Gloucestershire’s Clinical Audit Services

1. Gloucestershire’s Clinical Audit Services Primary and Community Health Care

2. History • What is clinical audit and the clinical governance framework • Constitutional principles of the PCCAG • Philosophy and structure of audit projects • Examples of collaboration with countywide audits • Examples of other work from community teams (Mark) Break • New team and structure • Range of services we are supporting • Current work • Future work • New accountability structures • Current issues Questions and suggestions

3. History • LMC • MAAG – Medical Audit Advisory Group under Gof Fairburn • PCCAG – Primary Care Clinical Audit Group under John Rocyn Jones

5. History • LMC • MAAG – Medical Audit Advisory Group under Gof Fairburn • PCCAG – Primary Care Clinical Audit Group under John Rocyn Jones • PCCAG (The Primary and Community Care audit Group)

7. It all started with • “Working for patients”

8. It all started with • “Working for patients” • “A First Class Service”

10. It all started with • “Working for patients” • “A First Class Service” • “The NHS Plan”

12. It all started with • “Working for patients” • “A First Class Service” • “The NHS Plan” • “Supporting Doctors, Protecting Patients”

13. It all started with • “Working for patients” • “A First Class Service” • “The NHS Plan” • “Supporting Doctors, Protecting Patients” • “Organisations with a memory”

14. It all started with • “Working for patients” • “A First Class Service” • “The NHS Plan” • “Supporting Doctors, Protecting Patients” • “Organisations with a memory” • “Assuring the Quality of Medical Practice”

16. On top of that we have had • National Service Frameworks • Commission for Health Improvement • NICE • PAF/PALS/VOICE • Revalidation and reaccredidation • PLPs, PDP’s and PPDPs • Commission for Healthcare Audit and Inspection

17. A definition of audit “The systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient” Working for Patients 1989

18. A definition of audit “The systematic critical analysis of the quality of medical care, including the patient experience, the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient” Working for Patients 1989 (abridged!)

19. Types of audit • Managerial • Financial • Clinical Multi-disciplinary Cross boundary Cohort based Comparative Significant event based

20. Effective audit • An educational activity • Promotes understanding • Resource effective • Raises standards • Promotes change • Source of information • Peer led

21. The audit cycle Problem or objective identified

22. The audit cycle Problem or objective identified Criteria agreed and standards set

23. The audit cycle Problem or objective identified Criteria agreed and standards set Audit (Data collected)

24. The audit cycle Problem or objective identified Criteria agreed and standards set Audit (Data collected) Identify areas for improvement

25. The audit cycle Problem or objective identified Criteria agreed and standards set Make necessary changes Audit (Data collected) Identify areas for improvement

26. The audit cycle Problem or objective identified Criteria agreed and standards set Re-audit Make necessary changes Audit (Data collected) Identify areas for improvement

27. The audit cycle Problem or objective identified Criteria agreed and standards set Re-audit Make necessary changes Audit (Data collected) Identify areas for improvement

28. Criteria and standards • Criteria are those aspects of care that you wish to examine • Standards are the pre-stated or implicit levels of success that you wish to achieve

29. Structure, process and outcome • Structure refers to resources you have available (including current knowledge, skills and attitudes) • Process refers to what you actually do, e.g. a protocol • Outcome refers to the health benefits, cost effectiveness or patient satisfaction

30. Why audit • Useful clinically • Encourages teamwork • Improves patient care • Financial benefits (sometimes!) • Effectively an obligation

31. Problems with audit • Audit and research • Statistical verification • Outcome measures and proxies • Reliance on manual systems • Closing the loop - introducing change and re-audit

32. What promotes change • Learning from what worked before • Mapping to staff’s own values • Investing in leadership • Investing in teamwork • Good things come in small packages • Support innovation • Be enthusiastic • Prioritise

33. Audit in its wider role Risk management Practice accreditation Personal re-accreditation Practice development plans Research Postgraduate medical education Evidence based medicine Audit Appraisal Personal development plans Dissemination of guidelines

34. Principles in Gloucestershire • Professionally led • Seen as an educational process to improve the quality of patient care • Part of the continuing professional development of all clinicians and supporting staff

35. Principles in Gloucestershire • Help practitioners, whether individually or together, evaluate their clinical practice against agreed standards of effective care. • Act as an audit resource to support the delivery of effective clinical governance in each PCT. • Develop and execute an ongoing, evidence-based audit programme agreed by the main stakeholders, which reflects national and local priorities. • Provide training in the principles of clinical audit.

37. Previous work in primary care • Support for audit undertaken • by individuals • eg nurse triage • by teams • eg monitoring of patients on lithium, thyroxine • across PCGs/PCTs • eg emergency contraception, repeat prescribing and….

38. Previous work in primary care • County wide • diabetes • atrial fibrillation • osteoporosis • coronary heart disease • Schizophrenia • Principles

39. Hallmarks of a successful audit project • based on research evidence • supported by key individuals • includes all perspectives • seen as timely; relevant • is adequately resourced • attracts a high level of participation • is well-designed; produces accurate and valid data • results in change at all levels

40. Evidence-based • explicit criteria • evidence cited • strength of evidence • target standards • agreed by practitioners

41. Supported by key individuals • key stakeholders involved • to influence audit design • to acknowledge possibility of change • to communicate! • to develop shared vision • value of independent coordinating group

42. Different perspectives • managers • clinicians • patients • wider understanding

43. Timely; relevant • where is it on individual agendas? • competing priorities • assess the climate

44. Adequately resourced • money • staff • time

45. High level of participation • gain county-wide perspective • comparative results • reduce isolation • involvement - “bandwagon” • demonstrable health gain

46. Well - designed • with appropriate methodology • consider choice of sample • with clear instructions • addressing different information systems • piloted • aim • results reflect practice • errors, missing data minimized

47. Data analysis and results • data internally consistent • results clearly presented • caveats • interpretation

48. Results in change • danger of the audit semi-circle • at all levels • practice/team • PCG/PCT • county • action plans • use of study day / conference • challenge complacency • forum for updating knowledge • increase communication / network