3. Clinical Audit Jill Warn, Audit & IT Lead Dr John Guy, Clinical Lead

4. What..... do you hope to achieve today? experience have you had of audit?

5. Today we will look at…... Enhancing your understanding of Audit Getting Audit right for Revalidation The benefits of Audit in Primary Care Implementing change Please ask questions / interrupt

6. A small change in practice is better than a major discussion of the possibilities

7. What is Audit?

8. Some Definitions Audit is a process used by health professionals to assess, evaluate and improve the care of patients in a systematic way in order to enhance their health and quality of life.  OR Deciding what you should be doing, looking at what you are doing, deciding whether you can do it better, implementing any changes and then making sure the changes have worked!

9. What do we audit? Structure Process Outcome

10. Why do an audit? Bring about change Best use of resources Improve standards Stimulate education Reduce errors (clinical and organisational)

11. GMC advice all doctors should take part in systematic audit and be familiar with the principles and practice of clinical audit

12. It is about Auditing your own practice!

13. What to consider when choosing a subject. Is your topic appropriate? Does it reflect the care undertaken by you the practitioner? Is it evidence based?

14. QOF areas will not be acceptable

15. Which topics to choose? For principals / static salaried doctors For sessional docs

16. Principals

17. Sessional

18. When Planning an Audit Measure care against a set standard or criteria Take action to improve care Monitor to sustain improvement

19. DDIAY

20. Consider Being a Learning Organisation  Look at the skills within the team  Empowerment  How might this work?

21. Audit and Revalidation At least one full clinical audit cycle during a revalidation period Significant Events Audit  A GP’s portfolio is expected to contain an analysis of at least ten significant events over a 5 year period

22. Clinical Audit At least one full audit cycle during a revalidation period  Initial audit results  Change implemented for the GPs’ patients  Re-audit – demonstrating improvement by the GP

23. The Audit Cycle Audit Cycle Objective / Standard What are we trying to achieve? Method Data Collection Are we achieving it? Data Analysis If not why are we not achieving it? Implementing Change Doing something to make things better Re-evaluate /Review Have we improve things?

24. What is an Effective Audit? An educational activity Promotes understanding Resource effective Raises standards Promotes change Source of information

25. Writing up your Audit

26. The great coffee audit Found on Google: Gloucestershire PCCAG

27. The great coffee audit Problem:The doctors feel that their coffee isn’t hot enough after slogging through morning surgery

28. The great coffee audit Problem: Criteria: The doctors feel that their coffee isn’t hot enough after slogging through morning surgery The coffee shall be hot and satisfying to the hard pressed docs

29. The great coffee audit Problem: Criteria: Standards: The doctors feel that their coffee isn’t hot enough after slogging through morning surgery The coffee shall be hot and satisfying to the hard pressed docs The coffee shall be served at a temperature of 85-90  C on 80% of occasions and there will be 90% satisfaction level expressed by the docs

30. The great coffee audit Methods:The junior receptionist shall check the temperature of the coffee daily for two weeks and circulate a questionnaire to the partners asking them to score a coffee satisfaction level between 1 and 10. The practice manager shall visit Tesco’s and interview the manager about the availability, costs, quality and sell-by dates of the coffee brands available.

31. The great coffee audit Review:After a rather tense audit team meeting it was found that the coffee temperature fell below 37  C on at least 33% of occasions and reached the standard on only 10% of occasions. The doctors scored the coffee at an average 3/10 and two expressed it undrinkable. The practice manager reported the results of her Tesco’s visit.

32. The great coffee audit Change:It was agreed to replace the aged coffee maker (after agreeing suitable redundancy terms for the senior receptionist) with a shiny new machine from Argos. As an additional ‘quality initiative’, cream cakes would be served after surgery. The coffee contract would be switched from the corner shop to Tesco PLC Trust.

33. The great coffee audit Re-audit: For a further two weeks it was agreed to measure the coffee temperature and re-circulate the questionnaire. It was gratifying to find 100% correlation with agreed standards with the exception of one partner who didn’t like coffee anyway.

34. The great coffee audit Re-audit: Future Audit: For a further two weeks it was agreed to measure the coffee temperature and re-circulate the questionnaire. It was gratifying to find 100% correlation with agreed standards with the exception of one partner who didn’t like coffee anyway. Cost implications of standard maintenance Cholesterol assays for partners

35. KISS

36. Writing Criteria A criterion is a statement of what should be happening. Evidence based Measurable Clear, unambiguous

37. Setting the Standard A standard is a number Usually quoted as a percentage One for each criterion Where you think you should be Use group discussion, journals and press, financial targets, last year’s results.

38. Collecting the Data Consistent information Dedicated time for audit Team Approach Sharing of information

39. Collecting Data Be Organised. Collect essential information only. Think of different possible sources of data.

40. Comparing the Results with the Standard Straight comparison If the standard is not met, what can be done to improve things?

41. We may not be quite as good as we think we are!

42. Onset of diabetes (a)

43. Onset of diabetes (b)

44. Onset of diabetes (c)

45. Onset of diabetes (d)

46. Making the Changes Is this something you have direct control over? Does patient opinion come into this? Who needs educating? Selling your changes to your colleagues How long will the changes need?

47. What can we do to improve things? ‘For every fatal shooting, there were roughly three non-fatal shootings. And, folks, this is unacceptable in America. It's just unacceptable. And we're going to do something about it.’ George W. Bush

48. Have the Changes Worked? Collect a second set of data Allow time for the changes to take effect Have the changes made a difference? Has the target now been reached? Can further changes be put in place? Is this going to be reviewed again in the future?

49. Presenting Results Results must be clear and understandable Present data in a visual way Avoid complex statistical analysis Quote the numbers before the % for less than 50 pieces of data Be tactful with difficult results

50. Why do we use graphs? The number of asthmatic patients attending for annual review varies according to age, with patients in the 16-24 age group least likely to attend.

51. Types of Graph: Pie Chart Percentage of patients discharged from hospital with either complete, incomplete or no discharge letter

52. Types of Graph: Bar Chart Patient who had a Health Check

53. Types of Graph: Line Chart

54. Writing it up for revalidation! Title Reason for choice Dates of first and second data collections Criteria and standards with justification Results of first data collection – reflection Summary of discussion and changes agreed

55. Changes implemented Results of second data collection – reflection Quality improvement achieved Reflections  Knowledge skills performance  Safety and quality  Communication partnership teamwork  Maintaining trust

56. Quality improvement projects

57. Significant event audit The audit should be:  transparent  It should not be confrontational or judgemental  It is not an opportunity to name, shame and blame.

58. It should be something in which you are involved It should be discussed in a meeting Changes involve you Reports should not identify the patients

59. Should include Title of event Date of event Date of meeting Description of event What went well? What could have been done differently?

60. and Reflections What changes were proposed  For me?  For the team? What changes were implemented and their effect?

61. Topics to pick

62. Some ideas New cancer diagnoses INR >8 What about sharing across health economy?

63. ANY QUESTIONS?