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Improving Standards ofPatient Care: Clinical

Audits

Sudigdo Sastroasmoro(Vice Chairman, Medical Committee

Cipto Mangunkusumo Hospital)

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Selected references

Starey N. What is clinical governance? Available at .evidence!based!medicine.co.u".#$$%.

National Prescribing Centre. &he audit cycle.

'epartment of (eneral Practice) *oyal +nited ,ospital. Studyguide - Clinical audit. aris.Christie/ruh!bath.sest.nhs.u"

Allen P. Accountability for clinical governance: developing

collective responsibility for 0uality in primary care. 123 #$$$45#%:6$7!%%.

,alligan A) 'onaldson 8. Implementing clinical governance:turning vision into reality. 123 #$$%4 5##:%9%5!.

National ,ealth Systems. Clinical governance. Available at

.doh.gov.u";pricare;clingov.htmNational Centre for ,ealth

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Value=Quality

Cost

MortalityMorbidityQoL

PatientSatisfact

ion

HealthStatus

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Clinical (overnance

  @A frameor" through hich N,Sorganiations are accountable for

continuously improving the 0uality oftheir services and safeguarding high

standards of care) by creating anenvironment in hich e>cellence in

clinical care ill Bourish.@

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Clinical (overnance

A poerful) ne and comprehensivemechanism for ensuring that high

standards of clinical care aremaintained throughout the healthsystems and the 0uality of service is

continuously improvedA system for improving the standardof clinical practice

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Important elements of

clinical governance

=ducation training

Clinical auditClinical eectivenessD=12E

*is" management*esearch anddevelopment

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ClinicalGovernance

Clinicalaudits

Education& Training

Ris !anage!ent

"ccount#ability

Research &develo$!ent

ClinicalE%ective#

ness

EM'F ,&A

F Clinical guideline

F Clin pathaysF AlgorithmsF Protocols

F Procedures

FStanding orders

Patient safety

Clinicalaudits

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Clinical audit

Clinical audit is a 0uality improvementprocess that see"s to improve patientcare and outcomes through systematic

revie of care against e>plicit criteria)folloed by the implementation ofchange. Aspects of the structure)

processes) and outcomes of care areselected and systematically evaluatedagainst e>plicit criteria. Whereindicated) changes are implemented at

an individual) team) or service level and

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Clinical audits

Hormally introduced in %7

Previous name: medicalaudits

2oves from JoptionalK toobligatory

 &he heart of clinical

governance

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Clinical indicators

Performance indicators: overallperformance of hospital or department

2ore speciGc: clinical indicators

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=>amples of clinical

indicators ,ospital death

+nplanned re!admission

Compliance to treatmentregimen

Admission for certain healthproblem

Surgery for certain conditions

8ength of hospital stay

!

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Clinical audits refer to 0uality of careevaluation method) a multidisciplinaryprocess of professional team

 &he usual approach: standard Devidence!basedE identiGcation) performanceevaluation) compare ith standard)problem identiGcation) recommendations)improvement implementation) re!audit

Audit may involve many hospitals in aregion) but can be implemented in

individual hospital or even department.

Clinical audits

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Audit is not L. *esearch. *esearch attempts to Gnd bestmanagement) audit revies if patient care hasbeen done correctly

1laming action or competition amongindividuals or groups

'iscipline mechanism. &he main purpose ofaudit is improving process and system) not

disciplineComple> statistical or"s. When statistics areneeded) focus is on the comparison tostandards

'atabase collection. 'atabase collects all data

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Clinical audits*evie of clinical performance)the reGning of clinical practice asa result and the measurement ofperformance against agreedstandard

A cyclical process of improving the0uality of care

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What is clinical audit?

Jthe systematic critical analysis of the0uality of clinical care) including theprocedures used for diagnosis andtreatment) the use of resources and theresulting outcome and 0uality of life forthe patientK (Secretaries of State, 1989)

Jthe process of revieing the delivery ofhealth care to identify deGciencies sothat they may be remediedK (Crombie et

al 199)

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Clinical audit is at the heart

of clinical governanceIt provides the mechanisms for revieingthe 0uality of everyday care provided to

patients ith common conditions) li"easthma or diabetes.

It builds on a long history of doctors)nurses and other healthcare professionals

revieing case notes and see"ing ays forbetter service

It addresses 0uality issues systematicallyand e>plicitly) providing reliable

information.

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Stage 1:

Preparing an audit

Stage 2:

Selecting criteria

Stage 3:Measuring performance

Stage 4:

Making improvements

Stage 5:

Sustaining improvements

Creating the

environments

Using the

methods

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Choosing an audit topic

An identiGed problem De.g.) increasedmortality of ',H;'SS patientsE

,igh volume) high ris") or high costareas of practice

Areas ith high variation in practice

=vidence of clinical eectivetreatment

Availability of clinical guidelines

'evelop a matri> to select theriorities

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Choosing an audit topic

opic Molume *is" Cost PP Physyian 2ngmnt Ptsconcern concern Concern

  A()*() )+*() )+*() ()*() )+*() ),*() )-*()

$7;%$ $7;%$ %$;%$ $O;%$ $O;%$ $O;%$ $O;%$ 96;

  C$O;%$ $O;%$ $O;%$ %$;%$ $6;%$ $7;%$ $7;%$ 9;$

  '%$;%$ %$;%$ %$;%$ %$;%$ $O;%$ $O;%$ $$;%$ O$;$

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'eveloping audit team

Select the team leader

Should be multidisciplinary

Involve all area here the patients ourney

Consider patient ; lay!maninvolvement

*emember that you should be sure

that the or" ill be applied to

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State your aims and

obectives

Write the bac"ground of doing audit

Write aims and obective asstatements or 0uestions

Write in brief the methods are goingto use in the audit

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Agree audit standards

'eGne the standards of aspects to bemeasured

 &he standard should follo the aimsand obectives

+se local) national) regional) orinternational standards asappropriate

All standards should be evidence!

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Setting standards

=vidence of setting standards canbe

obtained through:

8iterature revies

Comparison ith other hospitals ;

countries ; benchmar"ing

Clinical udgment

Assessment of current practice

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 &ypes of standards

E/ternal2edical literatures

World ,ealth

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Compare e>ternal ith

internal standards=>ternal

Imposed

*emote

+sually authoritative

Hi>ed

No eort for local

group8ess incentive for

further improvement

Internal

Negotiated

Sense of onership

Sometimes non!

rigorous

Adaptable

Considerable eort=volve to pursue

higher standard

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 &echnical process for health

care standardsClinical practice guideline: *ecommendation for health care based on

current researchClinical pathay: e>pected)multidisciplinary daily plan of treatment

Algorithm: Bo charts of decision grid

Procedures: ho to) step by step instruction

Protocol: management of patient care

Standing orders: a pre!established set of

medical orders

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 &ypes of clinical indicators

'eaths in hospital and afterdischarge

=mergency re!admissions to hospitalafter discharge

Admissions to hospital for certain

conditions

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Criteria Standards

riteria: Semua pasien raat inap harusdiperi"sa oleh 'P3P sebelum pu"ul%$.$$ pagi

Standar: $Q

riteria: ematian pada 'SS

Standar: R#Q

riteria: *aat ulang emergenc!  setelah pulang raat status

asthmaticus

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Consider ethics

Although not necessarily re0uireethical approval) audit should be

done according to highestprofessional standards

'ata protection and conGdentiality

In any doubt) consult the audit team

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Select an audit sample

2ay be formally estimated by usingsample sie formula) but morepractical sampling methods are

acceptableIn some instances a small number ofsubects is sucient to dra

conclusion and establishrecommendation

2ay be retrospective) prospective)concurrent

A ilot stud ma be necessar to

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'ata analysis

Compare that data you have ith thestandards.

2a"e sure that you compare the correct

data and standardsAll measurements and comparisonsshould refer the aims and obectives of

the auditHormal statistical analysis may beneeded but not a primary concern

2ay as" for consultation to the audit

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'evelop summary and

recommendations*esults of an audit should bepresented to those individuals

re0uired to agree recommendationsand implementation plan

 &hen should be presented to other

colleaguesSubmit to the Audit &eam for furtherdeployment

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'raft audit report

Should be ell structuredIntroduction - ustiGcation for doing audit

Aims and obectives - describe in brief butclear

Standards used - should be stated2ethods - detail of data collection) etc

*esults - description and analysis of data

Conclusion - obective statement supportedby Gndings

*ecommendations - based on audit results

Action plan - action that should be

underta"en including time frame for re!audit

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Implementing change

2a"ing change as recommended intimely and appropriate ay

Combine ith feed bac") consensus)opinions

2a"e sure that hat you are going to

change ill improve your practice &he Audit &eam may observe andgives suggestions during the

implementation process

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*e!audit

Hinal stage of audit cycle

Should be carried out at appropriatetime

*epeat every stage of audit cycleusing the same methodology

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*esearch vs. clinical auditAm I singing theright song?

Is T as eectiveas U?

T is alays moreeective than U?

 &o investigate

Am I singing thissong right?

Are e doing T)not U?

We did T in OQof cases?

 &o improve

i s k S e v e r i t !

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i s k S e v e r i t !

isk

"re#uenc!

$nsignificant Mild Moderate Severe %er! severe

5

 

4

3

2

1

Certain

%er! likel!

Possi&le

Unlikel!

are

5 1'  15 2' 25

4 (  12 1) 2'

3 ) *  12 15

2 4 )  ( 1'

1   2 3   4 5

1 2 3 4 5

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Physician1s co!$etence

2alid evidence Patient1s values

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Patient +ith

pro&lem

Search the

evidence

Criticall!appraise

the evidence

"ormulate

in ans+era&le#uestion

,ppl!the evidence

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C- . Committee

•  Clinical Practice -uidelines•  Standards of Clinical Care /SPM0

•  Protocols•  Clinical care path+a!s

•  ,lgorithms•  Standard perating Procedures /SPs0

du ,udit M isk Man

6eadership penness

Commitment Culture