THE NATIONAL AGENDA FOR CLINICAL AUDIT Kenneth Mealy, MD, FRCSI Clinical Director NOCA
Media interpretation of theMid-Staffordshire Report:
Why clinical audit?• To improve the quality of service provided to patients and hence patient care• It is a unique mechanism for ongoing quality improvement• Obliged to audit by the Medical Practitioners Act• Results of audits are a valuable sources of information for clinicians, healthcare managers, patients and the general public.
Clinical Audit• Educational• Benchmark outcomes Clinical against national activity standards Change Audit practice• Allow individual clinicians reflect on Assess against Measure practice standards outcomes – Change based on ‘no blame culture’ and ‘shared learning’
Madden Report found………….• Clinical audit is advanced in many organisations• But not linked to service improvements, planning or resource allocationLourdes Hospital Report (2006)- concluded that robust and effective peer review and auditwas the only process which could have identified thefailings in clinical practice and governance in that hospital
National Standards for Safer Better Healthcare (HIQA 2012)
Features of a hospital which meets theNational Standards include the following:
• The Royal College of Surgeons in Ireland (RCSI) and the Health Service Executive (HSE), under a jointly developed service level agreement have undertaken the establishment, administration and management of NOCA through the NOCA Governance Board.• NOCA established in 2012• The primary purpose is to establish sustainable clinical audit programmes in agreed specialties at national level• Through this framework, feedback will be provided to both clinicians and hospitals in order to ensure that individual and organisational learning occurs.
Improving clinical outcomes through peer review and education• By enabling continuous education through the issue of feedback from its findings.• By working with all stakeholders from both state funded and independent providers• By encouraging the identification and reporting of incidents to improve clinical outcomes and the care of future patients• By ensuring lessons from national clinical audit streams are applied either through the actions of individual participating clinicians or through the identification of more general systems improvements to the care of patients.Addressing the findings of Madden Report and anticipating the requirements of HIQA inspections
Irish Audit of Surgical Mortality• Based on the methodologies used by the Scottish Audit of Surgical Mortality (SASM) and the Australia and New Zealand Audit of Surgical Mortality (ANZASM).• Similarly to these established national audits the main aim of IASM will be to reduce surgical mortality in Ireland, through systematic, independent peer review.• A professional competence scheme associated with RCSI and CAI• Governance Committee of IASM overseeing audit
Irish Audit of Surgical MortalityObjectives of an audit of surgical mortality Reduction of mortality associated with surgery Increasing patient safety, confidence and overall experience Promoting and encouraging reflective practice Identifying systems failures in Irish hospitals and putting changes in place
Irish Audit of Surgical MortalityScope of IASM:•IASM will provide confidential, independent, peer review of all reporteddeaths which occur following an episode of surgical care.•Reporting will be encouraged and shared learning will be the focusThe experiences of SASM and ANZASM indicate that IASM is likelyto result in changes to clinical practice, at both individual andinstitutional level.
Irish Audit of Surgical MortalityA reportable death:Any patient death that occurs in hospital, where the patientis under the care of a surgeonIncluding:• All deaths following surgery• Deaths where patient was under a surgeon but no surgery took place• Surgical deaths, any where in the hospital, regardless of their inclusion in other audits
Irish Audit of Surgical Mortality IASM Workload…………….IASM Workload…………….• Mean of 11,500 public hospital deaths annually (2005-2010 inclusive, HIPE data) Year 2005 2006 2007 2008 2009 2010 Deaths in hospital 11524 11681 11933 11753 11582 10970• Breakdown of surgical deaths in hospital more difficult to ascertain• Medical deaths to Surgical deaths ratio 2:1………we can predict 3,858 surgical deaths• Population based calculations using the experience of SASM….4,000 surgical deaths
IASM – governance process First line assessment No areas for Sign off concern Areas for concern Areas for concern Sign off Second line assessment addressed -Consultant feedback -Clinical Director feedback Review process -Local M&M meeting IASM and NOCARepeat second line assessment Governance Boards
Irish Audit of Surgical MortalityConfidentiality and data protection:•IASM, and its Governance Committee and the Governance Board of NOCAwill endeavour to ensure that all records are retained in the strictest ofconfidence.•Freedom of Information requests will be considered on a case by case basis. Ifpossible requests will be denied, but refusals may be challenged under currentlegislation.•Additionally under current legislation an order of discovery may be granted bythe Courts in a civil action for audit data held by NOCA. Currently the data heldby NOCA cannot be claimed to be privileged and therefore maybe accessiblethrough an order of discovery.•NOCA is actively working with the HSE to ensure that the upcoming HealthInformation Bill will offer full protection to clinical audit data in Ireland.
Irish National Orthopaedic Register To provide a national system for monitoring joint arthroplasty To increase patient safety, confidence and overall experience To optimise inpatient care, waiting lists inpatient and out patient attendances To reduce surgical revision rates / reduce the cost of service To monitor and grade Implant performance To enable early detection and review of outliers efficient and accurate recall process if required To proactively include Consultant Orthopaedic Surgeons in the clinical audit process in both public and private practice
National ICU Audit• Measure – – activity data, case mix and patient outcomes – quality outcomes benchmarked against international standards• Audit of potential organ donors and organ donation• Use audit to drive improvements in ICU performance
• Health Service • Clinician – Quality assurance – Reflective practice • Benchmarking to national – Improved performance and international best- practice Improved patient outcome