Is My Trainee ’ s Audit Good Enough

1. Is My Trainee’s Audit Good Enough Dr. Mark Attah Associate Dean HEEoE

2. Definition • Clinical audit is the systematic and critical analysis of the quality of clinical care. • This includes the procedures used for diagnosis and treatment, the associated use of resources and the effect of care on the outcome and quality of life for the patient. • Clinical Governance = improving standards

3. The 7 pillars of clinical governance Clinical effectiveness Use of information Education and training Staff/staff management Patient/public involvement Risk management Clinical audit

4. Definition – less formal • Taking note of what we do • Learning from it • Changing it if necessary • With the aim of improving care

5. Why do It? • Development of professional education and self regulation • Improvement of quality of patient care • Increasing accountability • Improvement of motivation and teamwork • Aiding in the assessment of needs • As a stimulus to research • Clinical audit aims to lead to an improvement in the quality of service providing:- • improved care of patients • enhanced professionalism of staff • efficient use of resources • aid to continuing education • aid to administration • accountability to those outside the profession

6. Fundamental Principles • All about improving patient care • Should be seen as part of day to day practice • Developing a critical eye on what we are doing • Trying to improve things all the time

7. Clinical Audit Why should you do 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

8. The Audit Cycle What Should Be Happening What Is Happening? What changes are needed

9. Cost cutting exercise Audit Is Not…… Data collection for its own sake A piece of research/study A computer or number crunching exercise A witch-hunt

10. Comparison Between Clinical Research & Clinical Audit PROVE IMPROVE Scientific Inquiry Systematic Measurement Sets Standards Compares Standards Statistical Significance Commitment to Act Testing Hypothesis Standard of Practice New Treatment No New Treatment Increased Knowledge Improved Practice

11. The Audit Cycle Select a Topic (what should be happening) Observe Current Practice (What is happening?) Implement Change Compare with Standard/Guideline (What changes are needed?)

12. Making Audit Easier – Avoid the Blocks • BEFORE YOU START • Time – big audits can eat up time in an already busy schedule, so : • Keep it simple and small • Look at one or two criteria • Engage the whole team – otherwise it will be difficult! Is the team ready? (Enthusiasm, wanting to improve) • WHEN YOU START • Delegate & Share the workload – involve others • Make life easier – use computers to do the laborious stuff (patient searches) • Use protocols / standards already laid by others (why re-invent the wheel?) • Be careful of data collection – choose a topic which does not entail too much data collection to the extent it becomes exhaustive with subsequent loss of enthusiasm

13. Clinical Audit Choosing a topic • Relevant • Potential benefit • To patient or to the organization • Must have a known standard. • Own area of interest. • Areas you can influence.

14. Some Ideas • You can do an Audit of • Structure ie facilities being provided • Eg waiting times, availability of staff, record keeping (all patient records should have a summary card), equipment • Process ie what was done to the patient eg referrals, prescribing, investigations • Aspirin post MI, BP measurements 5 yearly in those aged 20-65 • Outcome ie result for the patient • Eg patient satisfaction, patients with high BP aged between 20-35 should have a diastolic below 90mmHg within the first year of treatment • high risk practices (significant event audits) eg pneumococcal vaccines in splenectomised patients, are significant events being acted upon? • The outcome is the ideal indicator for care but the most difficult to measure.

15. Clinical Audit Planning audit • Decide what to audit (Select topic & write objectives ) • Choose Criteria /Standards / Guidelines • Methodology(sample / timeframe / data source / prospective / retrospective) • Involve stakeholders - & if possible patient • Objectives to measures • Feature (s) of quality • % to meet standard • Exceptions • Definitions • Clarity about data source

16. Choosing a Topic • Remember, topic should be important : • Chronic Disease Management eg referrals or use of lab services (INR’s in warfarin) • Preventative Care eg childhood imms, Cervical Cytology • Prescribing eg post MI, PPI’s (cost issue)

17. Examples • Ways of spotting audit topicsexamples • Important clinical events                         admissions for asthma • “Significant events”                                 patient died of MI – no record of smoking history or BP • Patients' complaints                                too long to get an appointment • Observation                                             no system for ensuring bag drugs up to date • Observations of staff                               patient on Warfarin not had INR for 6 months • NICE subjects                                          post-MI patients on Mx

18. Criteria • = yardsticks • “An audit criterion is a specific statement of what should be happening.” • A statement which • A) defines a measurable item of health care which • B) can be used to assess quality • KEYPOINTCriteria should be explicit. You must demonstrate evidence for justifying them (literature search, Evidence Based!).

19. Criteria – KEY POINTS • Ensure that the criterion is measurable – • ·            “asthmatics should have had yearly PFs” is difficult to measure (how many years will you go back?); • ·            “asthmatics should have had a PF recorded in the past year” is more practical. • Don’t try to audit too many criteria at once – one or two will keep you busy enough. • Try filling in the gaps of the following phrase to set your audit criterion: • “All patients with xxxxx should have had a xxxxx in the last xxxxx.”

20. Criteria • "All eligible women aged 25-65 should have had a cervical smear in the last 5 years." • “All asthmatics should have had a Peak Flow recorded in the past year.” • “All drugs in our doctors’ bags should be in-date.”

21. Standards • “An audit standard is a minimum level of acceptable performance for that criterion.” • Make sure the standard is directly related to the criterion, also :- • Should include a suitable timeframe

22. Clinical Audit Audit standard The standard should reflect the clinical and medico-legal importance of the criterion In the example, “80% of women should have had a cervical smear” “But of those who had an abnormal smear, 100% should have had action taken”

23. Standards • → Examples: • "At least 80% of eligible women aged 25-65 should have had a cervical smear in the last 5 years." • “At least 60% of asthmatics should have had a Peak Flow recorded in the past year.” • “100% of drugs in our doctors’ bags should be in-date.” • The standard should reflect the clinical and medico-legal importance of the criterion. • in the example above, 80% of women should have had a cervical smear, • But of those who've had an abnormal smear, 100% should have had action taken.

24. Clinical Audit 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.

25. Standards • How to set standards • Look at national guidelines • Literature (journals), textbooks • Local guidelines • Discussion with consultants/GPSI’s • Discussion with trainer/partners • KEY POINT : Standards set should be realistic and attainable. Justifiable reasons for the standard set should be made explicitly clear.

26. Standards • Some criteria are so important that they need 100% standard. • However, 100% standards are unusual – patients or circumstances usually conspire against perfection and the standard needs to reflect that. • Your literature search should give you an idea of what standards others have managed to reach. • Your standard needs to follow on directly from your criterion – for example, • “Patients on thyroxine should have had TFTs done in the last year; this should have happened in at least 90% of patients”.

27. TYING IT ALL TOGETHERExamples of Standards & Criteria

28. Preparation & Planning • Must show evidence of teamwork – otherwise you will fail

29. Data Collection (1) • You can collect information from: • computer registers • review of contents of medical records • questionnaires – patients, staff or GPs • data collection sheets

30. Data Collection • Be careful of data collection – choose a topic which does not entail too much data collection to the extent it becomes exhaustive with subsequent loss of enthusiasm • ? Sampling – random or systemic • Only collect essential information • Use computers, ?data collection forms • Use other staff & delegate – don’t do all the work yourself • Set a deadline

31. Clinical Audit Sample selection • Sample selection: • Retrospective • Concurrent • Sample size: appropriate • Multi-professional • All data should be anonymous

32. Clinical Audit Data collection Tips • 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.

33. Presenting the Results • Collect Results • Analyse Results • Summarise Results • Present Results to the team • Simple arithmetic calculations • Use percentages • Results of 2nd data collection presented in the same way as the 1st

34. Discussion – Data Collection 1

35. Comparing Results to Standards

36. Discussion – Data Collection (1) • KEY POINT (Discussion of Data Collection 1) : You need to explain why you think the practice didn't meet the standard that was set.

37. Discussion – why standards not met • Think: What reasons are there for practices not meeting audit standards? • For example : reasons have included: • Practice reasons: • ·         Results having been put down as free text on computer, rather than coded; • ·         Opportunistic rather than formal recall system in use; • Doctor reasons: • ·         Not all GPs were aware of the practice policy; • ·         Not all partners agreed with the policy; • Patient reasons: • ·         Patients refusing to have tests done; • ·         Patients on holiday when tests due.

38. Implementing Changes • The most challenging stage • Audit can tell you whether changes are needed, but it can’t tell you what methods to use

39. Implementing Change • The changes to be implemented should be a team discussion and decision (?a practice meeting) • What to do at the Practice Meeting: • Emphasise what has been achieved. • What are we proud of? • What are we not so proud of? • How can we correct any deficiencies?

40. Implementing Change • Changes must be practical! • How are you actually going to make the changes? • Simply saying “We’ve got to do better” won’t result in change • You need to think through in detail • ·         what needs to be done • ·         who’s going to do it • ·         when • ·         and how. • If you get very low results, you may consider resetting the standards to a more realistic level (but justify it)

41. Implementing Change • KEYPOINT • Just telling people to do things better won't result in change. You need to write up in some detail how the changes will take place. • FAIL Example:    "The GPs agreed to do a serum rhubarb on any patient that they see who is on Viagra" - fail - this wouldn't be likely to pass, as there is no system to help them remember. • PASS Example :   • ”(a) The GPs were given a prompt card that they could stick on their computer screen as a reminder to do a serum rhubarb on any patient that they see who is on Viagra; • (b) the secretary will search every three months for patients who are overdue for their serum rhubarb, and flag it as an active problem on the computer system" - pass - as it should result in change.

42. Closing the Loop • Ie repeating the cycle • Re-evaluate care to ensure that any remedial action has been effective. • Audit is a continuous cycle – if you didn’t meet the standard and you’ve planned changes, you’ll need to repeat the audit to make sure the changes have happened.

43. Conclusions from the Audit •   Summary of main issues learned •  KEYPOINTS: • Comment on any improvements that have resulted. • How well did your proposals for change work? • If you again didn't reach the standard that you set, why not? • If you did, should you be aiming higher next time, or look at something else e.g. whether abnormal serum rhubarbs have actually been acted on? • Where should the practice go from here

44. Repeat the cycle Select or Re-select Topic Evaluate Effects Of Change Define criteria Set standards Implement Changes Plan Methodology Collect & Analyze Data

45. Clinical Audit EVER RISING STANDARDS REPEAT PROCESS IMPLEMENT CHANGES RECOMMENDATIONS OBSERVE PRACTICE SET STANDARD COMPARE WITH STANDARD

46. Clinical Audit Present audit data – write report • Written report • Show how actual practice compares with the audit measures and how the audit findings relate to the objectives (if re-audit were actions implemented?) • Use the following headings: • Care Group; Audit title; Audit team; Date; Objectives; Measures/standards; Data Source; Sample (timeframe); Results; Conclusions; Recommendations; Actions

47. How To Fail • No justification for choice of audit • No justification for criteria/standard settings • Not having explicit criteria/standards • Setting unreasonable standards • A general lack of evidence based literature or using material that is not peer referenced • Not explicitly displaying teamwork in the “method” – must give specific examples • Numerical errors re: data collection • Presentation of data collection eg no graphs, no percentages (ie the reader has to do the hardwork him/herself) • Not giving much thought to “changes to be evaluated” and not being specific enough. Not delegating specific changes to specific people/persons. • Poor conclusions and what the process has taught you • No inclusion for possible sources of bias • References not properly quoted

48. Checking GPR Understanding • DISCUSS THE FOLLOWING STATEMENTS • An example of the Audit of process is audit of referrals to hospitals. • Audit usually consumes an extensive amount of resources (of time, money etc.). • Rare conditions should be audited. • The higher the standard the practitioner starts with, the stronger is the resulting audit. • Maintaining clearly written notes of at least 20% of patients who are sensitive to penicillin is an acceptable standard in general • practice. • The higher the amount of data the practitioner collects, the easier is the decision making process in audit. • The most challenging stage in Audit is implementing change. • In data collection all in the target population must be included. • The agreed standards can be reset at realistic percentages after the first round of data collection.