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Grant Phelps - Department of Health & Human Services, & Deakin University - “Why Clinical Audit?  Is this just another quality assurance tool or can it be transformative?”
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Grant Phelps - Department of Health & Human Services, & Deakin University - “Why Clinical Audit? Is this just another quality assurance tool or can it be transformative?”


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Grant Phelps delivered the presentation at the 2014 Clinical Audit Improvement Conference. …

Grant Phelps delivered the presentation at the 2014 Clinical Audit Improvement Conference.

The Clinical Audit Improvement Conference explored the role of clinical audit in the new era of National Care Standards.

For more information about the event, please visit:

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  • 1. “Why clinical audit? Is this just another quality improvement tool or can it be transformative?” Grant Phelps Sydney August 25th 2014
  • 2. …“it depends”
  • 3. Declaration - My inbuilt bias We work for the owners of the health care system We have a professional obligation to leave the health care system in a better state than we found it  Cost, Safety, Consumer focus Improvement is all of our business  This is no longer optional The core business of health care is the delivery and receipt of clinical services.  Everything else is subservient to and supports that
  • 4. “Our Health care systems are perfectly designed to achieve the results they achieve” Don Berwick It’s a miracle it isn’t worse - our system survives on professionalism and goodwill
  • 5.
  • 6. We haven’t solved the safety problem yet 1 10 100 1,000 10,000 100,000 1 10 100 1,000 10,000 100,000 1,000,000 10,000,000 Number of encounters for each fatality Totalliveslostperyear REGULATEDDANGEROUS (>1/1000) ULTRA-SAFE (<1/100K) Health Care Mountain Climbing Base Jumping Driving Chemical Manufacturing Chartered Flights Scheduled Airlines European Railroads Nuclear Power Note: both dimensions are logarithmic scales c/o Dr. Rene Amalberti Scheduled Airlines
  • 7. We’re still changing the paradigm from.. “what’s the matter?” healthcare to … “what matters to you?” healthcare
  • 8. The business of Health Care is… The clinician patient interaction Supported by Management Influenced by policy This is where value is created, and destroyed And where the real improvements are to be found
  • 9. The transformation vision Experience of Care Improving Population health Reducing unit cost of care Berwick et al Health Affairs May/June 2008
  • 10. Source: Airbus industries 2014 A transformed industry?
  • 11. Fatal accidents vs number of flights
  • 12. We know how to fix healthcare. •Better care is systems care • Understanding clinical care in process terms • systems so that clinicians can do it right first time Better care is cheaper care Those saved resources can be used to do good It is possible to close the quality gap Clinicians driving clinical improvement through learning
  • 13. Clinical Microsystems Patient and Community Clinical Service deli Translating management into outcomes Receive care Improving healthcare delivery = changing behaviours Improving healthcare?
  • 14. Kizer K. NEJM 2003
  • 15. Health Affairs 2002 Health Affairs, 2002
  • 16.
  • 17. Measuring healthcare: clinical audit
  • 18. 1916 End Result cards
  • 19. Codman led thinking on Measuring outcomes Benefits of public reporting Transparency as an enabler of improvement Admitting error as prelude to improvement Creating a Learning organisation
  • 20. Clinical audit is largely a QC activity Continuous Improvement Quality Assurance Quality Control against a standard Quality Improvement – against ?
  • 21. Clinical audit for most clinicians is…? “the systematic review of elements of clinical care against predetermined criteria…” It’s about quality control Does it change behaviour?
  • 22. Individual Quality Control adjusted colonoscopy completion rate 2007. data presented in batches of 10 as % completion rate 70% 80% 90% 100% 1 3 5 7 9 11 13 15 17 19 21 23 25 27 completion mean target
  • 23. Audit can tell us what we already know..
  • 24. Registries and clinical improvement Risk of death with after hours discharge from ICU 1 in 7 patients are discharged from ICU after 6pm Relative risk of death 1.34 ( CI 1.30 – 1.38 p<0.0001) (Source – ANZICS Core) Now what do we do????
  • 25. Clinical audit should be about QI… “the systematic review of elements of clinical care against predetermined criteria, with the aim of identifying areas for improvement and then developing, implementing and evaluating strategies intended to achieve that improvement 2007
  • 26. Clinical audit should help us transform the system to this… A care system which generates no needless… • Deaths • Pain • Delays • Helplessness • Waste
  • 27. What would a transformed organization look like? A place where collaboration thrives; where everyone collaborates to improve both care and the organization – where organizational values really mean something… A place where the consumer is the business, in every way A place where staff experience reward and joy in their work Resources are sufficient
  • 28. Transforming our thinking on quality The right person Makes the right choice for them For the right reasons To receive the right treatment At the right price By the right person At the right time In the right place For the right outcome
  • 29. VTE prophylaxis - Does feedback work? Pre intervention November 2007 Post intervention May 2008 Result Numbers of cases reviewed 236 300 High risk cases (Defined risk assessment completed) 80% 83% Prophylaxis (Target 60%) as per ANZ Guidelines 34.9% 43.2% 8.3% Improvement but 16.8% below target Yates M., et al IMJ 2013
  • 30. The effects of guideline dissemination and implementation strategies Across four cluster RCT’s of various educational strategies, a median absolute improvement of +8.1% (range +3.6% to +17%) compliance with guidelines was observed. The impact is limited and sustainability is tenuous Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2003
  • 31. Cochrane review 2006 Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively Jamtvedt G., et al Cochrane Database of Systematic Reviews 2006
  • 32. What do we know? “audit and feedback will continue to be an unreliable approach to quality improvement until we learn how and when it works best. Conceptualising audit and feedback within a theoretical framework offers a way forward” Foy R et al BMC Health Services Research 2005;5(1):50
  • 33. What if you change the system? Clinical Site Baseline May 2008 (n=300) Post NIMC Change Jan 2009 (n=43) Follow up Audit September200 9 (n=40) Follow up Audit November 2009 (n=40) Medicine 43.2% 83.7% 95% 82.5% Surgery 60 % 78.4% 69% 67% Yates M., et al IMJ 2013
  • 34. Why isn't clinical audit more effective? Lack of clear purpose – QI vs CQ Data collection and management resources Lack of expertise in design and analysis Lack of planning Lack of clinical engagement and leadership Poor professional culture and poor relationships within and between teams Lack of integration with other activities ( within a clinical governance framework) An inability to improve care processes
  • 35. Culture change to drive Improvement in health care delivery Clinical Risk / Safety as our tool Retrospective management level Based on identified outcomes, which might be random. Is really Quality Assurance in disguise..  Are we good enough?  Element of big stick ? Real culture change Quality improvement as a tool Prospective Owned at Coal face level Based on process improvement Quality Improvement will reduce risk  How good can we be? Success = culture change
  • 36. What drove this improvement? WAASM - DVT prophylaxis MJA 21 Nov 2005
  • 37. Bampton P., et al BMJ 2006;332;1320-1323 Understanding and improving the care process
  • 38. Audit makes a difference to outcomes, but improving care processes is the main game Mortality Rate 6.04 3.65 0.71 8.57 0 1 2 3 4 5 6 7 8 9 2002 2003 2004 2005 Year %
  • 39. So…. We’ve moved on from ‘medical audit’ to something that’s more about understanding and improving systems?
  • 40. And it that’s the case, shouldn’t we be talking about suites of measures which are based in the process of care and which can tell us something about the system and how to improve it?
  • 41. High performing healthcare organisations understand the why and the how ..….  Why an organization produces its services  Who are the customers and what are the broader social needs the organization fulfils?  How those services are produced  What are the processes of daily work or, in other words, the means of production?  How the organization improves its services  What are the improvement activities or means of improvement? Batalden, P.B. and J. Mohr. 1997. Quality Management in Health Care 5(3): 1-12.
  • 42. HBR 1995
  • 43. The major enabler: Clinical Engagement ‘Full collaboration in relentless improvement’ Lee and Cosgrove; HBR June 2014
  • 44. Engaging Clinicians… “Clinicians are the process” Culture Quality based culture - “It’s all about the patient” Leadership Clinical leaders with ability to make decisions Welcome bottom up leadership Alignment Sharing knowledge Teamwork Ensuring clinical teams drive quality through department level Adapted from Kaplan & Norton “Balanced Scorecard” HBS press 1996
  • 45. Engaging clinicians Create shared goals See clinicians as drivers of clinical processes (and thus the source of cost and harm) Leverage the personal commitment to quality  Self motivated and autonomous  Lack understanding of ‘system’. Reinertsen J. et al “Engaging Physicians in a shared Quality agenda. IHI 2007
  • 46. Necessary but not sufficient? Quality control enabling quality improvement
  • 47. Summary Clinical audit  terminology needs to change  It is not an end in itself It’s just a quality tool and by itself isn’t terribly helpful if you’re interested in real improvement Transformation requires much much more – systems and systematic improvement is the main game  Clinical audit but one input Clinical Engagement is essential in understanding and changing any care process