Presentation for the 10th D. L. Shah awards- Quality Council of India

1. CLINICAL AUDIT PROGRAM - A FEEDER AND A
MODEL FOR THE NATION
CHRISTIAN MEDICAL COLLEGE (CMC), VELLORE

2. Project Leader
Dr. Sunil Chandy
Director
Christian Medical College,
Vellore - 632004
Dr. Oommen George,
Deputy Director (Quality)
Christian Medical College,
Vellore - 632004
directorate.qmc@cmcvellore.ac.in
Ms. Lallu Joseph
Quality Manager
Christian Medical College,
Vellore - 632004
directorate.qmc@cmcvellore.ac.in
Project Co-ordinators

3. CMC VELLORE
• An educational institution and tertiary care hospital
• Founded by Dr. Ida Sophia Scudder in 1900
• 2678 beds – 67 wards
• 7000 Out patients per day – 72 OP clinics each day
• Consistently ranked among the top five medical colleges in India
• The first’s
– College of Nursing in India (1978)
– Reconstructive Surgery for Leprosy in the World (1948)
– first Open Heart Surgery, Kidney Transplant, Bone Marrow
Transplantation and ABO incompatible Kidney Transplant in India
• CMC has the longest fully functional network of chute system in
South Asia (7000 meters)

4. VISION STATEMENT
• The Christian Medical College, Vellore, seeks
to be a witness to the healing ministry of
Christ, through excellence in education,
service and research.

5. PURSUIT OF EXCELLENCE
 India’s Best Employer by National Citizens Award in 2003.
 MM Award for Excellence in Healthcare.
 Gurukul Jyoti Award in 2007.
 Best Multi-Specialty (non-metro area) Award by the ICICI Lombard General
Insurance Company in 2011.
 Best Cardiology Care in India Award by CNBC-TV18 in 2011.
 5 - Star rating to CMC for the quality of education imparted awarded by the
National Assessment and Accreditation Council (NAAC)
 The Investment Information and Credit Rating Agency (ICRA) Ltd. categorized CMC
as a super specialty teaching hospital of the highest quality and gave an A1
grading.
 International Living Award by LeBonheur Healthcare, USA in 2008.
 Largest hospital in the country to be accredited by the NABH in 2013.
 CMC received 11 awards in 2014 from the prestigious SKOCH group of the national
level

6. ACCREDITATION JOURNEY
•Having grown too large, there was a felt need to embark on accreditation
•The Quality Management Cell was set up in 2007
•Quality Manager reporting to the Director of the Institution, through the designated
Deputy Director for Quality.
•Liaison staff from every department called “Department Quality Managers (DQMs)”. I
•Intensive training was imparted to the DQMs and continuous audits were conducted
•Subsequently, a group of Department Safety Advisors were also added to take on the
job of Safety
•The strategic planning was initiated in 2009
•“Quality” and “Safety” as the main points of discussion and decision making.
•Decided that the hospital should go in for NABH accreditation with specific action
plans and timelines drawn up.
•The Consultation 2010 also stressed on the need to setup a separate Audit
Facilitation Cell

7. THE CORE AREAS OF FUNCTIONING OF THE
QUALITY MANAGEMENT CELL WERE REFINED
Quality Management Cell
Audits / Audit
cycle completion
Training
Performance
Indicator
Research System Study
Accreditatio
n
Documentation
& Process
development

8. CONSULTATION 2010 GRID FOR QUALITY
No ACTION
PERSON
RESPONSIBLE
YEAR
BEGIN
YEAR
COMPLETE
ESTIMATE AS OF
2009
1 Set up Quality Audit Facilitation Cell
Director/Deputy Director
(Quality)
2010
2010 2 Lakhs
2
Evaluate the existing patient feedback
system and make changes.
” 2011 -
3 Set up the Patient Grievance Cell
MS/NS/ Director/Deputy
Director (Quality)
2011 3 Lakhs
4
Apply for accreditation and pre-
assessment
Director/Deputy Director
(Quality)
2011 5 Lakhs
5
Set up internal reporting system for
Audits
Director/Deputy Director
(Quality)
2010 2012 -
6
Conduct training programs in audits and
standards
”
2011
Ongoing 5 Lakhs
7
Complete the documentation of
departments/ hospitals processes and
policies
” 2012 -
8
Develop Key Performance Indicators
(KPIs) and establish the reporting
Mechanism.
” 2012 -
9
Get NABH Accreditation for the main
hospital
” 2012 20 Lakhs
10 Develop a system for Audit Compliance ”
2012
2013 -
11
Set up the scorecard and management
dashboard
” 2014 -
12 Get the NABL accreditation for all Labs ” 2014 25 Lakhs
13
Establish systems for resources
optimization
Director/Deputy Director
(Quality)
2013 2014 -
14 Establish EQAS for all labs ” 2014 2015 10 Lakhs

9. CONSULTATION 2010 GRID FOR SAFETY
No ACTION
PERSON
RESPONSIBLE
BEGIN COMPLETE
ESTIMATE AS OF
2009
1 Establish the Hospital Safety Cell GS / Director
2010
2010 5 Lakhs
2 Provide safety training to all staff ” Ongoing 2 Lakhs/year
3
Prepare the CMC Hospital Emergency
Response Plan and develop the Emergency
Response team
” 2011 2 Lakhs
4
Establish mechanisms to disseminate HICC
Surveillance information
MS / NS / Director
2011 1 Lakh
5
Evaluate the effectiveness of the safety cell
every year GS / Director
2011
Ongoing 1 Lakh/year
6
Educate the public of Vellore on Safety and
assess the effectiveness of the program every
year
GS / Director Ongoing 2 Lakhs
7
Establish the system for periodical preventive
maintenance of equipment
GS / MS / NS / Director
2011 10 Lakhs
8 Strengthen HICC and make it as an Unit NS / MS / Director 2011 5 Lakhs
9
Assess the hospital safety systems and the
emergency response plan using an external
agency
GS / Director
2012
2012 5 lakhs
10
Develop the CMC Hospital customized
Hospital Safety Index ” 2013 -
11 Conduct training courses in hospital safety ”
2013
Ongoing 2 Lakhs
12
Survey the hospital safety using the
customized safety index ” 2014 2 Lakhs

10.  NABH pre-assessment - September 2010
 NABH final assessment - October 2011
 NABH verification assessment - December 2013
THE JOURNEY

12. CLINICAL AUDIT
• A quality improvement process that seeks to
improve patient care & outcomes through
systematic review of care against explicit criteria and
the implementation of change1

13. IDENTIFICATION OF NEED
• Audit Facilitation Cell was set up in 2009
• Initial audits focused on reviews
• completeness of consents, medication orders, discharge
summaries, care plan
• NABH final assessment NC
“The organization does not have a structured system for
conducting clinical audits, presently, chart reviews are being
done”.
• Decided to use this NC as the main quality
improvement project for CMC

14. IMPLEMENTATION STAGE
Knowing Thyself
• Baseline survey there was lack of
understanding in the part of the clinicians
about the concept of actual clinical audit.

15. MAKING IT LOOK SIMPLE
• Standard presentation on conducting clinical
audit was prepared
• Identifying the topic/problem
• Defining criteria, defining standards
• Measurement- Inclusion, exclusion, sampling, time
frame, data collection
• Comparing the performance with the benchmark
• Recommendations/ Implementations and re-audit
• Simple examples of clinical audits.

16. COMMUNICATING TO THE
CORE GROUP
• Department Quality Managers and HODs/HOUs were
trained on conducting clinical audits
• The presentation was also uploaded on to the CMC
intranet

17. THE FACILITATION
• Circulars from Quality Management Cell (QMC) to all
clinical units to start selecting topics and to initiate
the audit
• Charts if required are provided by QMC through
Medical records department
• Data entry by QMC staff
• Few departments started doing it
• General Surgery
• Ophthalmology

18. CONVINCINGLY MANDATED
• The root cause for non-compliance were
analyzed and found that
• Clinical audit was not a priority in the already busy
work schedule of clinicians
• However, they all felt that this was the best way to
improve clinical care
• Written a letter to Dr. M.G.R University and
made see if it could be mandated for PGs and
Interns

19. LETTER TO UNIVERSITY FOR
INCLUDING CLINICAL AUDITS

20. SAB MINUTES (Dr. MGR Medical University
senatus minutes- 10/08/2012)

21. THANK YOU NOTE TO UNIVERSITY

22. THE AUTHORIZATION FROM THE TOP
• The Principal gave the responsibility of co-
ordinating this with Quality Management Cell
through the Post Graduate Co-ordinators of
the clinical units and the Vice Principal (Post
Graduate).

23. MENTORING
• Clinical audit was included as a topic in Mandatory Training
programs for
• PGs
• MBBS interns
• PG co-ordinators helped the PGs to refine their topics of
interest and the methodology
• Quality Management Cell ensured that the audits were
completed and submitted along with the Post Graduate
thesis
• Follow ups of the implementation of recommendations
were carried out by QMC.

24. THE BOOSTER
• Quality Journal of CMC was introduced
• Clinical audits are published after proper
review by the experts
• First issue –August 2013 with 20 audits
covered

25. THE QUALITY JOURNAL

26. THE QUALITY JOURNAL

27. HEADING TOWARDS QUALITY
DESPITE HURDLES
• The Tamilnadu MGR University has not been
actively mandating the submission of the audits.
• This has acted as a deterrent to the submission of
audits
• The institution felt the need for continuing the
clinical audits and mandating the same at the
institutional level
• CMC Vellore made it as responsibility for PGs and
Interns to conduct the clinical audit
• This encouraged them to publish the same in the
CMC Quality Journal

28. KUDOS FROM THE NABH ASSESSORS
• The efforts of the institution in promoting
clinical audit was well received by the NABH
assessors during
• NABH verification assessment in Nov 2013
• NABH Focused assessment in July 2014

29. NABH VERIFICATION ASSESSMENT
- NOV 2013

30. NABH FOCUS ASSESSMENT FOR ECHS
EMPANELMENT – JULY 2014

31. IMPACT OF CLINICAL AUDIT
TO THE INSTITUTION
• Better understanding of the scientific
methodology of conducting audits
• Serve as a learning exercise for the clinicians
• Exploration and awareness of the best
practices followed across the world
• Serve as an impetus towards research in
future
• Treating team of the institution in future will
be much better than the existing “best”.

32. IMPACT OF THE CLINICAL AUDIT
PROGRAMME OF CMC TO THE NATION
• On an average about 30% of the students stay back in CMC
for a few years and the others (about 70%) leave and join
mission hospitals or corporate hospitals.
• They carry with them a rich heritage and the first hand
experience of conducting clinical audits and their benefits
Sl. no Total No. of PGs’ 2012 2013 2014
1
Total No. of PGs’ (DM/MCh. MD/MS/
Diploma) pass out of CMC
195 217 251
2
Number of CMC PGs joining CMC
after finishing the course
77 71 47
3
Total number of CMC PGs joining
other hospitals after finishing the
course
118 146 204
60.5 % 67.29% 81.28%

33. IMPACT OF THE CLINICAL AUDIT
PROGRAMME OF CMC TO THE NATION
• This ripple effect will encourage others also to
join the movement and create a culture of
openness to self examine the existing protocols
set benchmarks as per good standards and
implement changes required to improve.
• Develop a culture of continuous quality
improvement in their respective Institutions
• This will ultimately result in good patient care.

34. APPENDIX

35. EXAMPLES OF AUDITS BY PG REGISTRARS
Audit Topic Department Standard Result
Audit on hospital stay after
laparoscopic sterilisation
Department of
Obstetrics and
Gynaecology
According to ACOG criteria, laparoscopic
sterilisation,
1. Can be done as a day care procedure.
2. Patients can be discharged on the day of the
surgery after a few hours of monitoring
The average number of days the patients in
our hospital were admitted for laparoscopic
sterilisation was found to be three.
Patients admitted in general, semi-private and
private wards for laparoscopic sterilisation
could have saved Rs.1947, Rs.2450 and Rs.
2857 respectively for bed charges alone if day
care system had come into existence.
Waiting time for emergency surgery
in open long bone fractures over
five months surgical audit
Orthopaedics, CMC
The American College of Surgeons Committee on
Trauma, in its resources for optimal care of the
injured patient, indicates 6 hours as the benchmark
for time from injury to debridement of open fractures
in trauma centers
In our hospital, the average time a patient has
to wait before undergoing first debridement is
17.9 hours, which is significantly greater than
the recommended waiting time
To determine the rate of conversion
of laparoscopic cholecystectomy to
open procedure.
Surgery
As per the study by Livingston, et al in 2004,
published in the American Journal of Surgery, the
laparoscopic to open conversion rate for
cholecystectomy should be between 5-10 %.
The conversion from laparoscopic to open
cholecystectomy was high (18%), as
compared to international standards.
An audit of blood culture
contamination rates in a tertiary
care centre
Microbiology
The American Society for Microbiology (ASM)
guidelines suggest that for all blood cultures drawn in
a hospital, the blood culture contamination rates in a
hospital should be <3%.
The blood culture contamination rate in our
hospital was found to be 8%, much higher
than the recommended standard. Therefore
measures to reduce the contamination rate
need to be implemented.
Audit on pre operative audiogram
for the month of November 2012
ENT
Benchmark - 100% of patients undergoing any
middle ear surgery should have a pre-operative pure
tone audiogram done within 6 months of surgery.
Approximately 9% patients included in this
audit did not have an optimal audiogram as
per the departmental policy

36. Example for Audit and Re- Audit
(Audit completion cycle)
• January 2010 - audited the availability of surgical consents for the patients who are
wheeled into operation theatre for surgery. Only 56% had the consent for surgery.
• The report was presented to the clinicians in the Medical board meeting.
• It was decided that the holding bay nurses will not permit the patients to be
wheeled into OT without the consent for surgery.
• A number of circulars and training sessions were conducted and various departments
were refined to meet the legal requirements.
• After the interventions, re-audited the consents for surgery in the month of October
2010.
• The result of the re-audit was overwhelming as the compliance improved to 99.30%
from 56 %.
• Every year an audit on the same is conducted and the results are put in the intranet
to follow up and ensure that it is meeting the requirements.
• The recent audit was conducted during the month of November 2014 and it was
found to be 97% compliance.

37. Example for Audit and Re- Audit
(Audit completion cycle)

38. THANK YOU