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  1. CLINICAL AUDIT Professor Syed Amin Tabish FRCP (London), FRCP (Edin), FAMS, MHA (AIIMS)
  2. Clinical Audit ‘Clinical audit is the systematic critical analysis of the quality of healthcare , including the procedures used for diagnosis , treatment and care, the use of resources and the resulting outcome and quality of life for the patient’.
  3. Why Audit? Audit allows one to see how near one gets to the standards. It shows how our systems and every day PRACTICE let us down. it gives us opportunity to change to allow our efforts to be optimized. Audit puts the control of the quality of our work into our own hands.
  4. The clinical audit cycle National Institute for Clinical Excellence. Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press, 2002.
  5. Audit Cycle What we are doing ? Collect (data or performance) Comparison [Assess performance against criteria & standard] Identify Needs for change Implementing change Define Criteria & Standards Select the issue Audit Cycle
  6. Goals of Quality assurance Increasing the capacity & effectiveness of health services Increasing efficiency of HS Maintaining good standards for HS Improving the outcome on interventions Increasing consumer satisfaction Increasing effectiveness of community participation
  7. Elements, Criteria, Standards Elements: represent the component parts of an activity Criteria: selected elements that are precise, clear, effective, measurable, & able to reflect the quality of that activity Standards: when the criterion has been defined at a descriptive or numerical level
  8. The Consumer Quality means from consumer point of view: A service that is available at all time Easily accessible Feeling of comfort Politeness of health providers Disappearance of symptoms
  9. Framework of Quality Structure: Manpower, drugs, equipment, buildings, records, etc Process: content, configuration Outcome: the results, the impact
  10. Quality Assessment Collection of data Analysis of trends Interpretation of results Corrective actions Follow-up
  11. Doing AUDIT Audit is concerned with monitoring performance against established stadards, and implementing appropriate change, as necessary, to meet those standards Audit Cycle/Spiral: Setting standards Monitoring performance Effecting change
  12. Types of Standards Protocols Options Guidelines: how the doctor should behave in most instances Standards: have a ring of absoluteness among them Criterion: standards with flexibility (all diabetics should have their feet inspected once a year)
  13. Monitoring Performance Collection of data Retrospective data collection (death & disaster type of case reviews) Prospective data collection: collecting data ‘on the run’
  14. Effecting change Audit is all about change Comparing present behaviour against standards and being willing to change that behaviour in order to bring yourself or your practice up towards those standards
  15. Approaching Change Education Feedback Financial reward Financial penalties Participation Administrative change (terms & conditions put in service contract)
  16. Achieving Change Be involved Choose a meaningful topic Set suitable standards Set an appropriate time scale for change Reward success Change for the better in a purposeful manner
  17. CLINICAL AUDIT It is primarily for accountability, for management control, for professional development It is multidisciplinary: concerns not only the clinical practice within individual professions but also demonstrates the contributions made by each & the organizational links between them
  18. Frame For Assessing Care Structure Process Outcome In which description , measurement, comparison and evaluation of quality of health care can be made. QUALITY OF: Building ) Equipments ) STRUCTURE Systems )
  19. Structure Health care is likely to be more effective if it carried out in comfortable surrounding with right equipment and by most appropriate people. The presence of structure attribute increase the chance of good quality of care but does not assure it. Quality assessed primarily on basis of doctors performance, So the performance of health professionals embodies the other two constituents of quality (process& outcome). Audit of Structure - assess quality of environment in which care is provided.
  20. Audit of process Process describe the care given by practitioner i.e. what the practitioner does , the sum of actions and decisions that describe a persons professional practice. Treatments Diagnosis / Intervention Dr. / Patient Communication Audit of process : describe quality of work done by health professionals.
  21. Patient current and future health status. Definite indicators of health, and describe effectiveness of care. Success in outcome Preventing Suffering of Illness Audit of Outcome - assess the benefit achieved by patient. Outcome
  22. The benefits of audit to a practice Bringing about change. Reducing organizational and clinical error. Improving effectiveness. Demonstrating good care. Meeting patients’ needs and expectations. Stimulating education. Promoting higher standards of hospital and community care for patients. Securing effective medical defense through risk avoidance.
  23. Methods of Clinical Audit Peer Review Audit should involve the Objective Peer Review of patterns of care, be sensitive to the expectations of patients, & be used on scientific evidence of good medical practice Case for review can be selected randomly or by pre-agreed criteria Patterns of practice can be compared with Guidelines
  24. Methods of Clinical Audit Adverse Patient Reaction involves systematic identification and analysis of events during a patient’s treatment which may indicate some lapse in the quality of care Screening criteria are defined by the participating clinicians: Peri-operative deaths Admission to ICU Unplanned second operations Unplanned readmissions
  25. Methods of Clinical Audit Criteria for whole hospital includes: Admission because of complications of out-patient management Readmission for complications or incomplete management of problems on previous admission Unplanned removal, injury or repair of organ or structure during surgery/invasive procedure Unplanned return to theatre Nosocomial infection
  26. Methods of Clinical Audit-II Pathology report varies significantly from pre-operative diagnosis Cardiac or respiratory arrest Cardiac arrest within 48 hours of surgery Neurological deficit on discharge not present at the time of admission Unexpected transfer to a High Dependency Unit Unexpected death
  27. Methods of Clinical Audit-III Clinical Indicators: monitoring of routinely generated data within a specialty, in order to identify exceptions or trends which may merit detailed adhoc review Includes Workload, Access (waiting times), Appropriateness, Outcome, Information. Efficiency (Theatre sessions cancelled)
  28. Methods of Clinical Audit Topic Review Analysis of an agreed topic may be carried out by prospective study or by retrospective analysis A systematic review of a large enough sample of similar cases in order to identify, quantify & compare patterns of practice Indicators: colonic resection, cholecytectomy, CABG, TURP, prolapsed disc, orchidopexy, hysterectomy, cataract, radical neck dissection
  29. Methods of Clinical Audit Medical Records Clinical guidelines for minimum standards of records are required Auditing the records of every patient who had general anesthesia or adverse reaction or death
  30. Clinical Audit Methods Therapeutics Audit of drug usage Appropriateness Route of administration Serum monitoring On what criteria are patients selected/refused (diagnosis, disability, disease, age) How should treatment be conducted (machine, safety, staff) When should treatment cease
  31. Methods of Clinical Audit Other Methods Diagnostic investigations (Radiology) Autopsy Random case Review Patient Satisfaction Comparative Audit (confidential pooling of aggregated data, standard definitions & formats of individual doctors compared with their peers)
  32. Audit of Outcome Assessment of outcome is much more difficult Indicator: post-operative mortality (account of severity of illness & fitness of patient for operation be taken) Death certificates are unreliable Random control trials for evaluating outcome of surgical interventions is universally accepted Audit of quality of life after surgery
  33. What matters Patients are likely to be satisfied with their treatment if medical and nursing staff observe the rules of communication, courtesy, concern, competence & comfort Prevention by control of their origin is cheaper, more humane and more effective than intervention by treatment after they occur.
  34. PLAN AN AUDIT 1. Define the nature of perceived problem. 2. Produce a clear written statements of aims. 3. Select the most appropriate method. 4. Decide upon the other basic design features. 5. Identify the main analysis to be made. 6. State who the audit will involve. 7. Start small. 8. Have a short time - scale. 9. Proceed step by step. 10. Indicate how the possible need for changes to be handled.
  35. Data Collection 1.Routine practice data. 2. Medical Records. 3. Practice activity analysis. 4. Prospective recording of specific data. 5. Surveys. 6. Interviews. 7. Direct Observations.
  36. How To Do It ? 1.Routine performance monitoring. 2. Practice activity analysis. 3. Surveys and Interviews. 4.Direct observation. 5. Confidential enquiries. 6. Use of tracer. 7.Pracice visiting.
  37. The stages of clinical audit National Institute for Clinical Excellence. Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press, 2002.
  38. Analysis Analysis must reflect the audit aim. Analysis should always be focused. First step: examine the frequency of occurrence of each item or event [example 8 out of 40 may be widowed , 15 out of 40 may be taken more than one drugs…etc] each of these could be expressed as percentage. Next step construct the tables that shows range of each item of data collected this will highlight unusual event occurrence &analysis can be focused As the result production one or more tables containing only data required.
  40. PROBLEMS OF AUDIT IN PRIMARY CARE: 1. Difficulty in setting standards for many aspects of primary care. Why ?? a) lack of scientific evidence.!! b) audit is relatively new activity – few area have been examined and few audit validated. c) process measure is not necessary correlate well with outcome measures. e.g a practice may have recorded B.P for all its patients (100%)- but if non of the patients with high BP are treated the quality of care is low. " remember –measuring activity dose not necessary mean measuring quality" e.g. referrals DR A- High referral rate. DR B – Low referral rate.
  41. PROBLEMS OF AUDIT 2. Good quality care means improved outcome, Outcome rather difficult to measure in G.P. “AIM OF TREATMENT HYPERTENSION IS TO REDUCE STROKES” ABSOLUTE OUTCOME MEASURES , STROKES NUMBERS To justify improved care of hypertensives, one has to look for intermediate outcome measures. e.g. Level of B.P. control – in treated hypertensives. Good control usually results in less strokes HbA1c intermediate outcome measure in diabetic care.
  42. PROBLEMS OF AUDIT IN PRIMARY CARE 3. Good care should take into account the patients’ views. This is usually difficult in practice based audit. However, patients’ views are vital when auditing appointments or availability AND satisfaction 4. The idea of Audit causes anxiety for some doctors. Expose – poor care and therefore problems with PHC Administration or problems within PHC Team.
  43. Thank you very much