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Guy Peacock 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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The Basic Physician Trainee
Clinical Audit Program:
Embedding Clinical Audit and Quality
Improvement within the Physicians Psyche
Guy Peacock
Quality & Improvement Manager
Division of Medicine & Critical Care
Southern Adelaide Local Health Network
Southern Adelaide Local Health Network
It is not a matter of willpower, but
rather the facilitation of a readiness
to fully embrace the notion of
change.
Southern Adelaide Local Health Network
Southern Adelaide Local Health Network
Southern Adelaide Local Health Network
> Population demographics
• Primary population: >350,000
• Subsidiary population: >173,000
• Tertiary referral scope: South Australia &
Northern Territory
> Cultural diversity
• Residents born overseas: 68,000 (8%)
• Indigenous residents: 2,700 people (<1%)
> Age profiles
• People >65 years: 52,500 (15%)
• Children and young people: 112,000 (32%)
• Adults of working age: 185,500 (53%)
Southern Adelaide Local Health Network
Southern Adelaide Local Health Network
> Acute Services Structure
• Flinders Medical Centre
Acute Tertiary Referral Centre
• Repatriation General Hospital
Acute General Medical
Aged Care – GEM Unit
Elective Surgical
Mental Health
Rehabilitation
Palliative Care
• Noarlunga Community Hospital
Emergency
Acute General Medical
Elective Surgical – fee for service
Mental Health
Southern Adelaide Local Health Network
Division of Medicine and Critical Care
> Scope: Acute and Ambulatory Care Services,
Southern Adelaide Local Health Network
> Staff: 2,046 (1,647 FTE)
> Capacity: 336 beds
> Admissions: 37,954 (2013/2014)
> Services: Emergency
Critical Care
General Medical
Full Sub-Specialty Medical Services
> Budget: $212,000,000
Southern Adelaide Local Health Network
Basic Physician Trainee Program
> Three year competitive entry program
> Candidates are selected on the basis of:
• Commitment
• Academic and clinical history
• Evidence of sound communication skills and
effective team work.
> Offers training and educational experience through
rotations across the Network
> Ensures specific RACP requirements are met
> Maximises training and preparation for the RACP
Physician Readiness for Expert Practice (PREP)
Program
Southern Adelaide Local Health Network
Basic Physician Trainee
Clinical Audit Program
> February – Clinical Audit Project Information Session:
• One hour lunch time session
• Lunch is provided
• 30 minute presentation
• 30 minute Q&A
> March – Plan Project:
• Establish partnership
• Identify & secure Project Supervisor
• Set criteria & standards for clinical audit
Southern Adelaide Local Health Network
Basic Physician Trainee
Clinical Audit Program
> April – May – Initiate Audit:
• Observe practice & data collection
> June – Review initial data collection:
• Compare actual performance against criteria & standards
• Write up initial findings report
> July – Initiate Change:
• Agree upon changes if indicated and implement
Southern Adelaide Local Health Network
Basic Physician Trainee
Clinical Audit Program
> August – September – Re audit:
• Re-run the initial audit to establish impact of implemented
change
> October – Incorporate results of second audit into report
> 11th October – Submit completed report to Q&I Manager
> 17th October – Presentations commence at Grand Round
Southern Adelaide Local Health Network
The imperative in this process is the
subsequent implementation of change in
order to actively facilitate clinical practice
improvement based upon contextually
appropriate and accurate health
informatics.
Southern Adelaide Local Health Network
Team Engagement:
Winning Hearts & Minds
> The Circle of Safety
> Engendering Trust & Cooperation
• Explaining the why
> The three rights
• Right People
• Right Time
• Right Place
Southern Adelaide Local Health Network
Incentives
> Opportunity to influence clinical practice
> Valuable addition to personal resume
> Publication
> Presentation
> Prize and Certificate for most outstanding project
> Mandatory component of Basic Physician Trainee
Program
Southern Adelaide Local Health Network
The Clinical Practice Improvement Journey
Evidence for a problem
worth solving
Improvement
Intervention
Managing
Change
Evidence of Impact
Future directions
Southern Adelaide Local Health Network
Clinical Audit:
An Action Orientated Framework
> Continuous Process
> Quality Improvement Intervention
> Managing Change
> Determining Evidence of Impact
Southern Adelaide Local Health Network
Embedding Clinical Audit within the
Culture of Health Care
> A continuous process – not simply an accreditation
stop gap
> Must be established as a clear expectation not
simply a preference
> Focus upon audit that is within your scope of
influence
> Target audit that holds meaning for you
> Build efficiency into your audit process
Southern Adelaide Local Health Network
Safe, Effective & Appropriate
> Relentlessly and continuously pursue the
reduction in the risks of injury from care, aiming for
zero harm wherever and whenever possible
> Ensure that every patient, every time, receives the
benefits of care based soundly within the current
evidence of best practice
> Refrain from providing services to those who are
not likely to benefit
Southern Adelaide Local Health Network
Patient Centeredness
> Actively Engaging patients and families in
managing their health and making decisions about
their care
> Honouring each individual patient and family
> Offering voice, control, choice, skills in self-care,
and total transparency
> Readily adapting to individual and family
circumstances, and to differing cultures,
languages, and social backgrounds
Southern Adelaide Local Health Network
Measuring Quality
> Structures
• factors effecting the context of care delivery
> Processes
• All acts of health care delivery both technical and
interpersonal
> Outcomes
• Outcomes are sometimes seen as the most
important indicators of quality because improving
patient health status is the primary goal of
healthcare. However, accurately measuring
outcomes that can be attributed exclusively to
healthcare is very difficult
Avedis Donabedian MD MPH (1919 – 2000)
Southern Adelaide Local Health Network
Right Design
> Is the stated objective of the clinical audit correct?
• Explicit about confirming the standard of current
practice relevant to the evidence of best practice
• Explicit about demonstrating the impact of quality
improvement interventions undertaken to address
the gap between current and best practice
• Clearly establish the intent of the audit in terms of
how it relates to confirming or improving Quality of
care
Southern Adelaide Local Health Network
Right Design
> What features of Quality are to be measured by
the audit?
• Translate the objectives of the audit into specific
aspects of patient care to be measured
• Determine the standards of care that the audit will
focus on
• Ensure data can be accessed for each aspect of
care that will be measured
Southern Adelaide Local Health Network
Right Design
> Has the audit time frame been determined?
• Clearly define the period of time for which the audit
criteria will apply
> Are the correct cases selected for audit?
• Explicit inclusion and exclusion criteria must be
established
> How many cases should be included?
• A minimum of 30 cases or 20% of total cohort,
working with the larger of these two figures
Southern Adelaide Local Health Network
Right Design
> How will data be collected?
• Within the context of the clinical audit
determine the most appropriate method of data
collection:
Who will collect the data
Prospective or Retrospective
Manual or Electronic
Ensure consistency
Target efficiency
Southern Adelaide Local Health Network
Right Design
> Ensure data quality by ensuring alignment
with the following characteristics:
• Accurate
• Available & Accessible
• Complete
• Fit for Purpose
• Relevant
• Reliable
• Timely
• Valid
Southern Adelaide Local Health Network
Quality Improvement Intervention
> Make it specific
• Who is involved
• What do you want to accomplish
• Stipulate location
• Establish time frame
• Identify requirements and constraints
• Specify reasons, purpose or benefit of
intervention
Southern Adelaide Local Health Network
Quality Improvement Intervention
> Ensure it is attainable
• It must be within your scope of influence
> Target what is realistic
• Can it be achieved within current constraints and
permissible time frames?
> Is it tangible to the broader team
• If it is tangible to the team within daily routine there
is greater potential for success
• If something is tangible it will be measurable and
specific
Southern Adelaide Local Health Network
“We can map new processes and systems
and call it change. But if people’s
behaviours have not changed much, all
we have is the illusion of change”
Dr Leandro Herrero
MD MBA FCMI
Consultant, Speaker, Author
Southern Adelaide Local Health Network
Change Management Process
> Engage relevant stakeholders from the outset
> Ensure transparency around the work that is being
undertaken
> Take your colleagues on the journey with you
> Ensure relevant staff receive appropriate
education prior to initiating any change
> Establish a process for effective feedback to
ensure problems are addressed promptly
Southern Adelaide Local Health Network
Evidence of Impact
> Always re-evaluate after initiating change
> Establish how long interventions should be in
place before re-auditing
> Modify audit criteria to ensure impact of any
interventions are captured
> Always duplicate the initial audit methodology to
ensure comparability
Southern Adelaide Local Health Network
Secondary Gains
> Movement away from a medico-centric model
> Promotion of a patient centred model
> Evolution of a multidisciplinary approach
> Promoting transparency
> Evolved sense of teamwork
> Enhanced communication skills
> Setting achievable goals
> Knowledge of change management fundamentals
> Appreciating the value of the journey
Southern Adelaide Local Health Network
Next Steps
> Submission of proposed clinical audits by
prospective supervisors
> Predetermined list of clinical audit supervisors
> Predetermined list of audit topics
Southern Adelaide Local Health Network
“Never doubt that a small group of
thoughtful, committed citizens can change
the world; indeed, it is the only thing that
ever does”
Margaret Mead (1901-1978
Anthropologist