CLINICAL AUDIT

CLINICAL AUDIT UNIT

MEDICAL CARE QUALITY SECTION
MEDICAL DEVELOPMENT DIVISION
 THE DIFFERENCES

INNOVATION KIK HAS/ DSA (QA) RESEARCH

Dental
Programme Pengurusan P & ST
(KSU) P & ST
• New Idea • IHSR, NIH • ICR, NIH
• Problem or no • Group (5-10 ppl) • Group
• Innovation • Can be
problem • Specific Cycles group/individual
• Expensive or • Creativity • Specific Criteria • ISR/ NISR
cheap
AUDIT

https://www.google.com/search
 AUDIT HISTORY
LATIN ORIGIN:

AUDIRE LISTENING
Control
Check Auditing existed primarily as a method to
Inspect maintain governmental accountancy, and
Revise record-keeping was its mainstay.

It wasn’t until the advent of the Industrial Revolution, from 1750 to 1850,
that auditing began its evolution into a field of fraud detection and financial
accountability.
https://iedunote.com/auditing-origin-evolution
 CLINICAL AUDIT DEFINITION

“A quality improvement process that seeks to improve patient

care and outcomes through a systematic review of care against
explicit criteria and the implementation of change. Aspects of the
structure, processes and outcomes 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.” ”
Principles for Best Practice in Clinical Audit, National Institute of Clinical Excellence (NICE), 2002
 MEDICAL AUDIT
VS CLINICAL AUDIT
 CLINICAL AUDIT HISTORY

• Scutari Barrack (Turkey), 1854

– Kept meticulous records of the mortality
rates among the wounded patients.
– Applied strict standards of hygiene for the
hospital and its equipment.
– Demonstrated a fall in mortality rates from
40% to 2%.
Florence Nightingale
1820-1910

Crombie IK, Davies HTO, Abraham STS and Florey C du V. The audit handbook.
 CLINICAL AUDIT HISTORY

• Frequently quoted for the remark:

“..collect information on all cases to determine whether treatment has
been successful, and then to inquire ‘if not, why not (sic)’”.
• It was reported that his initiative met with “the resistance of arrogance,
the molasses of complacency and the anger of the comfortable
disturbed”.
Ernest Codman
• Codman’s work ultimately developed into the demand for the setting of 1869 - 1940
national outcomes for medicine by Hey Groves (BMJ. 1908; Oct 3). Pioneering Boston
surgeon who made
contributions to
anaesthesiology,
More recently, the 1989 White Paper, Working for Patients, saw the first radiology, duodenal
attempt to standardise clinical audit as part of professional health care. ulcer surgery,
orthopaedic oncology,
Formally introduced into the National Health Service (NHS) in 1993. shoulder surgery, and
the study of medical
outcomes.
Crombie IK, Davies HTO, Abraham STS and Florey C du V. The audit handbook.
 PART OF CLINICAL GOVERNANCE

SIX PILLARS OF CLINICAL

Clinical Governance is a system through which GOVERNANCE
NHS organisations or Trusts are accountable for
continuously improving the quality of services,
and ensures that there are clean lines of
accountability within NHS Trusts and that there
is a comprehensive programme of quality
improvement systems.

Clinical audit was incorporated within Clinical

Governance in the 1997 White Paper, "The New
NHS, Modern, Dependable", which brought
together disparate service improvement
processes and formally established them into a
coherent Clinical Governance framework.
National Clinical Audit Program, NHS
 THE IMPORTANCE
Links both clinical effectiveness and clinical governance
Identifies and promotes good practice
(improvements in service delivery and patient’s outcome)

Provide the information needed to show others that your service is effective
Minimises error or harm to patients
Reduces the number of incidents and complaints
Provides opportunities for training and education
Can lead to the development of local guidelines and protocols
Helps to ensure better use of resources and therefore increased efficiency
Can improve working relationships, communication and liaison between staff,
staff service users and between agencies
TYPES OF CLINICAL AUDIT (TIME BASED)
 TYPES OF CLINICAL AUDIT
ADVERSE
OCCURRENCE PATIENT AND
STANDARD BASED
SCREENING AND PEER REVIEW SERVICE USER
AUDIT CRITICAL INCIDENT SURVEYS
MONITORING

Peer review cases

In terms of clinical
A cycle which which have caused
An assessment of audit, surveys can
involved defining concern /
the quality of care to be a useful tool
standards, collecting unexpected
improve clinical care. where measuring
data to measure outcome.
Individual cases are compliance against
current practice The multi-
discussed by peers your criteria
against those disciplinary team
to determine requires information
standards and discusses individual
whether the best that can only be
implementing any anonymous cases to
care was given, obtained from the
changes deemed reflect upon the way
include interesting patient and or the
necessary. the team functioned
or unusual. service user.
and to learn for the
future.
COMPARISON
COMPARISON
COMPARISON
COMPARISON
 ETHICS & NMRR

Clinical Audit only needs ethical approval if the audit

involves anything being done with patients which
would not otherwise be part of their routine clinical
management.

Clinical Audit only needs NMRR if the team plan to

publish the clinical audit in an international/ local
journal or plan to continue as a research project.

BUT……should check with ethic committee if involves sensitive areas which may affect
the patient, such as mental health issues, sexual health, some issues around maternity
and children.
Improving Patient Care through Clinical Audit A ‘How To’ Guide. NHS (2017)
 COVERS

Asking are we doing things right?

Baseline survey / pre-audit
Surveillance / monitoring
Benchmarking
Accreditation
The way to be sure something is an audit is to look for evidence-based Standards.
(These are sometimes called criteria or indicators).
Improving Patient Care through Clinical Audit A ‘How To’ Guide. NHS (2017)
QUALITY FRAMEWORK

Prof. Avedis Donabedian, 1985

QUALITY FRAMEWORK
 QUALITY FRAMEWORK

Prof. Avedis Donabedian, 1985

FACTORS

The London Protocol,

Clinical Safety Research Unit,
Imperial College London; 2004.
 TIPS FOR A SUCCESSFUL AUDIT
5
Adequate training
Agree confidentiality of findings and a 'no blame'
and support for all
culture.
staff involved.

1 2 6
• Audits are more Allow sufficient time - protected time is helpful.
likely to be
effective where
adherence to 7
recommended
practice is low. Good data collection and/or IT systems are required.
• Choose a topic
with high priority
(as above). Set realistic standards (optimum rather than ideal)
3 8 that are agreed by the team
A team 4
approach - Enlist support from 9
involve all Deliver intensive feedback
your organisation.
relevant staff.
Benjamin A; Audit: how to do it in practice. BMJ. 2008 May 31336(7655):1241-5.
CLINICAL AUDIT CYCLE
 STEP 1: IDENTIFY

When you are thinking about topics for audit, consider areas where there is:

Local concern
New treatment
Patients’ concerns
Risk issues
Wide variance
Trust priorities
Areas of high volume, risk or cost
 STEP 1: IDENTIFY – GOOD TOPIC

✓ Addresses a known quality issue

✓ Addresses an important area of practice
✓ Has the potential to achieve and
improvement in the quality of patient care
✓ Addresses an area of clinical certainty
and consensus
✓ Will use explicit audit measures
✓ Has clinical support
✓ Involves self audit
 STEP 1: OBJECTIVES & EVIDENCE
Define objectives of your audit
EVIDENCES
Areas Source of information Database
❖ Books ❖ The Cochrane Library of
❖ National guidelines
❖ Journal articles, reviews, Systematic Reviews
❖ Research findings,
letters, comments and ❖ MEDLINE – Index
particularly systematic
editorials Medicus
reviews
❖ Reports from MOH, Royal ❖ EMBASE – European,
❖ Local policies, protocols
Colleges excellent for drugs and
and procedures
❖ National guidelines pharmacology
❖ Local consensus (But
❖ Local care plans, protocols, ❖ National Registry
not because we’ve
guidelines etc
always done it!) ❖ PIK HMIS Information
❖ Patient information leaflets
Improving Patient Care through Clinical Audit A ‘How To’ Guide. NHS (2017)
 STEP 2: SETTING STANDARD

Be SMART & realistic!!

STEP 2: SETTING STANDARD
 STEP 2: SETTING STANDARD

You can set the target at a lower level that is:

✓ Taken from a baseline audit
✓ A national target
✓ The most you can aim at in the current circumstances.

Exceptions are clinical reasons why the standard may not be met for a patient or
record. Exceptions do not include organisational issues such as lack of staff –
the audit aims to discover any organisational problems and help change these.

Definitions and Instructions give further information to help measure practice

against the standard. They may expand on part of the standard, or may say
where the data can be found. They are very helpful for the person carrying out
data collection.
 SAMPLE
TEMPLATE
STEP 2: METHOD/ DESIGN
▪ Always do a pilot
▪ Look at 2 or 3 patients / cases /
records
▪ Check whether your audit design works
by testing it on a few cases. If it doesn’t,
re-design and pilot again.
▪ The data should enable you to measure
practice against the standards.

▪ Ways of collecting data

▪ Patient’s notes
▪ Interviewing patients of staff
▪ Questionnaires
▪ Recording when an event occurs
▪ Observing practice
▪ Looking at policies and minutes.
 STEP 2: METHOD/ DESIGN

▪ Sample Size
▪ You don’t need a big, or statistically significant
▪ Need a fair sample that represents all the
patients / cases / records.

▪ Questionnaires
▪ Use simple language and avoid jargon.
▪ Clarify abbreviations.
▪ Avoid leading questions which suggest a
particular answer, such as “Would you prefer this
treatment even though it is not effective?”
▪ Keep questions simple. Make sure they only ask
about one thing. For example “Was the record
dated?” NOT “Was the record dated and timed?”
▪ Give a section for comments, but try to collect
most information using set responses – it’s easier
to analyse
STEP 3: COMPARE PRACTICE
(ANALYSE & DISCUSS)
▪ Use a tool you are happy with to
analyse the data.
▪ This may be pencil and paper and a
calculator or a simple spreadsheet.
▪ You only need simple descriptive
statistics – averages and ranges, not
complicated statistical tests.
▪ Consider:
▪ Were the standards met?
▪ If not, why not?
▪ Does the data point to ways of
improving care?
▪ What do the results tell you?
 STEP 4: CHANGE PRACTICE &
IMPLEMENT CHANGES
▪ Write an audit report and/or make a presentation
so that all stakeholders can see what the results
of the audit are.
▪ The stakeholders will discuss the results and
decide if any changes are needed.
▪ If the audit says you’re meeting the standards,
BRILLIANT – tell the world!
▪ If you haven’t met some standards think about
possible solutions:
▪ Which will lead to change?
▪ Which are feasible and acceptable to staff and
patients
▪ Make an action plan with recommendations, actions,
responsibilities and timescale for implementation.
▪ Identify who will review how the action plan is going.
 STEP 5: RE-AUDIT

▪ You need to re-audit to check the changes have

made the difference you expected.
▪ Don’t re-audit until you have made the changes.
▪ The re-audit should use the same design as the
initial audit.
▪ You only need to re-audit standards where
changes have been made (unless the changes
may have affected other standards)
▪ If the re-audit shows you meet the standard,
you’ve finished, although it is good practice to
repeat the audit after a period of time (for
example a year) to ensure the improvements
have been sustained.
REPORT TEMPLATE/ SAMPLE
 IN A NUTSHELL

Clinical Audit is a quality improvement process that measures current patient care and
outcomes against agreed standards of best practice.

Not all ‘audit’ is clinical audit

Be aware of the differences between clinical audit, research and service evaluation.

Clinical Audit should be part of a routine clinical practice, patient focused, based upon
standards, requires commitment from disciplines, professionally led, generates results
which may be used to improve quality of care and outcomes and should be seen as part
of an educational process long term.
Thank you