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Clinical audit for the enlightened ian callanan hslg conference 2013


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Clinical audit for the enlightened ian callanan hslg conference 2013

  1. 1. Clinical Audit for the Ian Callanan MB FRCSI MBA Group Clinical Audit Co-ordinator St Vincent’s Healthcare Medical Director Aviva Healthcare Insurance PCC Committee Medical Council of Ireland uninitiated troubled confused harried enlightened
  2. 2. Clinical Audit for the Ian Callanan MB FRCSI MBA Group Clinical Audit Co-ordinator St Vincent’s Healthcare Medical Director Aviva Healthcare Insurance PCC Committee Medical Council of Ireland uninitiated troubled confused harried enlightened
  3. 3. What does it mean for health staff? CPD 50 points per year Clinical audit 1 per year (12 hrs suggested) CPD ? Accreditation HIQA JCI etc Clinical audit Healthstat KPIs
  4. 4. Life, according to Librarians…..?
  5. 5. What is quality?
  6. 6. Clinical AuditClinical Audit Systematic review and evaluation of current practice with reference to research based standards with a view to improving patient care
  7. 7. Clinical AuditClinical Audit It does exactly as it says on the tin “Ronseal”
  8. 8. Clinical Audit Identify and eliminate waste Identify and promote good practice Identify and stop bad practice Promote MDT working Improve professional practice Improve patient outcomes Release money to provide better patient care Select & support highest quality care Professional education
  9. 9. Identify Standard Measure activity Validate against standardMake appropriate changes
  10. 10. Standard and Criterion What should happen –98% of female population at risk should be immunised against rubella –100% of children needing attention for acute problems will be seen on the same day –All patients Rxed with statins should have an LFT carried out Criterion: a definable and measurable item of health care Standard: a statement of expectation
  11. 11. PDCA ACT
  12. 12. Example of wrist bands 0 printed 428 handwritten 21 ABSENT 54 printed 360 handwritten 10 ABSENT 165 printed 214 handwritten 15 ABSENT 339 printed 55 handwritten 34 ABSENT 368 printed 10 handwritten 31 ABSENT Aug 2006 Aug 2010 Oct 2010 April 2011 Sept 2012
  13. 13. Audit and Feedback 0% +70% -16% Change in practice after clinical audit – measured by adherence to specific guideline Jamtvedt et al 2006, Cochrane Database of Systematic Reviews
  14. 14. Plan Do Do CHeck Do CHeck ACT Plan CHeck ACT Plan ACT
  15. 15. Source Professional directions Research Benchmarks Guidelines Level of compliance Is 100% achievable Is 80% good enough Progressive improvement The First Rule of Aviation More than my jobsworth
  16. 16. Source of Standards • Pubmed • Cochrane • BMJ • SIGN • Clinical Evidence • EBM online • School of York reviews • Best BETS • Bandolier • Centre for Clinical Effectiveness • Centre for Evidence-Based Medicine • Centre for Evidence-Based Mental Health • Centres for Health Evidence • Clinical Assessment of the Reliability of the Examination • Clinical Decision Rules, The Samuel Bronfman Department of Medicine • Clinical Examination Research Interest Group • Clinical Resources, Clindx Update Listserv & Bibliography • Netting the Evidence • NHS Centre for Reviews and Dissemination • Ovid EBM • Physiotherapy Evidence Database (PEDro) • Resources for Practicing Evidence-Based Medicine • Department of Family & Community Medicine • Trip Database • EPIQ (Effective Practice, Informatics & Quality Improvement) • Evidence-Based Mental Health • Evidence based Nursing • Evidence-Based Paediatrics • Evidence-Based Practice Centers • McMaster Health Information Research Unit • National Library of Medicine's Health Services/Technology Assessment Text (HSTAT) + Google
  17. 17. Research is probably the nemesis of clinical audit
  18. 18. Information for research Detailed, focussed and minutiae Info not usually collected EXCITES doctors Information for monitoring / accountability Technical data Externally used (Lot of energy in getting agreement) Not illuminating how outcomes achieved or processes managed Information for quality improvement Quickly gathered Rapid cycle Identify problems / get baseline / measure improvements 1 2 3 After Solberg et al Jt Comm J Qual Improv. 1997 Mar;23(3):135-47.
  19. 19. Who does audit? 1. Self-audit 2. Peer audit 3. External audit Part of professional’s regular questioning Can be difficult to sustain (time, space, skills…. Private Adv: Frank discussion Disadv: Collusion, avoid the awkward “It takes one to know one” Likely to be Appropriate to context Acceptable to colleagues Principal risk May become collusive Most rigorous Most threatening Require resources
  20. 20. • Numbers needed • Clarity of gathering the right data • Using databases – Paper tots – Excel • Analyses / Stats!!!! Gathering the data
  21. 21. Framework for clinical audit Structure Process Outcome Physical attributes of health care •Tangible, easily counted •Presence increases the chance of good quality care but does not ensure it (appropriate use…..) •Examples: equipment; medical records Care given by a practitioner / service •Health professionals identify process with quality –It describes what they do –Reflects their attitudes, knowledge & skills •Examples: prescribing habits, hospital referral rates, lab & x-ray use Changes in patient’s current & future health status as result of intervention •Describe effectiveness of care •Difficult to measure…… •Example – lower incidence of specific disease; lower mortality; improvement of level of function, patient satisfaction
  22. 22. Criteria and Standards Criterion Standard Structure Patient records will include hard copy results (NHO audit) Should apply to 80% records Process Patients aged 20-65 will have their BP recorded at least once in last 5 years Should apply to: 50% records in Y 1 75% in Y 2; 95% in Y 3. Outcome Patients with ⇑BP aged u 40 will have diastolic < 90mm Hg within 1st yr of treatment Will be achieved in 80% cases
  23. 23. Gap models of service quality (SERVQUAL) Expected service Perceived service Service delivery Service standards External communications Company perceptions of customer expectations Gap 1 Gap 4 Gap 2 Gap 3 Gap 5
  24. 24. Good audit..... • Topic is a priority – Reflects local services – Agreed by all as priority • Measured against standards – Best available evidence • Supported by organisation – Time and planning • Engages with all – Ownership – Through to completion • Patient involvement – Patient priorities • Target sample appropriate – Generates meaningful results • Data collection robust – Clarity on criteria • Action plan – Ownership – Accountability • Repetition
  25. 25. Performance Davidoff, Ann Int Med 2011 Reflection Hands on experience Reflective observation Abstract conceptualisation Endless performance
  26. 26. 1. I am Clinical Audit….thou shall not wave a Research Idea at me 2. Thou shall close all clinical audit loops… unclosed loops are an abomination 3. Keep thine audits simple 4. Thou shall have a plan 5. Thou shall not bear false witness to statistics 6. Thou shall not collect needless data 7. Thou shall tell everyone about your audit 8. Tell “The Organisation” about your audit 9. Keep to thee all the data only for as long as it is needed…the God of Information shall visit all manner of plagues upon ye 10. Re-audit, in the name of all that is good and right in clinical care
  27. 27. Any questions? Now….. Later…..