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Grant Phelps delivered the presentation at the 2014 Clinical Audit Improvement Conference. The Clinical Audit Improvement Conference explored the role of clinical audit in the new era of National Care Standards. For more information about the event, please visit: http://bit.ly/clinicalaudit14
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“Why clinical audit? Is this just
another quality improvement
tool or can it be transformative?”
Grant Phelps
Sydney August 25th 2014
…“it depends”
Declaration - My inbuilt bias
We work for the owners of the health care system
We have a professional obligation to leave the health
care system in a better state than we found it
Cost, Safety, Consumer focus
Improvement is all of our business
This is no longer optional
The core business of health care is the delivery and
receipt of clinical services.
Everything else is subservient to and supports that
“Our Health care systems are
perfectly designed to achieve the
results they achieve”Don Berwick
It’s a miracle it isn’t worse - our system survives on professionalism and goodwill
http://www.bloomberg.com/visual-data/best-and-worst/most-efficient-health-care-countries
We haven’t solved the safety problem yet
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
To
tal li
ves l
ost
per
year
REGULATEDDANGEROUS
(>1/1000)
ULTRA-SAFE
(<1/100K)Health Care
Mountain Climbing
Base Jumping
Driving
Chemical Manufacturing
Chartered Flights
Scheduled
Airlines
European Railroads
Nuclear Power
Note: both dimensions are logarithmic scales
c/o Dr. Rene Amalberti
Scheduled
Airlines
We’re still changing the paradigm from..
“what’s the matter?” healthcare to …
“what matters to you?” healthcare
The business of Health Care is…
The clinician patient
interaction
Supported by Management
Influenced by policy
This is where value is created, and destroyed
And where the real improvements are to be found
The transformation vision
Experience of Care
Improving
Population
health
Reducing
unit
cost of care
Berwick et al Health Affairs May/June
2008
Source: Airbus industries 2014
A transformed industry?
Fatal accidents vs number of flights
We know how to fix healthcare.
•Better care is systems care• Understanding clinical care in process terms
• systems so that clinicians can do it right first time
Better care is cheaper careThose saved resources can be used to do good
It is possible to close the quality gapClinicians driving clinical improvement through learning
Clinical
Microsystems
Patient and Community
Clinical Service deliveryTranslating management into clinical
outcomes
Receive care
Clinical PracticeClinical rules
Service design and structure
Patient involvement
Interpreters of careDoes care meet needs?
Improving healthcare delivery
= changing behaviours
Improving healthcare?
Kizer K. NEJM 2003
Health Affairs 2002
Health Affairs, 2002
www.cec.health.nsw.gov.au
Measuring
healthcare:
clinical audit
1916
End Result cards
Codman led thinking on
Measuring outcomes
Benefits of public reporting
Transparency as an enabler of improvement
Admitting error as prelude to improvement
Creating a Learning organisation
Clinical audit is largely a QC activity
Continuous
Improvement
Quality
Assurance
Quality Control
against a standard
Quality Improvement
– against ?
Clinical audit for most clinicians is…?
“the systematic review of elements of
clinical care against predetermined
criteria…”
It’s about quality control
Does it change behaviour?
Health.vic.gov.au
Individual Quality Control
adjusted colonoscopy completion rate 2007. data
presented in batches of 10 as % completion rate
70%
80%
90%
100%
1 3 5 7 9 11 13 15 17 19 21 23 25 27
completion mean target
Audit can tell us what we already know..
Registries and clinical improvement
Risk of death with after hours discharge from ICU
1 in 7 patients are discharged from ICU after 6pm
Relative risk of death
1.34 ( CI 1.30 – 1.38 p<0.0001)
(Source – ANZICS Core)
Now what do we do????
Clinical audit should be about QI…
“the systematic review of elements of clinical
care against predetermined criteria, with the
aim of identifying areas for improvement and
then developing, implementing and evaluating
strategies intended to achieve that
improvement
Health.vic.gov.au 2007
Clinical audit should help us transform the
system to this…
A care system which generates no needless…
• Deaths
• Pain
• Delays
• Helplessness
• Waste
What would a transformed
organization look like?
A place where collaboration thrives; where everyone collaborates to improve both care and the organization – where organizational values really mean something…
A place where the consumer is the business, in every way
A place where staff experience reward and joy in their work
Resources are sufficient
Transforming our thinking on quality
The right person
Makes the right choice for them
For the right reasons
To receive the right treatment
At the right price
By the right person
At the right time
In the right place
For the right outcome
VTE prophylaxis - Does feedback work?
Pre intervention
November 2007
Post
intervention
May 2008
Result
Numbers of cases
reviewed 236 300
High risk cases
(Defined risk
assessment completed)80% 83%
Prophylaxis (Target
60%) as per ANZ
Guidelines 34.9% 43.2%
8.3%
Improvement
but 16.8% below
target
Yates M., et al IMJ 2013
The effects of guideline dissemination
and implementation strategies
Across four cluster RCT’s of various educational
strategies, a median absolute improvement of
+8.1% (range +3.6% to +17%) compliance with
guidelines was observed.
The impact is limited and sustainability is tenuous
Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline
dissemination and implementation strategies. Health Technol Assess 2003
Cochrane review 2006
Audit and feedback can be effective in improving
professional practice. When it is effective, the effects
are generally small to moderate. The relative
effectiveness of audit and feedback is likely to be greater
when baseline adherence to recommended practice is
low and when feedback is delivered more intensively
Jamtvedt G., et al Cochrane Database of Systematic Reviews 2006
What do we know?
“audit and feedback will continue to be an
unreliable approach to quality improvement until we
learn how and when it works best. Conceptualising
audit and feedback within a theoretical framework
offers a way forward”
Foy R et al BMC Health Services Research 2005;5(1):50
What if you change the system?
Clinical Site Baseline
May 2008
(n=300)
Post NIMC
Change Jan
2009
(n=43)
Follow up
Audit
September200
9
(n=40)
Follow up
Audit
November
2009
(n=40)
Medicine 43.2% 83.7% 95% 82.5%
Surgery 60 % 78.4% 69% 67%
Yates M., et al IMJ 2013
Why isn't clinical audit more effective?
Lack of clear purpose – QI vs CQ
Data collection and management
resources
Lack of expertise in design and analysis
Lack of planning
Lack of clinical engagement and leadership
Poor professional culture and poor relationships within and between teams
Lack of integration with other activities ( within a clinical governance framework)
An inability to improve care processesww.health.vic.gov.au
Culture change to drive Improvement in health care
delivery
Clinical Risk / Safety as our tool
Retrospective
management level
Based on identified outcomes, which might be random.
Is really Quality Assurance in disguise.. Are we good enough?
Element of big stick
? Real culture change
Quality improvement as a tool
Prospective
Owned at Coal face level
Based on process improvement
Quality Improvement will reduce risk
How good can we be?
Success = culture change
What drove this
improvement?
WAASM - DVT
prophylaxis
MJA 21 Nov 2005
Bampton P., et al BMJ 2006;332;1320-1323
Understanding and improving the care process
Audit makes a difference to outcomes, but
improving care processes is the main game
Mortality Rate
6.04
3.65
0.71
8.57
0
1
2
3
4
5
6
7
8
9
2002 2003 2004 2005
Year
%
So…. We’ve moved on from ‘medical
audit’ to something that’s more about
understanding and improving systems?
And it that’s the case, shouldn’t we be
talking about suites of measures which
are based in the process of care and
which can tell us something about the
system and how to improve it?
High performing healthcare organisations
understand the why and the how ..….
Why an organization produces its services Who are the customers and what are the broader social needs the organization
fulfils?
How those services are produced What are the processes of daily work or, in other words, the means of production?
How the organization improves its services What are the improvement activities or means of improvement?
Batalden, P.B. and J. Mohr. 1997. Quality Management in Health Care 5(3): 1-12.
HBR 1995
The major enabler: Clinical Engagement
‘Full collaboration in relentless improvement’
Lee and Cosgrove; HBR June 2014
Engaging Clinicians… “Clinicians are the process”
CultureQuality based culture - “It’s all about the patient”
Leadership
Clinical leaders with ability to make decisions
Welcome bottom up leadership
Alignment
Sharing knowledge
Teamwork
Ensuring clinical teams drive quality through department levelAdapted from Kaplan & Norton “Balanced Scorecard” HBS press 1996
Engaging clinicians
Create shared goals
See clinicians as drivers of clinical processes (and
thus the source of cost and harm)
Leverage the personal commitment to quality
Self motivated and autonomous
Lack understanding of ‘system’.
Reinertsen J. et al “Engaging Physicians in a shared Quality agenda. IHI 2007
Necessary but
not sufficient?
Quality control
enabling quality
improvement
Summary
Clinical audit terminology needs to change
It is not an end in itself
It’s just a quality tool and by itself isn’t terribly
helpful if you’re interested in real improvement
Transformation requires much much more –
systems and systematic improvement is the main
game Clinical audit but one input
Clinical Engagement is essential in understanding
and changing any care process