Dr Venkatesh Kairamkonda talks about how the neonatal unit at UHL have used root cause analysis & PDCA model to make the audits undertaken more effective as part of NQICAN Patient First conference 2016.

1. Clinicians and QI staff – creating effective partnerships
Improving Effectiveness & Outcomes
of Clinical Audit
Using Root cause analysis & PLAN-DO-CHECK-
ACT Model
Venkatesh Kairamkonda
Consultant Neonatologist & Audit Lead,
University Hospitals of Leicester NHS Trust

2. Clinicians and QI staff – creating effective partnerships
Background
• Approximately 12 audits completed per year
• Audit standard % achieved in 25% of completed
audits (15/59)
• Completed audit loops showed % achieved same or
declining -a worrying trend
• Urgent need of New approach

3. Clinicians and QI staff – creating effective partnerships
Neonatal Audit Pathway
• Audit task groups to carry out action plans from previous audits
instead of initiating new audits.
• Each audit should be conducted by a team - SpR, SHO and Nurse.
Audits involving multidisciplinary team (Dietician, Pharmacist,
Midwife, Baby Care Assistants, ward clerks) are encouraged.
• The team should discuss and agree audit title, aims, standards &
proforma with educational supervisors/audit lead/audit facilitator
within the first 4 weeks of your post.
• Teams work on root cause of deficiency and implement changes
• Audit competition on presentation day (January/August).
• Audit action plans reviewed at Neonatal Governance meeting
before forwarding to Clinical Audit Facilitator

4. Clinicians and QI staff – creating effective partnerships
Problem with traditional Audit cycle?
Make
recommendations
for change
Collect data
to measure
current
practice
Re-audit
Identify Topic Obtain guidelines / set standards
Compare
practice
with
standards
Implement
action plan
The
Audit Cycle

5. Clinicians and QI staff – creating effective partnerships
Root Cause Analysis Model
Random audit 2 to
assess improvement
Identify causes of
short comings
Increase awareness
before re-audit
Select Topic
Assess previous
audit results
Address root
cause of
shortcomings
Implement
action plan
Root Cause
Analysis
Random audit 1
to assess current
performance

6. Clinicians and QI staff – creating effective partnerships
Identify Topic / Re-audit
• Baseline audit / first audit
− A standard or guideline
hasn’t been audited.
− frequent topic of concern at
governance, senior team, and
ward rounds.
• Re-audit:
• Increase awareness of the
results of previous audit after
successful implementation of
changes.

7. Clinicians and QI staff – creating effective partnerships
Assess previous audit results
• Identify professionals
required to conduct the
audit
• Brief team meeting to
discuss title, aims,
objectives and review
previous audit standards,
methodology, results

8. Clinicians and QI staff – creating effective partnerships
Random audit 1 to assess current
performance
• Random audit1 to assess
current performance
•Comparison to previous
audit results
•Identify deficiency in key
standards and establish
target performance

9. Clinicians and QI staff – creating effective partnerships
Identify short comings
• Non formal User survey when
at work by the team
• Team meeting to discuss their
findings and identify common
theme/s
•Fish bone model to identify
root cause by analysing cause
and effect chain backwards
• Relook at standards and
current guidelines

10. Clinicians and QI staff – creating effective partnerships
Address root cause
of shortcomings
• Memorable acronym to give
simple structure to process.
• Posters in relevant areas.
• Brief opportunistic
PowerPoint presentations.
• Regular email & bulletin
reminders
• Ensure ready availability of
paperwork & guidelines.

11. Clinicians and QI staff – creating effective partnerships
Random audit 2 to assess
current performance
• Amend/Revise audit
standards
• Set achievable target %
• Revise/amend proforma
• Assess performance with
audit 1 and previous audit
• Presentation of audit results
to relevant stakeholders

12. Clinicians and QI staff – creating effective partnerships
Implement action plan
• Further recommendations
addressed at a departmental
and individual level.
• The recommended
changes should be guided by
the root cause assessments
of the audit teams as a
handover to the next team

13. Clinicians and QI staff – creating effective partnerships
Increase awareness
• Induction information
• Brief opportunistic
PowerPoint
presentations (medical
& nursing staff).
• Regular email &
bulletin reminders

14. Clinicians and QI staff – creating effective partnerships
• Lack of necessary
forms, leaflets, stickers
• Lack of awareness
• Barriers to who should
and when
• Lack of guideline
BLEED INITIATIVE

15. Clinicians and QI staff – creating effective partnerships
NECTAR INITIATIVE
• No thermometers available
to monitor and regulate
labour ward and postnatal
ward room temperatures
• Midwifery staff unaware of
thermostatic control
• Existence of 2 guidelines
with conflicting standards
• Staffing pressures and lack
of computers at LGH
• Baby thermometers failed
quality tests

16. Clinicians and QI staff – creating effective partnerships
OSTRICH INITIATIVE
• Change to the guideline in
view of results from SUPPORT
trial and BOOST II.
• Revised guideline had target
saturations and saturation
limits - Recipe for confusion.
• Target limits not easily
identified
• Default alarm limits on bedside
monitors not programmed to
reflect the protocol.

17. Clinicians and QI staff – creating effective partnerships
Outcomes
• Seeing improvements to
patient care as a direct result
of clinical audit projects
• Department audit programme
overview scores consistently
>90%
• UHL Audit speciality of year
2015

18. Clinicians and QI staff – creating effective partnerships
Summary
• Root-cause analysis system must be integrated
within each audit cycle to improve performance of
standards without delay
• The process must take advantage of people’s
knowledge while preventing their biases.

19. Clinicians and QI staff – creating effective partnerships
Summary
• Audit teams work together
- to draft audit standards based on clinical priorities and
governance agenda,
- review previous audit results and recommendations,
perform a random baseline audit, understand barriers
to achieving target % by random surveys, develop
and deliver short teaching sessions while on duty to
improve knowledge of standards, work to remove
barriers,
- finally perform final audit to recommend changes.