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Audit in Screening
Dr LS Wilkinson
South West London
Breast Screening Service
London, UK
What is clinical audit?
Clinical audit is a process that has been defined
as "a quality improvement process that seeks to
improve patient care and outcomes through
systematic review of care against explicit criteria
and the implementation of change”.
https://en.wikipedia.org/wiki/Clinical_audit
https://en.wikipedia.org/wiki/Clinical_audit
The audit cycle
Royal College of Radiologists
An example…
Anuma Shrestha, BSBR, 2015
Where do you start?
• Understand your process
• Guiding principles
eg maximise cancer detection
treat client well
meet process targets
• Create an organisational structure
– Ensure team ownership
Planning your audit programme
• Team approach
• Identify an audit lead
• Plan a schedule
– Rolling audits
– Ad hoc
• Communicate results
– Annual report
– Team meetings
– Regional level
Standardise the process
• Audit template
– Aim
– Define standards
– Describe methods and identify data to be
reviewed
– Time frames
• Dates of audit
• report to be produced
• Repeat the audit
Can’t see the wood for the trees?
Domains
Population
• Identify eligible
cohort
• Contact
individuals
• Ensure equity
• Optimise access
• Time
• Location
• Client satisfaction
Test
• Best test
• Criteria for
positive/negative
outcome
• Further evaluation
• Equipment
• Standardised
reporting
Individual
• Personal
specification
• Training
• Competence
• True positive
• False negative
• Volume
• Speed v
accuracy
• Turnaround times
Types of audits
Administrative
• Audit of QMS e.g.
Work instructions/
SOPs
• Audit of exclusions
• Audit of Campaign
work to increase
uptake e.g. DNA
rates, Health
Promotion activities
at pharmacy,
mosques, gyms
Clinical
• Audit of QA Images
• Audit of Diagnostic
Screening Accuracy
• Audit of Referrals over
5.5 cm but when
reviewed are under
5.5 cm
• Audit of non-
visualised images
Patient experience
• Audit of
Satisfaction
Surveys
• Audit of Clinic
Locations – DNAs,
Accessibility and
Transport
• Audit of DNAs
-audience to participate!
An example….
62 day target for breast cancer treatment
– From date of decision to recall
– To date of first treatment
1. Establish baseline
2. Identify areas for change
3. Communicate and manage change
4. Set up achievable monitoring
Pathway
Last read
Assessment
Results to client
Referral to treating hospital
Outpatient Appointment
Treatment
Second read or
arbitrationCommunication + time to
re-arrange appointment
Capacity for short
notice OPA
Client may need
more time
May need repeat /
additional tests
Optimal referral process
Capacity for
surgery
Optimal and Minimum Standard
From To Target
(days)
Minimum
standard
(days)
Total from
last read
(days)
Last read Assessment 10 21 10 (21)
Assessment Result to client
(inc MDM)
5 9 15 (30)
Results to client Referral received
by surgical team
1 2 16 (33)
Referral Surgical OPA 7 10 23 (43)
Surgical OPA Treatment 14 31 47 (74)
Target waiting times
62 days
0 10 20 30 40 50 60 70 80 90 100
Assessment
Results
Referral
OPA
surgery
31 days
0 10 20 30 40 50 60 70 80 90 100
Assessment
Results
Referral
OPA
surgery
Minimum standard waiting times
62 days31 days
SWLBSS 2013-14
0
50
100
150
200
250
300
350
400
1
9
17
25
33
41
49
57
65
73
81
89
97
105
113
121
129
137
145
153
161
169
177
185
193
201
209
217
225
233
241
249
257
265
273
281
289
297
305
313
321
329
337
345
353
361
369
377
Days to treatment
62 days
383 Cancers, 298 flagged as screening
0 10 20 30 40 50 60 70 80 90 100
Assessment
Results
Referral
OPA
Treatment
Pathway analysis -1 treatment centre
- referred 01/01 to 30/06/2014
62 days31 days
Breach analysis
Number Number
referred
after 31 days
Comments
<63 days 33 1 1 x Client delayed assessment
63 – 65 days 4 1 1 x mastectomy
1 x mastectomy + immediate reconstruction)
2 x ?
66-90 days 7 1 1 x B3 excision, coincidental small cancer
3 x mastectomy (inc 1xbilateral risk reducing)
2 x client holiday
1x surgical capacity
>90 days 3 3 1 x B3, VACE – dcis + 4mm ILC, needed MRI
2 x delayed assessment
Total 47 6
Screen detected
NBSS* v Open Exeter
Screening Cancers
on NBSS (episode)
2013/14
Screening Cancers on
Open Exeter (treatment)
01/9/2013 – 31/08/2014
Percentage of
NBSS/Open Exeter
- very approximate
NLBSS 508 290
(excluding West Herts)
57%
WoLBSS 358 314 88%
BHRBSS 215 157
(excluding Brentwood)
73%
CELBSS 193 186 96%
SELBSS 356 382 107%
SWLBSS 383 336 88%
Issues
1. Documenting screening origin
2. Delays to pathway
– Patient choice
– Complex diagnostics (B3 lesions)
3. Optimise referral process
– Documentation
– Allocated clinic spaces
Establish routine audit
Actions to date
• Require all screening services to log cancer
referrals on cancer tracking
– Issue breach comments for referrals after 31 days
• Ask screening services to provide data on
referrals with breach comments
• Standardise referral proformas (including
details of pathway dates)
How to improve AAA screening by
audit
• Use audit to:
– Confirm standards are maintained
– Strive for continuous improvement
• Incorporate audit into routine work
• Be systematic
– Audit programme
– Standardised processes
• Communicate
– Local
– External
– Use to compare and share good practice

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AAA London Network Event 27 Nov 2015 Louise Wilkinson clinical audit presentation

  • 1. Audit in Screening Dr LS Wilkinson South West London Breast Screening Service London, UK
  • 2. What is clinical audit? Clinical audit is a process that has been defined as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change”. https://en.wikipedia.org/wiki/Clinical_audit
  • 4. The audit cycle Royal College of Radiologists
  • 6. Where do you start? • Understand your process • Guiding principles eg maximise cancer detection treat client well meet process targets • Create an organisational structure – Ensure team ownership
  • 7. Planning your audit programme • Team approach • Identify an audit lead • Plan a schedule – Rolling audits – Ad hoc • Communicate results – Annual report – Team meetings – Regional level
  • 8. Standardise the process • Audit template – Aim – Define standards – Describe methods and identify data to be reviewed – Time frames • Dates of audit • report to be produced • Repeat the audit
  • 9. Can’t see the wood for the trees?
  • 10. Domains Population • Identify eligible cohort • Contact individuals • Ensure equity • Optimise access • Time • Location • Client satisfaction Test • Best test • Criteria for positive/negative outcome • Further evaluation • Equipment • Standardised reporting Individual • Personal specification • Training • Competence • True positive • False negative • Volume • Speed v accuracy • Turnaround times
  • 11. Types of audits Administrative • Audit of QMS e.g. Work instructions/ SOPs • Audit of exclusions • Audit of Campaign work to increase uptake e.g. DNA rates, Health Promotion activities at pharmacy, mosques, gyms Clinical • Audit of QA Images • Audit of Diagnostic Screening Accuracy • Audit of Referrals over 5.5 cm but when reviewed are under 5.5 cm • Audit of non- visualised images Patient experience • Audit of Satisfaction Surveys • Audit of Clinic Locations – DNAs, Accessibility and Transport • Audit of DNAs -audience to participate!
  • 12. An example…. 62 day target for breast cancer treatment – From date of decision to recall – To date of first treatment 1. Establish baseline 2. Identify areas for change 3. Communicate and manage change 4. Set up achievable monitoring
  • 13. Pathway Last read Assessment Results to client Referral to treating hospital Outpatient Appointment Treatment Second read or arbitrationCommunication + time to re-arrange appointment Capacity for short notice OPA Client may need more time May need repeat / additional tests Optimal referral process Capacity for surgery
  • 14. Optimal and Minimum Standard From To Target (days) Minimum standard (days) Total from last read (days) Last read Assessment 10 21 10 (21) Assessment Result to client (inc MDM) 5 9 15 (30) Results to client Referral received by surgical team 1 2 16 (33) Referral Surgical OPA 7 10 23 (43) Surgical OPA Treatment 14 31 47 (74)
  • 15. Target waiting times 62 days 0 10 20 30 40 50 60 70 80 90 100 Assessment Results Referral OPA surgery 31 days
  • 16. 0 10 20 30 40 50 60 70 80 90 100 Assessment Results Referral OPA surgery Minimum standard waiting times 62 days31 days
  • 18. 0 10 20 30 40 50 60 70 80 90 100 Assessment Results Referral OPA Treatment Pathway analysis -1 treatment centre - referred 01/01 to 30/06/2014 62 days31 days
  • 19. Breach analysis Number Number referred after 31 days Comments <63 days 33 1 1 x Client delayed assessment 63 – 65 days 4 1 1 x mastectomy 1 x mastectomy + immediate reconstruction) 2 x ? 66-90 days 7 1 1 x B3 excision, coincidental small cancer 3 x mastectomy (inc 1xbilateral risk reducing) 2 x client holiday 1x surgical capacity >90 days 3 3 1 x B3, VACE – dcis + 4mm ILC, needed MRI 2 x delayed assessment Total 47 6
  • 20. Screen detected NBSS* v Open Exeter Screening Cancers on NBSS (episode) 2013/14 Screening Cancers on Open Exeter (treatment) 01/9/2013 – 31/08/2014 Percentage of NBSS/Open Exeter - very approximate NLBSS 508 290 (excluding West Herts) 57% WoLBSS 358 314 88% BHRBSS 215 157 (excluding Brentwood) 73% CELBSS 193 186 96% SELBSS 356 382 107% SWLBSS 383 336 88%
  • 21. Issues 1. Documenting screening origin 2. Delays to pathway – Patient choice – Complex diagnostics (B3 lesions) 3. Optimise referral process – Documentation – Allocated clinic spaces Establish routine audit
  • 22. Actions to date • Require all screening services to log cancer referrals on cancer tracking – Issue breach comments for referrals after 31 days • Ask screening services to provide data on referrals with breach comments • Standardise referral proformas (including details of pathway dates)
  • 23. How to improve AAA screening by audit • Use audit to: – Confirm standards are maintained – Strive for continuous improvement • Incorporate audit into routine work • Be systematic – Audit programme – Standardised processes • Communicate – Local – External – Use to compare and share good practice