Current Drivers for Clinical Audit

1. CLINICAL AUDIT NHI National Study Day March 2010Presented byMajella Daly, BRad, Hdip, MAHealthcare Audit Team,Quality and Clinical Care Directorate, HSEmajella.daly@hse.ie

2. Current Drivers for Clinical Audit • To improve the Quality of patient/client care • DOHC 2001 Health Strategy – Quality and Fairness • HSE Transformation Programme- standards based performance measurement • Serious Incident Investigations and Reports • Review of Medical Consultant Contract • Mental Health Commission Quality framework • HIQA Quality Standards for Residential Care Centres for Older people 2009 • Professional Standards e.g. An Bord Altranais

3. Patient Expectation

4. Developments in Clinical Audit Nationally 1. DOHC Building a Culture for patient Safety – Clinical Audit Implementation Project- public and private healthcare providers • HSE Quality and Risk Standard and self assessment process • Risk Management framework • HSE Healthcare Audit criteria and Guidance 1-3 available on hsenet.hse.ie/HSE_Central/Office_of_the_CEO/Quality_and_Risk/Documents/ 5. Audit part of staff role and responsibility e.g. CNS • Clinical Audit Professionals employed nationally – Irish Clinical Audit network (ICAN) www.clinicalaudit.ie

5. Irish Clinical Audit Network • Mission • To create a national network for healthcare staff who have a working remit in clinical audit, to enable a shared approach to clinical audit and offer support and advice to members. • Part of the TOR • To link with the other elements of Clinical Governance nationally

6. HIQA Quality Standards and Clinical Audit • 32 Standards grouped into 7 dimensions • Person Centred and Focussed on outcomes • Section 7 Governance and Management: Standard 30- Quality Assurance and Continuous Iprovement • Clinical Audits and resultant action plans provide evidence to inspectors that standards of care are being audited and improvements in practice are identified and rectified.

7. Audit is underpinned by CQI. • Continuous Quality Improvement is a process by which services provided can be improved on a continuous basis. • It’s a continuous process that permeates every aspect of health services policies and services development. • Every employee has a vital part to play in the process.

8. Principles of Continuous Quality Improvement • Customer driven • System optimisation and alignment with strategy, goals and values • Continual learning and dissemination of good practice • Management through knowledge • Collaboration and mutual respect for all within the organisation (Continual Improvement principles: An introduction to concepts and tools for healthcare leaders; Executive Learning Inc. 1996)

9. Principles of Continuous Quality Improvement Supported by: • Strong leadership • Clear communication • Proactive culture • Supportive structure • No or low-blame culture • Multi-disciplinary working • On-going continuing professional development.

10. Definition of Clinical Audit. • Clinical Audit is a clinically lead quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and acting to improve care when standards are not met. The process involves the selection of aspects of the structure, processes and outcomes of care which are then systematically evaluated against explicit criteria. If required improvements should be implemented at an individual, team or organisation level and then the care re-evaluated to confirm improvements. (DOHC Building A Culture for Patient Safety 2008)

11. Definition • “Clinical Audit is the comparison of actual practice against agreed, documented, evidence based standards with the intention of improving patient care”. (M. Ferris)

12. Principles of Clinical Audit. • Multi-disciplinary in character • Due regard for the patient’s perspective • Audit undertaken as an integral and routine part of day to day work • Reviews clinical care against pre-set professional standards to identify opportunities for improvement • The process is repeated to ensure effective change • The results of the audit are specific to each particular setting • Does not require large numbers.

13. Clinical Audit Cycle

14. System for Clinical Audit. Inform /Educate Staff Negotiate Re-Audit Discuss Audits Presentation and feedback Select Topic Complete Proposal Form Start Audit

15. Purpose of Audit • Improve the quality of patient care • Educate and train healthcare professionals • Make best use of resources • Improve service organisation • Identifies and promotes good practice • Improves communication and liaison between staff and patients.

16. What Audit is not! • Anecdotal Reflection • Counting activity e.g. numbers of patients on a certain treatment • Research - research aims to identify best treatment. Audit aims to put research into practice by measuring the gap between practice and evidence based practice.

17. Clinical Audit ‘Are we following best practice?’ Measures against standards Is usually carried out on a small sample over a short period of time Results relevant to the local setting. Research Creates new knowledge Is based on an hypothesis. May involve patients receiving completely new treatment Usually carried out on a large scale over a long period of time Results are generalisable. Is it Audit or Research?

18. Who does Audit involve. • Involves a commitment from Management • Involves all professionals, healthcare workers whose job affects the quality of the service we deliver • Quality of our services depends on all staff • Patients.

19. Practical Clinical Audit Project Management Eleven steps to successful audit!

20. Step One: Win the support and commitment of colleagues • Commitment to participate • Supportive • Multi-professional approach where appropriate • Understand the aims • Understand their role in it • Management should also be involved.

21. Step Two: Decide on an area to audit. • Part of a prioritised programme of audit locally, regionally or nationally • High volume, high risk, high cost • Is there good evidence available? • Is there evidence of a serious quality problem e.g. complaints, incidents, complications rates, hospitals transfers, staff concern. • Should include an assessment of process and outcome of care • Measurable • Amenable to change

22. Risk Management

23. The Evidence - Research

24. Step Three: Who will do the audit? • Multiprofessional Team • Support quality staff

25. Step Four: Set objectives for audit • SMART • Specific • Measurable • Agreed • Realistic • Timely • Use verbs to describe your objectives

26. Step Five: Standards to measure current practice - establish baseline. • Agree standards-evidence base, research • Consultation with everyone • Measurable elements known as audit criteria • Establishing a baseline is important to measure current standards.

27. Step Six: Collect reliable valid data. • Prospective or retrospective • Agreeing sample size • Data collection tool design • Pre-test • Pilot • Collect data.

28. Step Seven: Analyse the results • Coding data should be anonymous • Data entry • SPSS, EPI-info, Excel, Access • Comparing audit results with standards set • Identifying gaps.

29. Step Eight: Identify areas for quality improvements

30. Step Nine: Develop the action plan • What standards were not met? • Identify areas for quality improvements • Prioritise these - areas of major concern etc • Decide where responsibility for implementation lies - identify key personnel.

31. Step Ten: Implement the Action Plan • Who’s responsible? • What resources? • What timescale? • Accountability structures e.g. clinical audit committee.

32. Step Eleven: Re-audit to measure effectiveness of changes • This is called the Audit Cycle and it is only by closing the loop that the process is complete

33. Choosing a Subject. May be specific to: • Structure • Administrative Process • Clinical Process • Clinical Conditions • Positive Outcomes • Negative Outcomes.

34. Standards for audit? • Overseas, international standards e.g. NICE, SIGN • Research- undertake a literature search and review - www.athens.ac.uk • Grey literature e.g. conference papers • HIQA, HSE and NHI • Opinion leaders in the service • Current practice.

35. Audit measurement. How? • Examination of information already existing • Prospectively collected data • Information from outside the practice e.g. GMS data, supplies dept • Information from patient /family/staff surveys/interviews.

36. Against Clinical Audit. • I am too busy • I haven’t got a computer • My colleagues won’t agree • All the figures are wrong • You can’t measure my practice /ward /dept • We can’t afford to improve anything • I’m retiring soon!

37. Practical Issues - what do you need for clinical audit to happen in your own work areas? • Brainstorm

38. Practical Issues - Resources • Agreed staff time • Access to support staff • Available clinical data • Access to information on audit • Training budget for quality improvement • Resources for quality improvement.

39. The Winning Formula! • Teamwork • Constructive Projects • Results /feedback • Measurable change • Improved Systems • Patient Gains

40. ‘Not everything you can count, counts, and not everything that counts can be counted’ Albert Einstein

41. Useful websites www.hqip.org.uk Healthcare Quality Improvement Partnership www.hsenet.hse.ie/HSE_Central/Office_of_the_CEO/Quality_and_Risk/Documents/ HSE Healthcare Audit criteria and Guidance www.clinicalaudit.ie www.hseland.ie5-module Clinical Audit eLearning programme, suitable for all healthcare professionals.