2. Brainstorm
▪ How do you evaluate our care against recommended
standards and how much is your trust level.
▪ TBI care, CPR, Burn managementand other…
▪ Triage,vital signs, medicationadministration,woundcare
▪ Our delays, equity of care…
▪ Process-outcome dissociation
▪ Ever seena patient who has good outcome but received
suboptimalcare?
2
4. Objectives
▪ Understand clinical audit and its process
▪ Clinical audit, research and performance audits
▪ Resident-engaged clinical audit
▪ Clinical audit governance
4
5. Clinical Audit
5
▪ A quality improvement process that seeks to improve patient care and
outcomes through systematic review of care against explicit criteria and the
review of changes.
▪ Involves comparing aspects of care against explicit criteria.
▪ Structure,processand outcome
▪ Measures what is happening in practice against set guidelines or standards.
6. Aim of clinical audit
Highlightdiscrepancy
betweenpracticesand
standards.
Identifychangesneeded. Improve quality of care.
6
7. Advantages of Clinical Audit
7
▪ Improved quality of care and patient outcomes
▪ Improved communication among colleagues
▪ Improved professional satisfaction
▪ Better administration
Johnston G, Crombie IK, Davies HT, Alder EM, Millard A. Reviewing audit: barriers and facilitating factors for effective clinical audit.
Qual Health Care. 2000 Mar;9(1):23-36. doi: 10.1136/qhc.9.1.23.PMID: 10848367; PMCID: PMC1743496.
8. Advantages to medical students
▪ Helps students to translate knowledge into practice
▪ Improved post graduate practices
▪ Improved awareness of health system and healthcare quality
▪ Participation in post-graduate quality activities
8
Davis, S., O'Ferrall, I., Hoare, S., Caroline, B., & Mak, D. B. (2017). Perceptions of medical graduates and their workplace supervisors
towards a medical school clinical audit program. International journal of medical education, 8, 244–251.
https://doi.org/10.5116/ijme.592a.a936
9. Disadvantages
9
▪ Overall attitudetowards clinical audit is favorable.
▪ Perceived disadvantages mentioned
▪ Increasedworkload- detractsfrom workat the expenseof care.
▪ Worthy but remote frompractice
▪ Restrictionof clinical freedom
▪ Fear of litigation.
10. Principles of effective clinical audit
10
▪ Confidentiality
▪ Supportiveorganizationalenvironment
▪ Non-judgmental
▪ Data driven
▪ Structured program
▪ Participatory
11. Facilitating factors for clinical audits
11
▪ Modern medical recording
▪ Effective training
▪ Dedicated staff
▪ Protected time
▪ Structured program
12. Barriers to clinical audit
12
▪ Lack resources
▪ Lack of expertise or advise
▪ Problems between groups and members
▪ Lack of overall plan
▪ Fear of blame
▪ Organizational impediments
13. Related Concepts
13
▪ Research
▪ Systematicinvestigationintoasubject in order to discoverand establish fact.
▪ ASA has establishedefficacyand safetyin the acute therapyof patients with NSTE ACS.
▪ Clinical audit
▪ A quality improvementprocessthat seeks to improve patientcare and outcomes through
systematicreview of care against explicitcriteriaand the reviewof changes.
▪ In our hospital only 40% of patient with NSTEACS received ASA.
▪ Performance reports
▪ There werea total of 1000 emergencyvisits,60 admission to ICU. NSTEACS was the the
most common admission diagnosisto Red zone. (40%)
14. Research and clinical audit
14
Research Clinical Audit
Purpose Creates new knowledge.
E.g. Phenytoin prevents posttraumatic seizure in
high-risk groups.
Testif a care is given according to
knowledge gained from research.
E.g. Are high-risk groups receiving
phenytoin?
Method Uses rigid statisticalmethods and carried
out in large scale. It may involve
experiments. Tests hypothesis.
Uses less rigid methods and carried out in
small scale. It doesn’t involve anything
beyond normal clinicalpractices. Measures
performance against standards.
Results Results are generalizable and influence
practice as a whole.
Resultsare relevantlocallyand influence
localpractice only.
15. Clinical Audit Cycle
▪ Clinical audit is a cyclical process
Set objectives
and standards
Data
collectionand
analysis
Make
Improvement
Re-evaluate
15
16. Planning before entering into the cycle
16
▪ Effective planning is important for successful clinical audit.
▪ Twoimportant area
▪ Audit team
▪ Determiningtheaudit topicand its objective
17. What to audit
17
▪ Audit topics should be selected with the view of improving quality of care.
▪ Important points to consider
▪ Alignment with nationalpolicy
▪ Case volume, mortality or morbidityburden, economicimpacts
▪ Patientscomplaints
▪ Personalinterest,morning sessionsuggestionsand other issues
▪ Prioritization tools can be used.
18. Standards and criteria
18
▪ Clinical audit involves measuring performance against explicit criteria.
▪ Standard
▪ Aspect of care to be measured.
▪ Criteria
▪ Statementthat explicitlydefinesaspect of care
▪ Should be objectivelymeasured.
19. Good and valid criteria
19
▪ Relevant
▪ Clearly defined
▪ Easily measured
▪ Based on evidence
20. Sources for standards and criteria
▪ National documents
▪ Guidelines and manuals
▪ Recommendations
▪ Literature reviews
▪ Departments agreement
20
21. Data collection plan
▪ Data sources
▪ Collection methods
▪ Sample size and sampling
▪ Data collection tool
21
22. Example: Emergency burn care audit.
22
▪ Possible sources for standards and criteria.
▪ Standard I: appropriate initial evaluation and assessment.
▪ Standard II: appropriate fluid management
▪ Standard III: wound care
▪ Standard IV: pain management
▪ Standard v: disposition.
23. Example: Emergency burn care audit.
23
▪ StandardI: appropriateinitial evaluation and assessment.
▪ Primary surveymust be done.
▪ Historyshould include durationof injury,mechanismof injury…
▪ Depth of burn must be assessed.
▪ Burn size and importantanatomiclocation must be assessed and documentedon burn
diagram.
▪ Burn must be classified.
▪ Initial lab investigationmust be obtained.
24. Example: Emergency burn care audit.
24
▪ StandardII: appropriate fluid management
▪ How do you determine if a burn patient received appropriate fluid management?
▪ Patientsweight must be measured or estimated.
▪ Fluid requirementmust be calculated and documented.
▪ RL is used.
▪ Fluid must be administered as per theorder.
25. Example: Data source and obtaining data
25
▪ How do you know
▪ If the depthof burn is assessed correctly
▪ If the size of burn is assessed appropriately
▪ Burn must be classified.
▪ How do you know
▪ If fluid requirementiscalculated appropriately or not
▪ If the patienttookthe calculated amount or not
26. Data analysis
26
▪ Is converting collected facts into useful information.
▪ Answeraudit objectives
▪ Identifygood practicesand area of improvements
▪ Canuse spreadsheets
▪ Tables, figures and charts
27. Resident-Engaged Clinical audit
27
▪ Is a proposed clinical audit program that helps resident to participate in
healthcare quality improvement.
▪ A team of residents own selected audit topic.
▪ Develop clinicalaudit and data collectiontools
▪ Regularly conduct the audit and present recommendation.
▪ They also facilitate implementationofchanges.
28. Resident-Engaged Clinical audit
28
▪ The department will have at least 3-5 important audit topics.
▪ Develop agreed standards, criteria and data collection tool for each topic.
▪ Regularly conduct audit and present areas of improvement.
▪ Improvement in selected areas of excellence.
29. Two phases from dept. perspective
29
▪ Phase I: Audit planning
▪ Audit topicselection and Team formation.
▪ Standards,criteriaand data collection plan.
▪ Phase II: Audit cycle
▪ Regular datacollection and analysis
▪ Implementingchanges
▪ Re-auditing
30. Audit topic selections
30
▪ The department will own 3-5 audit topics.
▪ Department head and chief resident
▪ Prepare prioritizationcriteriaandtools
▪ Preparelist of audit topics
▪ Presentaudit topics on morningsessions.
▪ Form clinicalaudit team and assign consultant
31. Standard and criteria
31
▪ Each audit team led by year III residents and advised by consultant
▪ Selectstandard and criteriasources
▪ Preparestandardsand criteria
▪ Local standardsand criteria
▪ Preparedata collection tool and plan
▪ Presenttheir standardsand criteriaand data collection tool
▪ The department have agreed up on standards and data collection tool.
32. Data collection tools
32
▪ Each audit team prepare a data collection plan.
▪ Data collection plan states how to measure criteria and its data sources.
▪ Decide the data source, sample and sampling methods
▪ Howto measure
▪ Data collection tools should be presented
▪ Using Google Forms
33. Conducting the data collection and audit
▪ Data collection using the data tool and analysis
▪ Time protected team sessions
▪ Discussions
33
34. Identifying problems
▪ After measuring performance against standards, teams
must identify areas of improvement.
▪ Group discussion with important stakeholders
▪ Brainstorming, 5 whys and other tools can be used.
34
35. Reporting and presentation
35
▪ The team prepare formal report and present to the department
▪ Audit findings
▪ Identifiedproblems
▪ Recommendation
▪ Delivery platform:
▪ Morning sessionor designatedsessions
▪ Printedor online distribution
▪ Important stakeholders attendance
36. Discussion
▪ Regular and attractive sessions
▪ Stakeholders participation
▪ Avoid blame
▪ Blame doesn’timprove quality and fear of blame is
a barrier to successful clinicalaudits.
▪ Department should set feedback protocol
and should monitor.
▪ Discussion points should be documented.
36
37. Brainstorm
▪ How do you integrate your reading with practice?
▪ A sample randomized trial
▪ Enoxaparin significantly reduced the incidence of death,
reinfarction and recurrent angina compared with UFH in
non-reprefusedSTEMI patients.
▪ Enoxaprain and UFH have similarsafety.
37
38. Implementing recommendations
38
▪ Individual engagement
▪ Communicate audit standards with professionals.
▪ The audit team and the department take responsibility
to implement recommendations.
▪ Implementation tools
▪ Develop guideline,manuals and policy
▪ Action plan and QI projects
▪ “Department’sAgreement”
39. Department’s Role
39
▪ The Department directly own the clinical audits.
▪ Ensure theirrelevance, quality and conductance.
▪ Must govern the clinical audits.
▪ Clinical audit guideline
▪ Annual plan.
▪ Facilitate data collection and presentation platforms
▪ Implement and monitor recommendations
40. Department’s support
40
▪ Each steps in planning and audit cycle require department’s support.
▪ Technicalsupports
▪ Facilitate data collection
▪ Leading discussion
▪ Consider residents involvement as an evaluation criteria.
▪ Attach such involvement withopportunities.
41. Hospital’s or QU roles
41
▪ The hospital and its QU indirectly own the audits.
▪ Provide supports- technical and financial
▪ Implementing recommendations
▪ Ensure conductance of audits
42. Summary
42
▪ Clinical audits is an important tool to improve patient care outcomes.
▪ Involves measuring reality against standards.
▪ Clinical audit should be planned and conducted in organized efforts.
▪ Resident-engaged clinical audits helps to participate in healthcare quality
improvement.
▪ Department and the hospital should support clinical audits at each steps.
43. References
43
▪ National clinical auditimplementationguide, FMOH, sept2019
▪ Johnston G, Crombie IK, Davies HT, Alder EM, Millard A. Reviewing audit: barriers and facilitating
factors for effective clinical audit. Qual Health Care. 2000 Mar;9(1):23-36. doi: 10.1136/qhc.9.1.23.
PMID: 10848367; PMCID: PMC1743496.
▪ Davis, S., O'Ferrall,I., Hoare, S., Caroline, B., & Mak, D. B. (2017).Perceptions of medical graduates
and their workplace supervisors towards a medical school clinical audit program. International
journal of medicaleducation, 8, 244–251. https://doi.org/10.5116/ijme.592a.a936
