Introduction to Clinical Audit

Amare H.

1 Amare H. 2/22/2019
 Aim of next 2 days…
 The aim is to provide you with the
skills/knowledge to understand the basic
principles of clinical audit

 So that you are able to carry out a clinical

audit within your own working environment

2 Amare H. 2/22/2019
 Objectives:
 Identify and explain all stages of the
audit cycle

 Explain what to consider when

choosing an audit topic

 Identify where to find/develop clinical

audit standards

3 Amare H. 2/22/2019
  Understand about potential data
sources and methods of data
collection

 Be aware of Data Protection, ethics

and Confidentiality aspects of clinical
audit

 Initiate, implement and maintain

4 change
Amare H. 2/22/2019
 Nit picking
How do you know that you are doing
specific clinical procedure in either high,
medium, acceptable or low level of
competency?
 In groups of 3 colleagues from the same
discipline – discuss what standards follow /
you work towards in your jobs?

 Tip: Think back to your Evidence-based

Practice and Health Informatics course
5 work
Amare H. (Pubmed findings) 2/22/2019
 What is Clinical Audit?
 A Clinically led initiative, which seeks to
improve the quality and outcome of
patient care,

Whereby clinicians examine their practices

and results against agreed standards and
modify their practice where indicated.

 Adapted from definition in ‘Clinical Audit in

the NHS’ NHS Executive 1996
6 Amare H. 2/22/2019
 What is Clinical Audit?
 Clinical audit is a quality improvement
process that seeks to improve patient
care and outcomes

 Through systematic review of care

against explicit criteria…Where
indicated, changes are
implemented…and further monitoring is
used to confirm improvement in
7 healthcare
Amare H. delivery. 2/22/2019
 What is Clinical Audit?
Put simply:

 Improving the quality of patient care by

looking at current practice and modifying
it where necessary

(Working for Patients, White Paper 1989)

8 Amare H. 2/22/2019
Why we need clinical audit..

Sir Bruce Keogh, NHS Medical

Director

‘Doctors and clinicians need to accept

that they have a moral and professional
duty to ensure they know what they are
doing and how well they are doing it

Amare H.
(Health Service Journal, 2008)
2/22/2019
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The Audit Cycle
Identify Obtain guidelines / set
Topic standards
Collect data to
Re- measure
audit current
practice

Impleme
nt action Compare
plan practice
Make
recommendatio with
ns for change standards
10 Amare H. 2/22/2019
  Clinical audit is not just a data collection
exercise:

It involves measuring current patient care

and outcomes against explicit audit criteria
(also termed standards).

 There is an expectation from the outset

that practice will be improved.

 Further clinical audit may be required to

11 confirm that practice has improved.
Amare H. 2/22/2019
 Key
 At a local level clinical audit links into
both clinical effectiveness and clinical
governance.

 Firstly, clinical effectiveness aims to

identify and appraise existing evidence
of best practice.

 Once identified, if necessary, local

practice may be amended to ensure that
12 it H.is conforming to best practice.
Amare 2/22/2019
 Key
 Once implemented a clinical audit
project might be undertaken to ensure
that:

Best practice is being followed

That patient outcomes are the desired

ones

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 Key
 Secondly, concerns regarding clinical
care are often identified through other
clinical governance structures.

 These concerns can often be used to

inform a clinical audit project. This
includes:

14 Amare H. 2/22/2019
 SOURCES OF CLINICAL AUDIT
PROJECTS
 Publication of conclusive new evidence
about clinically effective healthcare

 Local or regional treatment guidelines,

protocols or frameworks

These will ideally be based on best

evidence (perhaps from national
guidelines), or maybe a local consensus
of best practice
15 Amare H. 2/22/2019
 SOURCES OF CLINICAL
AUDIT PROJECTS
 User views or complaints

 Adverse incident/near miss reporting,

aka clinical/critical incident reporting

 Identified local priorities or concerns e.g.

areas of high volume, risk or cost

16 Amare H. 2/22/2019
 Examples audit topics
 Have patient history and examination
been properly recorded following
admission?

 Were appropriate investigations carried

out?

 Was the treatment appropriate and

timely?
17 Amare H. 2/22/2019
 How does clinical audit help
the Patient?
 The audit process will enable us to
access whether the patient is getting
the correct care

 A good quality audit will often lead to a

change a in the way we work

 This change may improve the patient’s

care, or experience, as well as the
18 patient’s outcome
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 • You will have to be involved in Clinical
Audit throughout your career as a
clinician (so get good at it now).

• Your participation in Clinical Audits:

 Shows patients that you reflect on and
improve your care

 Provides evidence that you have met

training requirements

 Demonstrates commitment to progress in

19 your career
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 Distinguishes you from your
colleagues in a competitive situation

 Win prizes in audit competitions

 Publications

 Provide links with research

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 How is research
different
to clinical audit?
Exercise

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IN THE SIMPLEST
TERMS...

 Research creates new knowledge

about what treatments work best, asking:
“What is best practice?”

• Clinical Audit takes that knowledge

and makes sure that we are doing
the things that work best, asking:
“Are we following best practice?”
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CA
 WHY IT’S IMPORTANT TO
KNOW THE DIFFERENCE…

‘Research is concerned with discovering

the right thing to do, clinical audit with
ensuring that it is done right’

(Smith R. ‘Audit and Research’ British

Medical Journal, 1992; 305;905-6).

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 WHY IT’S IMPORTANT
TO KNOW THE
DIFFERENCE…
 Research and Clinical Audit projects:
have different purposes, and therefore…
use different methodologies
 Research requires ethics approval:
clinical audit does not

 Clinical Audit and Research are managed

24
and funded in different ways
Amare H. 2/22/2019
 Planning your audit
 Most important part of a successful
clinical audit is to ensure that you
make a good plan

 Possible to use different types of audit

planner – track keeper not to miss
anything

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AUDIT CYCLE – Background

 Background
What is prompting you to look at this
topic?

Why do you think this is a priority area for

action?

What benefits for patients do you hope to

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32
bring about by doing this audit? 2/22/2019
Audit Aims & Objectives

 Aims
What exactly is the project trying to achieve
What are the overall benefits that you
are trying to achieve?

 Objectives
Describes what aspect of quality you
are going to measure to show that your
aims have been met.

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 Aim
 It should be related to the rationale
behind choosing your audit topic and
should not merely be to ‘count the
number of’ or ‘examine’ but should focus
your audit towards achieving
improvements in practice where
necessary.

 Eg. ‘To improve the care received by

34 patients who develop leg ulcers.’
Amare H. 2/22/2019
 Objective
 Use action verbs such as:

-determine -verify -
identify
-describe - assess - compare
– calculate - establish -
explore

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 Aspects of clinical audit
 Appropriateness – Is the right
treatment being provided to the right
patient?

 Timeliness – Was the treatment given

at the right time?

 Effectiveness – Was the treatment

given in the right way? With desired
36 effect?
Amare H. 2/22/2019
  Other aspects of quality that do not tend
to be assessed through clinical audit
are:

 Efficiency – Was the treatment given

with minimum effort, expense, waste?
Efficiency issues are best resolved
through service improvement work.

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  Acceptability - Is the treatment
acceptable to the patient? Acceptability
is usually a focus of research or patient
involvement activity, rather than clinical
audit.

 Equity - Is the treatment available to all

patients on an impartial basis?

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 Aims & Objectives for
Pathology Example
 Aims
• To improve the quality of completion of
pathology request forms

 Objectives
To ensure pathology request forms are
appropriately completed
Identify the gaps/errors in the
information provided
To inform relevant clinicians of the
findings
39 Amare H. 2/22/2019
AUDIT STANDARDS (Where
are they?)
 Does a policy/guideline/standard already
exist (nationally or locally)
if not
 Develop your own standards by:-
Contacting other Trusts
Gaining a consensus locally
Write up your own standards or create a
new local guideline

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 AUDIT STANDARDS

What are audit standards?

Statements about how patients should be

managed or services should be delivered

41 Amare H. 2/22/2019
JB
 AUDIT STANDARDS
Think SMARTER!
 Specific
 Measurable
 Agreed
 Realistic
 Timely
 Evidence based
 Relevant {clinically}
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JB
 Audit standards

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EXAMPLE AUDIT
STANDARDS

 All entries into the medical record should be written

in black ink

 All patients who visit the emergency department of

the hospital should be seen within 2 minutes

 All newly diagnosed cancer patients should be seen

within 2 weeks by an appropriate clinician

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JB
 STANDARDS - IN
SUMMARY
• Your standards are what you will measure to
determine how good practice actually is

• Aim to achieve the agreed standard 100% of

the time unless there is justification for less

• Keep focussed on your aim - you don’t

always need to audit every standard or
every aspect of the guidance related to your
Handouts –Standards
45 topic
Amare H. 2/22/2019
 Standards for pathology
request form audit
Source Where data
Standard Exceptions Target of will be
Evidence found
Name of
Consultant or
None Pathology
GP sending UHL
100% request
request will be guidance
forms
legibly
recorded
If patient
Patient confidentiality
100% of Pathology
surname will be is a priority, a UHL
applicable request
legibly unique ID No guidance
cases forms
recorded is required
instead.
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Audit Methodology - Project
team
Nurse Docto
rs Pharmaci
s
Laboratory
sts
staff Clinical Physiotherap
Audit ists
Head of
Audit clerk
Department
Records
Secretari Clerk
es
etc
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 Audit Methodology

 Identify your project team

Should include
Audit supervisor (senior clinician/
manager)
Audit lead (person undertaking the audit)
Representative from those areas the
results will impact upon.

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EXERCISE

Complete “Project Team” and

“Participation Details” on page 1 of
the Planner

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CA
 Audit Methodology – Audit
Population
 Audit Population is the total population that
meets your audit inclusion criteria, within
the audit time frame.
eg. All pathology requests received from
……on the 1
September 09
Consider all available data sources
May be necessary to combine more than
one to “catch” all applicable patients
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Audit Methodology

 Sample size
It may not be practical to include every
single patient who meets your inclusion
criteria.

You therefore need to select a sample of

patients that can be taken as being
representative of the total group.
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 Audit Methodology

 The sample size will depend on the type of

audit:-
 Audits of the delivery of care (standard
based)
Require enough to convince people to
make changes
Should use current/recent patients
 Audits of the results of treatment
(outcomes)
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 Sample size

 When using a sample for a clinical audit, the

important factors to consider are:
1) Population size
2) Prevalence of occurrence of what you are
auditing
3) Level of confidence
4) Level of accuracy/precision, margin of error

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 Prevalence

 Prevalence ("proportion“) of a disease in a

statistical population is defined as the total
number of cases of the disease in the
population at a given time, or the total
number of cases in the population, divided by
the number of individuals in the population.

 Calculated in the same way as a %

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 Prevalence in Audit (1)

For standards based audits the prevalence

is the level of compliance, which is set to
0.5 as we make no assumptions % (rate) of
compliance

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 Prevalence in Audit (2)

 For outcomes audit if the prevalence is low

or the topic is of high importance then the
sampler is not appropriate to use – and you
will need to audit all cases to be confident
that you have audited the cases with for
example the complication

(for example - Breast Cancer Audit).

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 Confidence levels

 How confident do we need to be?

 How important is it that we get it right?

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 Different Sampling Techniques

 Stratified – matches population exactly (i.e. if

more women than men with the disease
make sure sample reflects)
 Random – every patient has an equal chance
of being selected
 Systematic – every nth name on list
 Consecutive – every patient during a specific
time period
 Opportunity sampling – anyone who agrees
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to Amare
take H.
part (patient surveys) 2/22/2019
 Reality Check

 If you are expecting low response or a

difficulty in locating your sample
selections then it is prudent to over sample
to ensure that the sample size achieved
provides the required level of precision.

 Make the extra effort to locate these

patients as they may be important
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 JB

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JB
Audit Methodology – Data
Collection

Retrospective data Prospective data if:-

if:-  Pre-existing data is not
 Utilises pre-existing available
data  Audit may rely on
 Needs data routinely observing practice
and reliably recorded (ensure that practice
doesn’t change just
 Data easily
because audit is taking
accessible (either in
place – the “Hawthorne
paper files or on data
61 Amare H. Effect”) 2/22/2019
systems)
 Audit Methodology – Data
Collection

What is the purpose of data

collection?
 Find out if the standard has been met
 Identify areas of best practice
 Identify where improvements need to be
made
 Identify trends and/or reasons why care
does not meet the standard that we have
set
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JB
 Audit Methodology – Data
Collection
WHAT TYPE OF DATA WILL YOU
COLLECT?
 Quantitative (numerical)
Numerical data
 Dates
 Number of responses to questions
(yes/no; LRI/LGH/GH;)
 Qualitative (descriptive)
Patient experiences
Opinions
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JB
Confidentiality

Data must be anonymous

 Patients
 Clinicians

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Data Collection – Data
Protection

 Need to ensure security of data

 Avoid collecting patient/colleague identifiable
data
X Name and address
X Hospital number
X Adm. number
 Give forms a unique identifier
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JB
Project Planning - Exercise

 Look at Page 4 of the Project Planner

 Complete Methodology section

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 Assignment

Present your clinical audit plans to us

and the rest of the group

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 Half-time…

 End of Day One

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 Data Collection – Form
Design

WHAT DATA DO I NEED?

 To answer audit objectives / standards
X Avoid irrelevant data items

Data Protection Act:

Data must be adequate, relevant and not
excessive for purpose
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 Data Collection - Pilot

 Pilot your form using a few cases only

Were your questions clear?
Could you get the data you need?
Is there anything you don’t need?
Could you collect data in a reasonable
timeframe?
70 Amare H. 2/22/2019
 DESIGNING A DATA
COLLECTION FORM
 In clinical audit data collection forms are
also referred to as ‘audit forms’ or ‘audit
proformas’

 The word ‘questionnaire’ is usually

reserved for surveys, where patients or
staff are being asked questions

71 Amare H. 2/22/2019
 Compare Data With Standards
(Analysis)
 Familiarise yourself with the data
 Clean up the data!
 If using a spreadsheet, do column
headings make sense?
 Check for blanks
 Spot-check for data inputting errors or
variations

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 Data Analysis

 Most simple analysis is to create

percentages of compliance against the
standards:
Number of pathology
requests that meet the
x 100
standard
Number of pathology
requests to whom the
standard applies
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 ANALYSING
STANDARDS
BASED DATA
Audit standard:
“Consultant or GP Name should be documented
on the Pathology Request Form”
Results:
Yes No
8 11
8 Pathology request forms had the
consultant/GP name documented but 11 didn't
= 8/19 X 100 = (42%) compliance with
standard
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FURTHER NUMERICAL DATA
ANALYSIS
 Keep it simple!

 Use simple statistics

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 CHARTS IN EXCEL

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Feeding back the results – key
findings
 Focus on key points in your
presentation/summary
 Get the message of your audit across to key
staff
 Generate discussion and agreement about
changes to practice in light of the audit results

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 Data tables

STANDARD Met No Resul

standar eligibl t
d e
Consultant/GP name 8 19 42%
documented

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 Visual results..

Was the Consultant / GPs name

clearly documented? (n=19)

42%

58%

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 Feeding back results - methods

 Options:
 Forums, Reports, Posters, Meetings, Email –
(a combination of all)
 Timeliness of reporting – don’t wait too long
to discuss results and agree actions
 Presenter needs to have confidence and
familiarity with project
 Helps if presenter is respected / expert

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Basic content of audit
report
 Background / Reason for Audit
 Aims & Objectives
 Standards (include Evidence / References)
 Method (how you did the audit)
 Results
 Conclusions and Recommendations
 Action Plan

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 Agreeing Actions
 Pros and cons of having actions agreed
ahead of presenting results

 Immediate feedback on what needs

doing
 Opportunity to raise potential barriers

May cause irritation if

felt to be poor consultation about action
planned
not all agree with audit findings
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 INITIATING CHANGE

 Do people recognise the need for

change?
 Are they willing to change?
 May need to ‘sell’ your proposal
 Address the concerns of staff
 Inspire them
 Give them facts and figures
 Use power or influence
 Get ‘opinion leaders’ on side

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 Managing Change
The Change Process

Three Phase Model

a) Unfreezing
b) Moving
c) Refreezing

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 Managing Change
Unfreezing:-
Five approaches to overcome resistance:-
a) Education / communication
b) Participation and involvement
c) Facilitation and support
d) Negotiation and agreement
e) Manipulation / co-option / coercion

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 Managing Change
Moving:-
Factors to consider:-
 Make staff know what is required.
 Provide training and support
 Provide adequate resources
 Ensure conflict does not arise with
providers or users.
 Maintain motivation

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 Managing Change
Refreezing:-
 A time of consolidation
 Recognise and give praise
 Learn – as individuals and as a
department

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 Managing Change
Understanding your current situation:-
Five tools (a-e) to enable an
understanding of the present situation
and to help plan the next step:-

a) Force Field Analysis

If driving forces are stronger than
opposing forces then progress will be
made

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 b) Environmental Mapping
Identify all elements involved in
change and consider the demands
and responses

c) Commitment Planning
What key people or groups are involved
and how committed are they:-

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 Commitment Planning

 Level of Commitment:-
Opposing
Neither oppose or support
Will support with time
Will lead and make it happen

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 Managing change
 To get commitment:-
 Praise desirable behaviour
 Help to resolve the problem
 Provide understanding
 Educate and develop
 Use peer pressure
 Be a role model

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 Managing Change
Understanding your current situation:-
a) Force Field Analysis
b) Environmental Mapping
c) Commitment Planning
d) Change Equation
e) Problem Solving

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 Based on the assumption that interest in
change is rare unless factors supporting
change are greater than costs.
ie A+B+C>D

A = Dissatisfaction with the now

B = Vision of a better future
C = Acceptable first steps
D = Cost to an individual or group
The key is to increase the sum of A+B+C
or reduce D
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TYPICAL CHANGES FROM
AUDIT
 Better information and communication
 Staff training and education
 Introduction of new methods /
procedures
 Better documentation
 Revised patient or carer information
 Raising awareness with staff
 Putting a checking mechanism into
94 Amare H. 2/22/2019
place
 ACTION PLAN
TEMPLATE

Action Lead for Timescale / Progress with

implement deadline Action/s
ation (i.e. completed,
ongoing or to start)

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CA
 “The most important
part of the audit cycle
is making change”
Baker et al (1999)

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 How to confirm
improvements made?
 Re-audit
 But should be focused on areas where
greatest improvement needed

 Consider other ways –

Teaching sessions delivered
Policy revised
Reduced complaints

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 How to conduct a re-audit..

 Keep your methods the same!

 Identify patients in the same way
 Do not change your data collection
forms
 Involve the same audit team (if possible)
 Try to conduct a re-audit in good time

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 Explain contributing factors why
change in result
 Eg different doctors, sampling bias,
change in practice since last audit,
timings

 Design audit methodology to minimise /

take into account above factors

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RE-AUDIT (“Closing the Loop”)

Identify Topic Obtain guidelines / set standards

Collect data
Re-audit to measure
current
practice

Implement
action plan
Compare
practice with
Make recommendations standards
for change

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CA
 Is all clinical audit good?

 Normally down to the Methodology and

information collected

 Link to appraising the posters with

prompt sheet

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 Why Appraise Clinical Audits
 Gain ideas for topics we can audit
 To identify good practice (we can copy)
 To examine and assess methodology (is it
sound?)
 Examine the findings? (level of improvement?)
 Asking questions of the audit and what and
how it is presented
 Assess if there the data is robust enough to
convince clinicians to change practice

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 Why bother to appraise
audit papers?
 The reality of the working in a hospital often
means it is impossible to do a ‘perfect audit’
- so you can expect some flaws in all audits.
 However it is up to you to decide if these
flaws matter and how much bearing they
will have on the findings and the ability to
act on the results.
 It will assist you in being able to recognise
whether audit results are good enough to
bring about change in practice
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 Audit of Standard of
hygiene & cleanliness
in the wards of Gondar
Hospital

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 Aim
 To improve hygiene and cleanliness of
Gondar Hospital Wards

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 Methodology
 Prospective observation
 Questions based on standards
 Assessment of four wards
(observational)
 Variety of wards

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 Standards for the audit..

 Clean floor
 Windows / curtains / doors open
 No litter/rubbish on the floor
 Waste bins available
 Safety boxes available
 Clean beds / sheets available
 Enough space between beds
 Soap and water available
 Smell nice and clean
 No overcrowding / with people

107 Amare H. 2/22/2019

Results

Standards Ward 1 Ward 2 Ward 3 Ward 4

Clean floor √ √ √ √

Windows/curtains/doors open √ √ √ X

No litter/rubbish on floor √ √ √ X

Waste bins available X X √ √

Safety boxes available √ X √ √

Clean beds/sheets available X √ √ X

Enough space between beds X √ √ X

Soap & Water available X X X X

Smell nice and clean X √ √ X

No overcrowding/ with clear bed X X √ X

spaces
4/10 6/10 9/10 3/10
 Conclusions
Areas of good practice
 All ward floors are clean
 Windows, curtains, doors opened
 No litter/rubbish on floors
 Ward C is very good
 Ward B is acceptable

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 Conclusions
Areas which need improvement
 Wards A & D need to be improved
 Waste disposal
 Crowding

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Action Plan
Action to be implemented By Whom Timescale
Provide water/soap/waste 1.Hospital management, Next week
bins/safety boxes (Clinical Director and Head
Nurse)
2. Infection Prevention
committee
Hygiene information for Ward nurses Tomorrow
patients and relatives on
wards
Infection Prevention training for 1.Hospital management, (CD 2 months
all staff and HN)
2. Infection Prevention
Committee
Special attention to A & D 1. Hospital management, (CD Soon
wards and HN)
2. IP committee
3. Head nurses of A & D
 Assessments (part 1)

Group Assessment

 Plan a clinical audit relevant to your group

and present your plan to the group
 Marks: 30. Complete

 Re-Audit - 20

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 Assessments (part 2)
Individual Assessment
 Undertake a simple clinical audit in your clinical
area (using one or two standards). Plan your audit
using the planner and detail your findings using the
‘Clinical Audit Planning and Summary Form’
provided in your student handbook and any actions
you feel are necessary.
Word count: 2300-2500
 Marks: 50

The assessments must be handed in on 13th

December
2015,
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Amare H. 2/22/2019
 Closing Remarks

Thank you for attending

amaretom22@gmail.com
December 16, 2016

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 End of Day 2

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