gloucestershire pccag clinical audit and the audit cycle

Gloucestershire PCCAG

Clinical Audit and the Audit Cycle

What we are going to cover today

• The audit cycle

• Criteria and standards

• The audit cycle

• Structure, process and outcome

• The audit cycle

• An audit example

• The audit cycle

• Problems with audit

• The audit cycle

• Problems with audit

• How audit fits into ‘Clinical Governance’

A definition of audit

“The systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient”

Working for Patients 1989

Reactions to audit

• Enthusiasm

• Cynicism

• Obligation

• Doubt

• Exhaustion

Types of audit

• Managerial

Types of audit

• Managerial

• Financial

Types of audit

• Managerial

• Financial

• Clinical

Types of audit

• Managerial

• Financial

• Clinical Multi-disciplinary

Types of audit

• Managerial

• Financial

Cross boundary

Types of audit

• Managerial

• Financial

Cross boundary

Cohort based

Types of audit

• Managerial

• Financial

Cross boundary

Cohort based

Comparative

Types of audit

• Managerial

• Financial

Cross boundary

Cohort based

Comparative

Significant event based

Effective audit

• An educational activity

Effective audit

• Promotes understanding

Effective audit

• Resource effective

Effective audit

• Raises standards

Effective audit

• Promotes change

Effective audit

• Promotes change

• Source of information

Effective audit

• Promotes change

• Source of information

• Peer led

Effective audit• An educational activity• Promotes understanding• Resource effective• Raises standards• Promotes change• Source of information• Peer led• Involves patients

The audit cycleProblem or objective identified

Criteria agreed and standards set

Audit (Data collected)

Identify areas for improvement

Make necessary changes

Re-audit

Another way of expressing the audit cycle

• Determine which aspects of current work are to be considered

• Describe and measure present performance

• Describe and measure present performance• Develop explicit standards

• Describe and measure present performance• Develop explicit standards• Decide what needs to be changed

• Describe and measure present performance• Develop explicit standards• Decide what needs to be changed• Negotiate change

• Describe and measure present performance• Develop explicit standards• Decide what needs to be changed• Negotiate change• Mobilise resources for change

• Describe and measure present performance• Develop explicit standards• Decide what needs to be changed• Negotiate change• Mobilise resources for change• Review and renew the process

Criteria and standards

• Criteria are those aspects of care that you wish to examine

• Standards are the pre-stated or implicit levels of success that you wish to achieve

Structure, process and outcome

• Structure refers to resources you have available (including current knowledge, skills and attitudes)

• Process refers to what you actually do, e.g. a protocol

• Outcome refers to the health benefits, cost effectiveness or patient satisfaction

The great coffee audit

Problem The doctors feel that their coffee isn’t hot enough after slogging through morning surgery

Problem

Criteria

The doctors feel that their coffee isn’t hot enough after slogging through morning surgery

The coffee shall be hot and satisfying to the hard pressed docs

Problem

Criteria

Standards

The doctors feel that their coffee isn’t hot enough after slogging through morning surgery

The coffee shall be hot and satisfying to the hard pressed docs

The coffee shall be served at a temperature of 85-90C on 80% of occasions and there will be 90% satisfaction level expressed by the docs

Methods The junior receptionist shall check the temperature of the coffee daily for two weeks and circulate a questionnaire to the partners asking them to score a coffee satisfaction level between 1 and 10. The practice manager shall visit Tesco’s and interview the manager about the availability, costs, quality and sell-by dates of the coffee brands available

Review After a rather tense audit team meeting it was found that the coffee temperature fell below 37C on at least 33% of occasions and reached the standard on only 10% of occasions. The doctors scored the coffee at an average 3/10 and two expressed it undrinkable. The practice manager reported the results of her Tesco’s visit.

Change It was agreed to replace the aged coffee maker ( after agreeing suitable redundancy terms for the senior receptionist) with a shiny new machine from Argos. As an additional ‘quality initiative’, cream cakes would be served after surgery. The coffee contract would be switched from the corner shop to Tesco PLC Trust

Re-audit For a further two weeks it was agreed to measure the coffee temperature and re-circulate the questionnaire. It was gratifying to find 100% correlation with agreed standards with the exception of one partner who didn’t like coffee anyway.

Re-audit

Future audit

For a further two weeks it was agreed to measure the coffee temperature and re-circulate the questionnaire. It was gratifying to find 100% correlation with agreed standards with the exception of one partner who didn’t like coffee anyway.

• Cost implications of standard maintenance• Cholesterol assays for partners

Contents of an audit

• Background

• Literature review

• Background

• Methods or protocol

• Background

• Results

• Background

• Results

• Recommendations for change

• Background

• Results

• Recommendations for change

• Recommendations for further audit

Why audit

• Useful clinically

Why audit

• Encourages teamwork

Why audit

• Improves patient care

Why audit

• Financial benefits (sometimes!)

Why audit

• Financial benefits (sometimes!)

• Becoming contracturally an obligation with the arrival of PCG’s

Problems with audit

• Audit and research

Problems with audit

• Statistical verification

Problems with audit

• Outcome measures and proxies

Problems with audit

• Protocols

Problems with audit

• Protocols

• Closing the loop - introducing change and re-audit

A word about clinical governance

“A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards by creating an environment in which excellence in clinical care will flourish”

A First Class Service 1998

‘Clinical Governance’

Research

Audit Evidence based

medicine

Research

medicineDissemination of

guidelines

Research Practice development plans

guidelines

Research Practice development plans

guidelines

Personal development

Research Practice development plans Postgraduate

medical education

guidelines

medical education

guidelines

Practice accreditation

medical education

guidelines

Practice accreditation

Special interest groups

Accountability

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