Audit for Registrars
Dr. Ramesh Mehay
Course Organiser
Bradford VTS
NOTE : Key points = core points to note for any
sytematic approach to audit
Definition
• Clinical audit is the systematic and critical
analysis of the quality of clinical care.
• This includes the procedures used for
diagnosis and treatment, the associated
use of resources and the effect of care on
the outcome and quality of life for the
patient.
• Clinical Governance = improving
standards
• Crombie et al. defined
• Audit as the process of reviewing the
delivery of health care to identify
deficiencies so that they may be remedied.
• Marinker (1990)
• the attempt to improve quality of medical
care by measuring the performance in
relation to desired standards and by
improving on this performance
Definition – less formal
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Taking note of what we do
Learning from it
Changing it if necessary
With the aim of improving care
Why do It?
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Development of professional education and self regulation
Improvement of quality of patient care
Increasing accountability
Improvement of motivation and teamwork
Aiding in the assessment of needs
As a stimulus to research
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
Fundamental Principles
• All about improving patient care
• Should be seen as part of day to day
practice
• Developing a critical eye on what we are
doing
• Trying to improve things all the time
The Audit Cycle
What Should Be Happening
What Is Happening?
What changes are needed
The Audit Cycle
What Audit Is Not
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Not about:
Performance Appraisal of Staff
Disciplinary Actions
Needs Assessment
Research (which is usually about establishing
new knowledge)
• Computers and Statistics
• Competition between doctors
• “Never judge good and bad professionals based
on audit” – it is about improving care
Audit vs Research
Research
Audit
Defines Good Practice
Assess extent to which good practice
is being obeyed/improvements
May involve allocating pts to random
treatment groups
Never involves this
May involve placebo Rx
Never involves placebo Rx
Disturbs the pt beyond that required
for normal clinical management
Never does this
May involvea completely new
treatment
Never involves a completely new
treatment
One off process
Other notes
Ongoing
Both audit and Research are concerned with clinical practice effectiveness
Audit can contribute to research – issues that need further exploration
When to Use What
Method
When to use it
Why
Research
Good practice is not
defined and
comparisons are
needed
To define good
practice
Data Collection or
structured
observation
Practice patterns
unknown
To catalogue
prevailing practice
without making
judgements
Audit
Good practice is
defined but we want
to know how much
we are sticking to it
To improve current
performance
Does Audit Lead to Change
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Hearnshaw et al, BJGP 1998
Of 1257 audits
Around 80% on clinical care
Around 65% led to change
Making Audit Easier – Avoid the
Blocks
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BEFORE YOU START
Time – big audits can eat up time in an already busy schedule, so :
Keep it simple and small
Look at one or two criteria
Engage the whole team – otherwise it will be difficult! Is the team
ready? (Enthusiasm, wanting to improve)
WHEN YOU START
Delegate & Share the workload – involve others
Make life easier – use computers to do the laborious stuff (patient
searches)
Use protocols / standards already laid by others (why re-invent the
wheel?)
Be careful of data collection – choose a topic which does not entail
too much data collection to the extent it becomes exhaustive with
subsequent loss of enthusiasm
Some Ideas
• You can do an Audit of
• Structure ie facilities being provided
• Eg waiting times, availability of staff, record keeping (all patient
records should have a summary card), equipment
• Process ie what was done to the patient eg referrals, prescribing,
investigations
• Aspirin post MI, BP measurements 5 yearly in those aged 20-65
• Outcome ie result for the patient
• Eg patient satisfaction, patients with high BP aged between 20-35
should have a diastolic below 90mmHg within the first year of
treatment
• high risk practices (significant event audits) eg pneumococcal
vaccines in splenectomised patients, are significant events being
acted upon?
• The outcome is the ideal indicator for care but the most difficult to
measure.
Choosing a Topic
• Condition has an important impact on health or of great local
concern KEY POINT ie serious consequences otherwise
• Condition affects a large number of people
• Good reasons for believing current performance can be improved or
improvements are needed KEY POINT
• Convincing evidence about appropriate care is available
• Data collection – choose a topic which does not entail too much data
collection to the extent it becomes exhaustive with subsequent loss
of enthusiasm (? A pilot??)
• CHOOSE SOMETHING THAT REALLY INTERESTS YOU
• NO POINT AUDITING SOMETHING YOU THINK THE PRACTICE
IS DOING REALLY WELL
• Then discuss with others – are they interested too?
Choosing a Topic
• Remember, topic should be important :
• Chronic Disease Management eg referrals
or use of lab services (INR’s in warfarin)
• Preventative Care eg childhood imms,
Cervical Cytology
• Prescribing eg aspirin post MI, PPI’s (cost
issue)
Examples
• Ways of spotting audit topics
• Important clinical events
• “Significant events”
record of smoking history or BP
• Patients' complaints
appointment
• Observation
drugs up to date
• Observations of staff
INR for 6 months
• NICE subjects
examples
admissions for asthma
patient died of MI – no
too long to get an
no system for ensuring bag
patient on Warfarin not had
post-MI patients on aspirin
Criteria
• = yardsticks
• “An audit criterion is a specific statement of what
should be happening.”
• A statement which
• A) defines a measurable item of health care
which
• B) can be used to assess quality
• KEYPOINT
Criteria should be explicit. You must
demonstrate evidence for justifying them
(literature search, Evidence Based!).
Criteria – KEY POINTS
• Ensure that the criterion is measurable –
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“asthmatics should have had yearly PFs” is
difficult to measure (how many years will you go back?);
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“asthmatics should have had a PF recorded in
the past year” is more practical.
• 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 xxxxx in the
last xxxxx.”
Criteria
• "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.”
Standards
• “An audit standard is a minimum level of
acceptable performance for that criterion.”
• Make sure the standard is directly related
to the criterion, also :• Should include a suitable timeframe
Standards
• → 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.”
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• 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
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How to set standards
Look at national guidelines
Literature (journals), textbooks
Local guidelines
Discussion with consultants/GPSI’s
Discussion with trainer/partners
KEY POINT : Standards set should be realistic
and attainable. Justifiable reasons for the
standard set should be made explicitly clear.
Standards
• 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 TFTs done in the
last year; this should have happened in at least 90% of
patients”.
TYING IT ALL TOGETHER
Examples of Standards & Criteria
Criteria
Standards
All children under 2 years should
90% of registered patients under
be immunised against tetanus and the age of 2 years should have
polio
been immunised against polio and
tetanus
All notes of those patients with an
allergy to penicillin should be
marked
95% of patients with an allergy to
penicillin should be clearly marked
All patients in the surgery should
wait no longer than 30 minutes
before a consultation
70% of patients in the surgery
should wait no longer than 30
minutes before a consultation
Preparation & Planning
• Must show evidence of teamwork –
otherwise you will fail
Data Collection (1)
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You can collect information from:
computer registers
review of contents of medical records
questionnaires – patients, staff or GPs
data collection sheets
Data Collection
• Be careful of data collection – choose a topic
which does not entail too much data collection to
the extent it becomes exhaustive with
subsequent loss of enthusiasm
• ? Sampling – random or systemic
• Only collect essential information
• Use computers, ?data collection forms
• Use other staff & delegate – don’t do all the work
yourself
• Set a deadline
Presenting the Results
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Collect Results
Analyse Results
Summarise Results
Present Results to the team
Simple arithmetic calculations
Use percentages
Results of 2nd data collection presented in
the same way as the 1st
Discussion – Data Collection 1
Comparing Results to Standards
Criterion
All patients should be
seen within 15
minutes of their
appointment
timeMinimum
Standard
Observed Result
70%
45%
70%45%All diabetics 95%
to have had HbA1C in
last 3
monthsMinimum
90%
90%Drug allergies to
be marked as “active
problem” on
computerMinimum
95%
100%
Discussion – Data Collection (1)
• KEY POINT (Discussion of Data Collection
1) : You need to explain why you think the
practice didn't meet the standard that was
set.
Discussion – why standards not
met
• Think: What reasons are there for practices not meeting audit
standards?
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• For example : reasons have included:
• Practice reasons:
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Results having been put down as free text on computer,
rather than coded;
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Opportunistic rather than formal recall system in use;
• Doctor reasons:
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Not all GPs were aware of the practice policy;
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Not all partners agreed with the policy;
• Patient reasons:
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Patients refusing to have tests done;
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Patients on holiday when tests due.
Implementing Changes
• The most challenging stage
• Audit can tell you whether changes are
needed, but it can’t tell you what methods
to use
Implementing Change
• The changes to be implemented should be
a team discussion and decision (?a
practice meeting)
• What to do at the Practice Meeting:
• Emphasise what has been achieved.
• What are we proud of?
• What are we not so proud of?
• How can we correct any deficiencies?
Implementing Change
• 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
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what needs to be done
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who’s going to do it
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when
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and how.
• If you get very low results, you may consider resetting
the standards to a more realistic level (but justify it)
Implementing Change
• KEYPOINT
• 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.
• FAIL Example:
"The GPs agreed to do a serum rhubarb on any patient that they see
who is on Viagra" - fail - this wouldn't be likely to pass, as there is no
system to help them remember.
• PASS Example :
• ”(a) The GPs were given a prompt card that they could stick on their
computer screen as a reminder to do a serum rhubarb on any
patient that they see who is on Viagra;
• (b) the secretary will search every three months for patients who are
overdue for their serum rhubarb, and flag it as an active problem on
the computer system" - pass - as it should result in change.
Closing the Loop
• Ie repeating the cycle
• 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.
Conclusions from the Audit
• Summary of main issues learned
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KEYPOINTS:
• Comment on any improvements that have resulted.
• How well did your proposals for change work?
• If you again didn't reach the standard that you set, why
not?
• If you did, should you be aiming higher next time, or look
at something else e.g. whether abnormal serum
rhubarbs have actually been acted on?
• Where should the practice go from here
Useful Resources
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MAAGs – medical audit advisory groups
Clinical Governance Advisory Groups
National/Local Guidelines
RCGP database of simple tested audits for
day-to-day use
• Literature, Books
• The WWW
• Consultants, GPSI’s, Trainers, Partners
How To Fail
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No justification for choice of audit
No justification for criteria/standard settings
Not having explicit criteria/standards
Setting unreasonable standards
A general lack of evidence based literature or using material that is not peer
referenced
Not explicitly displaying teamwork in the “method” – must give specific
examples
Numerical errors re: data collection
Presentation of data collection eg no graphs, no percentages (ie the reader
has to do the hardwork him/herself)
Not giving much thought to “changes to be evaluated” and not being specific
enough. Not delegating specific changes to specific people/persons.
Poor conclusions and what the process has taught you
No inclusion for possible sources of bias
References not properly quoted
IF YOU DON’T WANT TO FAIL
• Go through the following online tutorial
• http://www.mharris.eurobell.co.uk
• Look at the Marking Schedule – (yes, they
provide you with an answer sheet!)
• www.mharris.eurobell.co.uk/marking.htm
• You must pass on all 8 criteria.
SHO’s doing Audit for Summative
Assessment
• If you are doing the audit while an SHO, you
need to choose a topic that looks at the GPhospital interface. Referrals or discharge letters
are possible areas for audit. Again, you need to
demonstrate that you've found a problem that
needs to be investigated.
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I suggest that you discuss your proposed
audit with your GP Scheme Organiser before
you go ahead - your hospital colleagues may not
know what's needed for Summative
Assessment.
Checking GPR Understanding
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DISCUSS THE FOLLOWING STATEMENTS
An example of the Audit of process is audit of referrals to hospitals.
Audit usually consumes an extensive amount of resources (of time, money
etc.).
Rare conditions should be audited.
The higher the standard the practitioner starts with, the stronger is the
resulting audit.
Maintaining clearly written notes of at least 20% of patients who are
sensitive to penicillin is an acceptable standard in general
practice.
The higher the amount of data the practitioner collects, the easier is the
decision making process in audit.
The most challenging stage in Audit is implementing change.
In data collection all in the target population must be included.
The agreed standards can be reset at realistic percentages after the first
round of data collection.
Clinical Audit Association Ltd
• Clinical Audit Association Ltd
Cleethorpes Centre
Jackson Place
Wilton Road
Hunberton
Lincolnshire DN36 4AS
• Tel: 01472 210 682
http://www.the-caa-ltd.demon.co.uk
Clinical Governance Research
and Development Unit
• Dept of General Practice and Primary Health
Care
University of Leicester
Leicester General Hospital
Gwendolen Rd
Leicester LE5 4PW
• Tel: 0116 258 4873
Fax: 0116 258 4982
email: cgrdu@le.ac.uk
• http://www.le.ac.uk/cgrdu
Cochrane Database of
Systematic Review
• 020 7383 6185
c/o
British Medical Association
BMA House
Tavistock Square
London WC1H 9JP
NICE
• 11 Strand
London
WC2N 5HR
Tel: 020 7766 9191
Fax: 020 7766 9123
http://www.nice.org.uk
RCGP Effective Clinical Practice
Unit
• School of Health and Related Research
Regent Court
30 Regent Street
Sheffield S1 4DA
• Tel: 0114 222 5454
Fax: 0114 272 4095
Email: scharrlib@sheffield.ac.uk
• http://www.shef.ac.uk/~scharr/
RCGP NE Scotland Faculty
• The Primary Care Resource Centre
Foresterhill Road
Aberdeen AB25 2ZP
• Tel: 01224 558 042
Fax: 01224 558 047
• Email: rcgp@pcrc.grampian.scot.nhs.uk
• http://www.rcgp.org.uk/rcgp/faculties/
nescot/index.asp
UK Cochrane Centre
• Dr Iain Chalmers, Director
NHS Research and Development
Programme
Summertown Pavilion
Middle Way
Oxford OX2 7LG
Tel: 01865 516300
Cochrane Collaboration in the
field of primary care
• For information concerning work by the
Cochrane Collaboration in the field of primary care,
contact:
Dr Lorne Becker
Professor and Chair
Dept of Family Medicine
SUNY Upstate Medical University
475 Irving Avenue
Syracuse, NY 13210
USA
Tel: +1 315 464 7010
Fax: +1 315 464 6982
E-mail: beckerla@hscsyr.edu
http://www.update-software.com/ccweb/
default.html
NHS Centre for Reviews and
Dissemination
• University of York
York, YO1 5DD
• Tel: 01904 433 634
Fax: 01904 433 661
Email: revdis@york.ac.uk
• http://www.york.ac.uk/inst/crd
Sources
• This power point has been derived from :
• http://www.mharris.eurobell.co.uk
• http://kims.org.kw/bulletin/Issues/issue2/A
udit.pdf