Audit: what works and what doesn’t

1. Audit: what works and what doesn’t Dr Jo Hayes Consultant in Palliative Medicine Marie Curie Hospice, Penarth Course Tutor, Diploma in Palliative Medicine / Care, Cardiff University

2. Overview • What audit is • What audit is not • Why perform audit • The audit cycle • Standard setting • Types of audit • Good and bad

3. Definition of audit • Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and implementation of change NICE: Principles for best practice in clinical audit. 2002 • Introduced in the UK in the 1980s • Part of the clinical governance framework in the UK

4. History of audit • Crimean War 1850s • soldiers 7 x risk of death from cholera & typhus than from battle injuries • Mortality decreased dramatically due to:- • Hygiene measures • Fresh water • Fresh fruit and veg • Hospital equipment

5. What audit is • A measure of compliance with defined best practice • Do we know what we should be doing? • Are we doing it?

6. What audit is not • What should we be doing? - research • What are we doing? – survey / review etc

7. Tests care given against known best practice Measures against standards Normal clinical practice No randomisation or placebo Most relevant locally Creates new knowledge Tests hypotheses Experimental May involve randomisation or placebo Generalisable Audit vs Research

8. Why perform audit? To provide a high quality service and improve patient care • Compulsory for all UK doctors • Royal colleges require ongoing departmental audit to be in placed before approving training posts • Meetings are educational • Encourage teamwork • Protected time

9. The Audit Cycle • Identify topic / issues and agree importance Set standards • Observe practice Reflect / consider new standards Compare practice with standard • Compare new practice with standard • Review current practice and implement change

10. What can you audit ? • Structure: premises, staffing, equipment • Process: waiting times, investigations • Outcomes: survival, improved symptoms, achieving desired place of death, improved quality of life etc ‘Not all that can be counted matters and not all that matters can be counted.’

11. Audit standards

12. SMART Standards • Specific (clear, unambiguous and jargon-free) • Measurable – and with a target attached e.g. 100% • Agreed (by all concerned with delivering that aspect of care) • Relevant • Theoretically sound (based on evidence about best practice, reviewed and updated as new evidence becomes available) UBHT Central Audit Office

13. Writing standards UBHT Central Audit Office

14. Targets • Often set at 100% (or 0%) • Exceptions to criteria can allow 100% standard • May set a target below 100% to be realistic for a first audit in an aspect of care where you know that your team performs badly. • Figures suggested by research literature could be set as a target e.g. percentage deaths at home

15. Identify problem & agree need for audit • Team or own ideas of area/issue of concern or with potential for improvement Staff on surgical ward 10 at Memorial Hospital say all their palliative care patients are nauseated / GPs report patients discharged with uncontrolled nausea

16. Determine a standard • SMART • Qualified: existing (search literature) or guided by experts (ask) or agreed by team (discuss) • Quantified: standards should have a percentage attached 90% patients on ward 10 should be asked about nausea as part of their initial assessment 75% patients should have acceptable relief within 48hrs of treatment for nausea

17. Measure current practice • Retrospective/prospective (time factor) • Tools, scales, questionnaires Trawl patients’ notes from ward 10 for medical/nursing entry about nausea (bias?) – define time-scale Trawl drug charts for antiemetic (bias?)

18. Compare practice with standard • Simple arithmetic • If standard already met, was standard too low? • Consider extent of likely improvement 40% of patients on ward 10 had a record of enquiry about nausea in their notes 24% of nauseated patients achieved relief within 48hrs

19. Implement change & run for a time • Team working needed ++ • Education / forms / posters / guidelines Barriers/cascading/resistance/ownership • Agree time to allow change to take effect Ward 10: teaching sessions - need to enquire about nausea & management of nausea/vomiting to nurses and junior drs; simple guidelines flowchart devised and displayed

20. Compare modified practice with standard • Repeat survey – same time frame as first view • Arithmetic comparisons 63% of patients on ward 10 had a record of enquiry about nausea in their notes 18% of nauseated patients achieved relief within 48hrs

21. Reflect and consider future plans • This part is very important in the project…and in life • Barriers / cascading / resistance / ownership Ward 10 - Standards not met Better rate of enquiry about nausea Guidelines not followed/prescribing failure as junior doctors rotated between teaching and re-audit

22. Diploma audit proposal form

23. What makes a good audit? • Relevant topic / team ownership • Multi-professional involvement • SMART standards • Good methodology • Change happens • Change benefits the patients / carers / staff • Complete the cycle • Acknowledge the limitations

24. What makes a bad audit? • Audit for audit’s sake • Seen as a chore • No standards / survey / research • Poor data collection • Unrealistic time frames • Inadequate time to do a good job