Nor is it… Buying computers Buying software Having others put in all the data and you pushing the button Extra work Optional work We don’t need to do that I’m too busy If only we had that package Can’t you do it for me

What is quality?

Safe Best Smooth / No gaps Patient centred Patient Best care Rescue principle Responsive Empathic Quick Professional Best safest care Continual improvement Satisfied patient Advanced research Clinical freedom Responsive support Managerial Best patient care More efficient Least risk Satisfaction Least strife Smooth running

Gap models of service quality 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

Clinical Audit Identify and eliminate waste Professional education 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 and support only highest quality care

DefineMeasureAnalyseImproveControl Traditional improvement projects Implementation of CA

Effectiveness Information for research Detailed, focussed and minutiae Info not usually collected Information for monitoring Technical data Lot of energy in getting agreement Information for quality improvement Quickly gathered Rapid cycle

Some misconceptions…… It is not about cook book medicine

Identify Standard Measure activity Validate against standardMake appropriate changes

Plan Do Check Do Check ACT Plan Check ACT Plan ACT

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

Continuous vs. Big Bang

Feedback Intervention Theory Emphasis on clinical performance task Specifying performance target Presenting information on how target can be reached Information on progress since last target Emphasis on recipient Discouragement Praise ???

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

Why audit Measuring for compliance Measuring for research Measuring for improvement Win over the sceptics Sharing the experience True short cycle improvement

Good audit The right processes –Prescribing practice The right objectives –Continual self improvement The right measures –Logistics of the prescribing actions The right actions –Reinforcing concept / reinforming stakeholders

Challenges Understanding Good audit Professional competence Measurement of audit Sustaining audit

Joining up the dots Building CA into a central plank of monitoring Understanding context of CA Matching CA to strategic goals Making CA comfortable

Recommendations Motherhood and apple pie More education More forms More awareness More research “We (I) will do x, y and z in the next 6 weeks and we will know we have succeeded

DefineMeasureAnalyseImproveControl Traditional improvement projects Implementation of CA