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Audits: Introduction and Procedure
- 1. Snap-Shot & DetailedAudits: Introduction and Procedure
- 2. ACCREDITATION CANADA 2010 VTEProphylaxis ROP 1. The hospital has an organization-wide, written thromboprophylaxis policy or guideline. 2. Identifies patients at risk for VTE and provides appropriate, evidence-based VTE prophylaxis. 3. Establishes measures for appropriate thromboprophylaxis use, audit its implementation, and uses this for quality improvement. 4. Identifies major orthopedic surgery patients who require post-discharge prophylaxis and provides it. 5. Educates health professionals and patients about VTE and its prevention. www.accreditation.ca
- 3. Why do Audits? Auditsand feedback are an effective strategy to identify gaps between evidence and practice, and should drive change in healthcare settings.
- 4. • It willhelp identify gaps between the evidence (embedded into the local thromboprophylaxis policy) and what is actually done in practice. • Will be used to guide where to implement quality improvement (QI) interventions. • Should assess the proportion of patients at risk for VTE who are prescribed appropriate (evidence-based) VTE prophylaxis − capturing correct option, dose, onset, compliance and, where possible, duration. What will a VTE prophylaxis audit tell us?
- 5. • Data collection/generation •Computerized pharmacy system (ability to generate Drug Use Evaluation (DUE) reports) • Data Collection Tables • Supplemental Data Collection sheets • Staffing resources • Pharmacy staff: pharmacists, pharmacy students • Quality Improvement: QI personnel • Nurses • Research Personnel • Medical Students • Health Records Analysts • Other Health Personnel Resources and Considerations for an Audit
- 6. Choosing an AuditType Snap-Shot Audit Detailed Audit Purpose: To identify prevalence of thromboprophylaxis use in one or more patient groups. Purpose: To identify prevalence and appropriateness of thromboprophylaxis Key Points: •Provides point estimates of the use of local TP options •Indicates if evidence-based TP is prescribed/ordered on that given day •Easy and most efficient audit •Provides estimate of how well the various services are doing •Helps identify possible care gaps •Provides a measure that could be utilized for dashboards/balanced scorecards if used as a measure of quality of care Key Points: •Captures appropriate selection of TP option, initiation, and dose •Requires direct auditing of a greater number of charts (DUE reports are not sufficient), making it more labour intensive •Provides more useful information and more appropriate estimates
- 7. Audit Advantages &Limitations Snap-Shot Audit Detailed Audit Advantages: •Estimate of TP •Quick •Identifies major gaps in the provision of local TP options •Less labour intensive •Can be completed by personnel with less clinical experience Advantages: •Can provide information on initiation, dose, adherence (if and when given), and duration of TP •Estimates and provides greater insight into suboptimal TP use, leading to the creation of remedial Quality Improvement (QI) strategies Limitations: •Does not measure appropriateness, initiation, dose, adherence, or duration of TP Limitation •Requires the direct review of actual patient charts (DUE not enough •Labour intensive •Requires personnel with clinical experience
- 8. • Where apharmacy informatics system is in place generate a report indicating patients currently receiving any anticoagulant Audit Steps
- 9. Accounting for allthe Patients
- 10. IMPORTANT: Audit tools shouldbe aligned with policy/ guidelines of your institution or consistent with clinical order set
- 11. • For real-timedetailed audits, options are: • all beds on a given day or • audit different services/wards/nursing care units on consecutive days or • audit a single or limited number of nursing care units Frequency and Audit Sample As rates of appropriate prophylaxis increase less time will be needed, with fewer chart audits required.
- 12. • Only patientswho are determined NOT to be on an anticoagulant will require a chart review • All patients captured by the DUE as being on an anticoagulant can be classified as receiving therapeutic or prophylactic anticoagulation • Patients not appearing on the DUE report require a chart audit to determine if they are receiving mechanical prophylaxis or no prophylaxis and whether those decisions are appropriate Snap-Shot Audit
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- 15. Putting it allTogether The Audit Report
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- 18. • To drivechange the results must be shared/disseminated with stakeholders, including healthcare providers and administration. • Data should be broken down at various levels including: • Hospital Service • Ward Individual Physician • Wards/ service areas should be provided with outcomes from the audit to assist them with improving patient safety and care. Driving Change Toward Best Practices
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- 20. Various methods ofdissemination include: − Newsletters − Educational/in-service sessions − Department Head meetings − P&T − Organizational public newsletters Dissemination of Audit Results
- 21. The Goal ofevery Hospital/Institute: 100% appropriate prophylaxis for all patients at risk, when clinically indicated
Editor's Notes
- #3 Speaker Notes: 60-70% of all VTE is hospital-acquired (i.e. this is a public health issue). Pulmonary embolism is the commonest, preventable cause of hospital death. These facts support the Accreditation Canada VTE ROP which recommends that the team establish measures for appropriate thromboprophylaxis use, audits the implementation of appropriate thromboprophylaxis, and uses this information to make improvements to their services. “ Patients without risk factors for VTE are called outpatients .” G. Maynard (2010)
- #4 Speaker Notes: Numerous audit methodologies are available that consider the following: the depth of information desired (snap-shot vs. detailed) timing with respect to a patient’s admission (real-time vs. retrospective)
- #5 Speaker Notes: Importantly, the audit methodology (snap-shot vs. detailed) should be consistent with your local VTE prophylaxis policy/guideline.
- #6 Speaker Notes: The type of audit your institution chooses to perform will depend upon the resources available to conduct the audit, as well as the type and depth of information sought. Once the audit type has been decided then resources need to be determined and allocated.
- #7 Speakers Notes: A VTE prophylaxis audit should assess the proportion of patients receiving recommended or indicated prophylaxis and/or appropriately prescribed prophylaxis (capturing onset, type and duration) Appropriate thromboprophylaxis should be: 1 provided within 24 hours of admission to hospital and within 24 hours following major l surgical procedures involve evidence-based (ACCP recommended) thromboprophylaxis continued until hospital discharge or post-discharge for selected patient groups, if appropriate (at least until hospital discharge in major non-orthopedic surgical patients and at least 10 days for hip/knee arthroplasty or hip fracture surgery) Reference: Geerts WH, et al . Prevention of venous thromboembolism: ACCP evidence-based clinical practice guidelines, 8 th edition. Chest 2008;133:381S-453S.
- #8 Speaker Notes: At some point in time each audit methodology, both snapshot and in-depth, should be performed to ensure a complete audit/review of thromboprophylaxis practices is conducted, with the information gained being used for quality improvement purposes.
- #9 Speaker Notes: In situations where a pharmacy informatics system is in place, the appropriate pharmacy personnel will/should generate a report indicating patients currently receiving any anticoagulant, including LMWH, LDUH, warfarin, rivaroxaban and dabigatran. All patients that are captured by the DUE report as being on an anticoagulant can be classified as receiving therapeutic or prophylactic anticoagulation. Patients not appearing on the DUE report require a chart audit to determine if they are receiving mechanical thromboprophylaxis or no thromboprophylaxis and whether those decisions are appropriate.
- #10 Speaker Notes: Important for any audit is that every patient be accounted for including those who do not require thromboprophylaxis due to a lack of indication. If the entire hospital will be audited consider excluding some patient groups where there are no clear guidelines regarding appropriate thromboprophylaxis: paediatric psychiatric palliative/long-term care rehab
- #12 Speakers Notes: On average, an organization wide point-in-time audit in a 400-bed hospital with moderate rates of thromboprophylaxis will require 4-8 hours, depending on audit staff efficiency. With experience, significant improvements in efficiency will be noted.
- #13 Speaker Notes: For a snap-shot audit, only patients who are determined NOT to be on an anticoagulant will require a chart review. All patients that are captured by the DUE report as being on an anticoagulant can be classified as receiving therapeutic or prophylactic anticoagulation. Patients not appearing on the DUE report require a chart audit to determine if they are receiving mechanical thromboprophylaxis or no thromboprophylaxis and whether those decisions are appropriate. For each patient who requires a chart review, this review can be used to determine if they have contraindications to a pharmacological agent, received mechanical thromboprophylaxis, or did not have an indication for thromboprophylaxis.
- #14 Speaker Notes: The data collection forms should be adapted to fit the policy/guideline of your hospital. These examples are very comprehensive and offer a good start point for designing you own data collection forms. It is important that a SUMMARY section be provided to capture the key point of a patient’s risk and treatment (if any).
- #15 Speaker Notes: The data collection table should be adapted to fit the policy/guideline of your hospital. This example is a good start point for designing you own tables.
- #17 Speaker Notes: Once the audit is complete a report should be generated. Most helpful is comparisons to previous audits to clearly show successes and care gaps.
- #18 Speaker Notes: In this case the success should be celebrated (83%, 10% better than 2010) and the gaps identified (missing 17%). It is important that a strategy be worked out to support continued improvement. Vigilance in awareness and improvements are key to a backwards slide.
- #19 Speaker Notes: In order for audit results to drive change toward best practices, it is important that the results be shared/disseminated to stakeholders, including healthcare providers and hospital/institution administration.
- #20 Speaker Notes: Next steps to drive awareness and change should be built into the audit report. Care units/wards/service areas should be provided with outcomes from the audit to assist them with improving their patient management.
- #21 Speaker Notes: Wide dissemination is key to success. Displaying the results in prominent locations such as the hospital entrances, nursing care unit/ward entrances, staff washrooms, staff locker room or lunch rooms will raise awareness and ensure the majority of staff are made aware of the outcome, successes and gaps.
- #22 Speaker Notes: This is the goal. Protection and prevention of VTE in all our patients.