I need to take it in for a service. Note that nothing disastrous needs to have happened to my car. The benefit of audit is that I can pick up small problems before they become serious ones. Congratulations, youve just done an audit!
Clear nationally agreed criteria such as auditing to NABH, NICE standards or national Royal College audits Audits that involve multidisciplinary teams to get a complete picture of patient care
A realistic appraisal of how difficult it will be to complete the audit both in terms of time and in being able to access the data.
S have I defined my audit topic well enough for it to be truly Specific M have I chosen criteria such that they are practical and Measurable A Have I enough resources/access to make the audit Achievable R in appraising the difficulty in completing the audit have I been Realistic T Can I give the audit enough effort to complete it in a Timely way.
Is this a good audit subject? We can decide by going down our checklist remember its a guide, not a rulebook, we dont have to answer ever question yes, but if you answer every question no, is it really a worthwhile audit?
Does the prescription contain instructions as to dose and frequency? Does the patient know how to take the medication? Is the patient compliant? Does the patient suffer side effects? Does the patient know their last blood glucose level? Does the patient smoke? Has the dose been added to the medication label? There could well be others you can think of, but these were the ones actually chosen for this particular audit which was conducted at a NHS Trust in Wales in 2005
2) Does the patient know how to take the medication? We feel this is very important so the standard should be 100% YES
3) Is the patient compliant? We feel this is important but the standard should be more that 85% YES since we cannot enforce total compliance. 4) Does the patient suffer side effects? We recognise that some people may suffer side effects, however the evidence suggests it should be less than 15% of patients, so the standard should be less than 15% YES
No
total
No
total
0 patients
48 patients
48 patients
0%
In this case the audit staff realise there actually two distinct patient group those who are prescribed insulin and those who are prescribed oral hypoglycaemic agents. So they modified the audit tool to capture the data slightly differently presented this way we see that the two patient groups have markedly different results for 4 of the 7 criteria
New audit tool with data for insulin dependent patients and those taking oral hypoglycaemic agents (HGA) recorded separately
Insulin YES
Was there Appropriate instructions? Did the Patient know how to take medication
0 patients 8 patients
8 patients
2 patients 3 patients 1 patients 0 patients
0 patients
6 patients 5 patients 7 patients 8 patients
100%
25% 37.5% 14% 0%
34 patients
5 patients 23 patients 12 patients 0 patients
6 patients
35 patients 17 patients 28 patients 40 patients
85%
12.5% 57.5% 30% 0%
Generally no, unlike research, most audits will not require heavy number crunching In fact, a simple graphical display is often the most effective method of sharing your data. Dont be tempted to overcomplicate things just because your computer will let you! Lets have a look at those diabetic patients in the audit we just did who are smokers
35 30 25 20 15 10 5 0 Smoker Non-smokers S1
Smoker 27%
Non-smokers 73%
0 patients 8 patients
8 patients
2 patients 3 patients 1 patients 0 patients
0 patients
6 patients 5 patients 7 patients 8 patients
100%
25% 37.5% 14% 0%
34 patients
5 patients 23 patients 12 patients 0 patients
6 patients
35 patients 17 patients 28 patients 40 patients
85%
12.5% 57.5% 30% 0%
criteria
Appropriate instructions
Patient knowledge patient compliance patient side effects last Blood Glucose known patient Smoking Dose added to label
Criterion 1 It was notable that whilst most patients taking the tablets had appropriate documentation with the prescription, none of those taking insulin did Criterion 2 On the other hand, whilst insulin taking patients were very knowledgeable about their treatment, tablet-taking patients were much less sure of what to do. Criterion 3 Again, whilst insulin-taking patients were very compliant with their treatment, tablet-taking patients were much less so. Criterion 4 Whilst overall side effects were within acceptable levels when look at as separate patient groups insulin-taking patients may be suffering an unacceptable level of side effects Criterion 5 Both patient groups fall below the standard we set for knowing their last blood glucose Criterion 6 A higher than desirable number of patients smoke Criterion 7 A disaster apparently no labelling at all!
Finally why did we score 0% for dose on label are staff unaware of procedure? are staff aware but unwilling to adopt new practice? has new legislation just implemented? However if you suspect a particularly poor outcome for a given criterion you should explain to staff why you are measuring it. It is often the system that is at fault not the individual
Criterion 1 Agree with doctors what details should be on all patients prescriptions New audit standard all prescriptions to contain agreed details Criterion 2 and 3 Ask staff to review what information is given to improve patients understanding of their medication. Criterion 4 Ask the doctors to review the side effects suffered by insulin-taking patients New audit subject specifically investigate insulin-taking diabetics in your area to see if there is generally a higher than expected rate of side effects
Research: Do patients recover better if they take 2 red pills or 3 blue pills per week?
Patient interface: Do patients find it easy to take the correct dose with blue pills or red pills?