Falling in Love with Audit Dr Ian Livingstone Saltaire Medical Centre

Aims & Objectives To help us learn how and why to do Clinical Audit. By the end we should be able to define clinical audit define jargon like “criteria” and “standards” Plan your next audit be able to make any changes needed as a result of your audit. Feeling that audit is useful Aims To help us learn how and why to do Clinical Audit and leave feeling inspired to do at least 2 audit projects a year. Objectives By the end we should be able to define clinical audit define jargon like “criteria” and “standards” explain how to choose a subject for an audit know how to collect data for your audit be able to make any changes needed as a result of your audit.

Why do clinical audit? Trainer reappraisal NHS reappraisal Teach registrars Why do clinical audit? Trainer reappraisal and it’s what training practices are supposed to do NHS reappraisal Teach registrars, summative assessment, nMRCGP, something for their CV To measure and improve the quality of care and service - clinical governance

Why do clinical audit? To measure and improve the quality of care and service - clinical governance Most importantly of all the reason why we really bother is the patients

Clinical governance ‘a new system in NHS Trusts and primary care to ensure that clinical standards are met and that processes are in place to ensure continuous improvement’ Clinical governance is a system for improving the standard of clinical practice. It was first described in a government white paper as

NICE states that: “Clinical Audits monitor the use of particular interventions, or the care received by patients, against agreed standards. Any departures from ‘best practices’ can then be examined in order to understand and act upon the causes.”  

an improvement in the quality of service improved care of patients enhanced professionalism of staff efficient use of resources aid to continuing education aid to administration accountability to those outside the profession Clinical audit aims to lead to an improvement in the quality of service providing:- improved care of patients enhanced professionalism of staff efficient use of resources aid to continuing education aid to administration accountability to those outside the profession

 The Audit Cycle: Can you draw the audit cycle?                       

The Audit Cycle: its basic form

The Audit Cycle: slightly more detail Observe Practice Define Criteria & Standards Compare Results to Standard Implement Change repeat the cycle

The Audit Cycle: if u wanna get serious

Stages in audit Stage 1 - Deciding what to audit Stage 2 – a Setting criteria b Setting standards Stage 3 - observing practice Stage 4 - Compare results with standards Stage 5 - Implementing change Stage 6 - repeating the cycle

Stage 1 - Deciding what to audit Identifying problems, choosing a topic Choose something that interests you. Is the problem common? Does it have serious consequences? Can I do something about it? Choose something that interests you. Check with others that would be involved with making changes – do they agree with your proposal? This is important – you won’t get changes made if you don’t carry people with you from the start. There’s no point in auditing something that you think is already being done well – you will find plenty of problems that need to be sorted out first! Setting priorities You may come up with a number of possible subjects to audit. To help yourself prioritise, ask yourself: Is the problem common? Does it have serious consequences? Can I do something about it? Important clinical events“Significant events”Patients' complaintsObservationObservations of staff NICE subjects Potential for change Relevant to the practice      Tips: Try making the audit title a question. For example, if your criterion is "All patients on Viagra should have had a serum rhubarb done in the last year", a good audit title would be: "Have all patients on Viagra had a serum rhubarb in the last year?"             If your audit results from a problem you've noticed in the practice, document it in your write-up; it suggests that there is a potential for change.             Think about whether you will be able to make any changes that are needed as a result of the audit. If you know you won't be able to make any changes, there's not much point in doing the audit.

Stage 2 - Setting criteria and standards “An audit criterion is a specific statement of what should be happening.” = THE IDEAL “All patients with xxxxx should have had a yyyyy in the last zzzzz year/months.” “An audit criterion is a specific statement of what should be happening.”   → Examples: "All eligible women aged 25-65 should have had a cervical smear in the last 5 years." “All asthmatics should have had a Peak Flow recorded in the past year.” “All drugs in our doctors’ bags should be in-date.”      Tips: Make sure that there is evidence for your criterion – do a literature search. Ensure that the criterion is measurable – ·            “asthmatics should have had yearly peak flows” is difficult to measure (how many years will you go back?) ·            “asthmatics should have had a PF recorded in the past year” is more practical For quickest results, make sure that what you are doing is fairly easy to measure, e.g.’ is Read-coded, though don’t let other data-gathering methods put you off if you you’re really interested in the subject Don’t try to audit too many criteria at once – one or two will keep you busy enough. Try filling in the gaps of the following phrase to set your audit criterion: “All patients with xxxxx should have had a yyyyy in the last zzzzz.” Relevant to audit subject and justifiable, e.g. current literature      Tips: Don't make your audit complicated or overambitious! Often the best audits are the simplest; ones with too many/too complex criteria tend to run into trouble. I suggest you limit it to one or two criteria.             Make sure that your criteria are clearly stated and unambiguous - try using the one on the Setting audit criteria page as a model.             You must justify your criteria with references. You will need to do a literature search

Stage 2 - Setting criteria and standards “An audit standard is a minimum level of acceptable performance for that criterion.” The standard should reflect the clinical and medico-legal importance of the criterion or should be something that is realistic to achieve eg if only 70% of your patients are on aspirin post MI, you might want to go for 80% this year, 90% the year after, and 95% the year after that etc Standards may change with time eg 90% of patients with an myocardial infarct should be on aspirin “An audit standard is a minimum level of acceptable performance for that criterion.”   → Examples: "At least 80% of eligible women aged 25-65 should have had a cervical smear in the last 5 years." “At least 60% of asthmatics should have had a Peak Flow recorded in the past year.” “100% of drugs in our doctors’ bags should be in-date.” The standard should reflect the clinical and medico-legal importance of the criterion. in the example above, 80% of women should have had a cervical smear, But of those who've had an abnormal smear, 100% should have had action taken. Standards may change with time: 70% of patients with IHD should have a cholesterol <5mmol/l  - this is pertinent clinically today because the NSF says so but in the future a higher standard may be expected as a result of clinical governance.      Tips Some criteria are so important that they need 100% standard. However, 100% standards are unusual – patients or circumstances usually conspire against perfection and the standard needs to reflect that. Your literature search should give you an idea of what standards others have managed to reach. Your standard needs to follow on directly from your criterion – for example, “Patients on thyroxine should have had TSH done in the last year; this should have happened in at least 90% of patients”. Make sure that you can justify your standard. If you can't find any literature evidence to back it up, explain why you chose the percentage that you did.

Stage 3 - observing practice What is happening?   What other ways are there to gather data for audits? You can collect information from: computer registers review of contents of medical records questionnaires – patients, staff or GPs data collection sheets      Tip Delegate! You don’t have to collect all the data yourself. Most practices have a member of staff who can help you set up the search or organise questionnaires. Audit will only result in change if you involve all the relevant team-members from the start. This may include the GPs and Nurses who will have to implement any changes, as well as office staff who can help you doing a computer search. Again, you will need to document this.

Stage 4 - Compare results with standards The comparison is the easy bit What reasons are there for practices not meeting audit standards? – planning change You might not have achieved your standard because of an organisational problem for instance Before you start planning changes, you need to work out possible reasons why the practice hasn’t met the standard you’ve set.   What reasons are there for practices not meeting audit standards? In recent audits at our practice, reasons have included: Practice reasons: ·         - Results having been put down as free text on computer, rather than coded; ·         - Opportunistic rather than formal recall system in use; Doctor reasons: ·         - Not all GPs were aware of the practice policy; ·         - Not all partners agreed with the policy; Patient reasons: ·         - Patients refusing to have tests done; ·         - Patients on holiday when tests due.

Stage 5 - Implementing change Medical audit shows what changes are needed actually making the changes is the most difficult part of audit! What are we proud of? What are we not so proud of? Introducing change Medical audit shows what changes are needed: ·         it isn't a method for changing care; ·         actually making the changes is the most difficult part of audit! Actions to remedy identified deficiencies Emphasise what has been achieved. What are we proud of? What are we not so proud of? How can we correct any deficiencies? Changes must be practical! How are you actually going to make the changes? Simply saying “We’ve got to do better” won’t result in change You need to think through in detail       - what needs to be done       - who’s going to do it       - when       - and how. Keep a record Keep brief written record of:                        The reason for doing the audit; Criteria and standards; Results Plans for change Action taken When/whether to repeat the audit. Just telling people to do things better won't result in change. You need to write up in some detail how the changes will take place. Example

Stage 6 - repeating the cycle "Closing the loop" Re-evaluate care to ensure that any remedial action has been effective "Closing the loop" Re-evaluate care to ensure that any remedial action has been effective. Audit is a continuous cycle – if you didn’t meet the standard and you’ve planned changes, you’ll need to repeat the audit to make sure the changes have happened.   When Keep a record Audit meetings every 4 months, follow up old ones, plan new ones, inspire those around you

Audit may Be seen as a threat. Be seen as an unpleasant, time-consuming distraction from day-to-day practice. Antagonise if introduced in an insensitive way. Give the impression of implied criticism. Audit may - Be seen as a threat. Be seen as an unpleasant, time-consuming distraction from day-to-day practice. Antagonise if introduced in an insensitive way. Give the impression of implied criticism.

Audit is an easy technique is effective at improving care. Not be a menace or a means of discipline. Audit must - Assist staff. Be effective at improving care and assist staff Not be a menace or a means of discipline. Have a clear purpose.      Tip: use the no-blame approach, can change the rules, dates, size Respect the individual skills of staff - they know their own jobs better than anybody else. Create an atmosphere in which mistakes can be admitted without blame. Audit in the right atmosphere can be fun!

Audit in the right atmosphere can be fun! A useful tool to examine the quality of service provided to our patients