Presenter-Dr. L.Karthiyayini Moderator- Dr. Abhishek Raut Medical audit Presenter-Dr. L.Karthiyayini Moderator- Dr. Abhishek Raut

Framework Origin Definition of medical audit Need for medical audit Difference between clinical audit & research Stages of medical audit Audit cycle Successful clinical audit Barriers to clinical audit Application

Origin Florence Nightingale and Ernest Codman in the late 1880s and early 1900s were the first to use a systematic form of clinical audit. Since the late 1990s clinical audit has been utilised as part of clinical governance and quality and safety strategies as a method monitoring and improving the quality of healthcare. It received special mentioned as an improvement strategy in the Bristol Royal Infirmary Inquiry in the UK.

Definition The UK’s National Institute for Health and Clinical Excellence (NICE) defines clinical audit as: “ a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the review of change. Aspects of the structure, process and outcome of care are selected and systematically evaluated against explicit criteria. Where indicated changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery”

Clinical audit is a cyclical process where individuals, teams or services: identify a clinical topic of interest or concern identify sources of appropriate data which will assist in assessing the topic, including medical records and feedback from senior doctors, other clinicians and consumers review the data against set criteria and standards identify areas for improvement implement those improvements assess the impact of those improvements.

Need for medical audit The main reason is that it helps to improve the quality of the service being offered to users. It identifies and promotes good practice and can lead to improvements in service delivery and outcomes for users can provide the information we need to show others that our service is effective (and cost-effective) and thus ensure its development provides opportunities for training and education helps to ensure better use of resources and so, increased efficiency. can improve working relationships, communication and liaison between staff, staff and service users, and between agencies.

Difference between medical audit & research Clinical audit Research 1 Aims to evaluate how close practice is to best practice & to identify ways of improving the quality of health care Aims to establish what is best practice 2 Is specific & local to particular patient group results are not transferable to other settings Is designed so that it can be replicated & so that its results can be generalised to other similar groups 3 Aims to Improve services Aims to generate new knowledge 4 Is usually led by service providers Is usually initiated by researchers 5 Is practice-based Is theory driven 6 Is an ongoing process Is often a on-off study 7 Never involves allocating patients randomly to different treatment groups May involve allocating service users randomly to different groups 8 Never involves a placebo treatment May involve administration of a placebo 9 Never involves a completely new treatment May involve a completely new treatment Adapted from Madden (1991) and Firth-Cozens (1993)

Stages of audit

STAGE-1:PREPARING FOR AUDIT Involving stakeholders & including consumers, in the process Select a topic (based on cost, volume, risk to consumers, serious quality problem, complaints, available evidence, amenability to change, priority, policy directives or guidelines) Defining the purpose of the audit (improvement, enhancement, ensuring quality, or instigating change) Establishing or activating necessary structures (committees and meetings, feedback systems) Identifying skills and people needed to carry out audit Providing training to audit team as necessary (project management, audit method skills, change management skills, data collection and analysis and facilitation skills)

STAGE-2:SELECTING CRITERIA Defining criteria & standards against which to assess the process & outcome of care Drawing criteria from existing guidelines or systematic reviews Prioritising criteria (based on the research evidence) Making criteria explicit and subjecting it to external peer review STAGE:3-MEASURING PERFORMANCE LEVES Identifying the data to be collected ,determining sample size, data sources, data extraction tools and techniques, reviewer training and method of analysis.

STAGE:5-SUSTAINING IMPROVEMENT Monitoring and evaluating change STAGE-4:MAKING IMPROVEMENT Identifying the level and location of change (organisational, group, individual); the barriers to change establishing the environment for the audit and involving stakeholders. STAGE:5-SUSTAINING IMPROVEMENT Monitoring and evaluating change Maintaining and reinforcing the change

Success of medical audit Successful clinical audit requires: a clearly defined issue or problem an ability to measure clinically relevant elements of care which clearly reflect that problem an ability to apply that measure in a rigorous and consistent way which best reflects patient care an ability to change care processes to drive any subsequent improvement in the chosen measure sufficient resources to ensure that the work can be undertaken appropriately and in a manner which ensures clinician engagement and support clinical leadership.

Barriers lack of clarity re purpose of audit (what are we trying to achieve?) – audit must be framed around improving patient care and has no role as an investigational tool inconsistent approaches to data collection and management insufficient resources to support the audit process lack of expertise in audit project design and analysis lack of planning lack of medical engagement and leadership poor professional culture and poor relationships between professional groups and agencies, and within audit teams absence of trust between senior doctors and managers lack of integration with other activities (including clinical governance processes) an inability of senior doctors to change or improve the care processes being measured.

Application In providing better quality of care to patients. Safety of patients Continuing medical education Helps in maintaining the clinical practice standards

References National Institute for Health and Clinical Excellence. Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press, 2002. http://www.health.vic.gov.au/clinicalengagement/downloads/ pasp/understanding_clinical_practice_toolkit.pdf Clinical audit: a comprehensive review of the literature . Travaglia J, Debono, D. University of New South Wales. Centre for Clinical Governance Research in Health. 2009. http://clingov.med.unsw.edu.au Undertaking a clinical audit project: a step-by-step guide