Clinicians and QI staff – creating effective partnerships

Improving Effectiveness & Outcomes of Clinical Audit

Using Root cause analysis & PLAN-DO-CHECK-ACT Model

Venkatesh KairamkondaConsultant Neonatologist & Audit Lead,

University Hospitals of Leicester NHS Trust

Clinicians and QI staff – creating effective partnerships

Background

• Approximately 12 audits completed per year• Audit standard % achieved in 25% of completed

audits (15/59)• Completed audit loops showed % achieved same or

declining -a worrying trend• Urgent need of New approach

Clinicians and QI staff – creating effective partnerships

Neonatal Audit Pathway

• Audit task groups to carry out action plans from previous audits instead of initiating new audits.

• Each audit should be conducted by a team - SpR, SHO and Nurse. Audits involving multidisciplinary team (Dietician, Pharmacist, Midwife, Baby Care Assistants, ward clerks) are encouraged.

• The team should discuss and agree audit title, aims, standards & proforma with educational supervisors/audit lead/audit facilitator within the first 4 weeks of your post.

• Teams work on root cause of deficiency and implement changes• Audit competition on presentation day (January/August).• Audit action plans reviewed at Neonatal Governance meeting

before forwarding to Clinical Audit Facilitator

Clinicians and QI staff – creating effective partnerships

Problem with traditional Audit cycle?

Make recommendations

for change

Collect data to measure

current practice

Re-audit

Identify Topic Obtain guidelines / set standards

Compare practice

with standards

Implement action plan

The Audit Cycle

Clinicians and QI staff – creating effective partnerships

Root Cause Analysis Model

Random audit 2 to assess improvement

Identify causes of short comings

Increase awareness before re-audit

Select TopicAssess previous audit results

Address root cause of

shortcomings

Implement action plan

Root Cause Analysis

Random audit 1 to assess current performance

Clinicians and QI staff – creating effective partnerships

Identify Topic / Re-audit

• Baseline audit / first audit− A standard or guideline hasn’t

been audited. − frequent topic of concern at

governance, senior team, and ward rounds.

• Re-audit:• Increase awareness of the

results of previous audit after successful implementation of changes.

Clinicians and QI staff – creating effective partnerships

Assess previous audit results

• Identify professionals required to conduct the audit

• Brief team meeting to discuss title, aims, objectives and review previous audit standards, methodology, results

Clinicians and QI staff – creating effective partnerships

Random audit 1 to assess current performance

• Random audit1 to assess current performance

• Comparison to previous audit results

• Identify deficiency in key standards and establish target performance

Clinicians and QI staff – creating effective partnerships

Identify short comings

• Non formal User survey when at work by the team

• Team meeting to discuss their findings and identify common theme/s

• Fish bone model to identify root cause by analysing cause and effect chain backwards

• Relook at standards and current guidelines

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Address root cause of shortcomings

• Memorable acronym to give simple structure to process.

• Posters in relevant areas.• Brief opportunistic

PowerPoint presentations. • Regular email & bulletin

reminders• Ensure ready availability of

paperwork & guidelines.

Clinicians and QI staff – creating effective partnerships

Random audit 2 to assess current performance

• Amend/Revise audit standards

• Set achievable target %

• Revise/amend proforma

• Assess performance with audit 1 and previous audit

• Presentation of audit results to relevant stakeholders

Clinicians and QI staff – creating effective partnerships

Implement action plan

• Further recommendations addressed at a departmental and individual level.

• The recommended changes should be guided by the root cause assessments of the audit teams as a handover to the next team

Clinicians and QI staff – creating effective partnerships

Increase awareness

• Induction information• Brief opportunistic

PowerPoint presentations (medical & nursing staff).

• Regular email & bulletin reminders

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• Lack of necessary forms, leaflets, stickers

• Lack of awareness• Barriers to who should

and when• Lack of guideline

BLEED INITIATIVE

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NECTAR INITIATIVE

• No thermometers available to monitor and regulate labour ward and postnatal ward room temperatures

• Midwifery staff unaware of thermostatic control

• Existence of 2 guidelines with conflicting standards

• Staffing pressures and lack of computers at LGH

• Baby thermometers failed quality tests

Clinicians and QI staff – creating effective partnerships

OSTRICH INITIATIVE

• Change to the guideline in view of results from SUPPORT trial and BOOST II.

• Revised guideline had target saturations and saturation limits - Recipe for confusion.

• Target limits not easily identified

• Default alarm limits on bedside monitors not programmed to reflect the protocol.

Clinicians and QI staff – creating effective partnerships

Outcomes

• Seeing improvements to patient care as a direct result of clinical audit projects

• Department audit programme overview scores consistently >90%

• UHL Audit speciality of year 2015

Clinicians and QI staff – creating effective partnerships

Summary

• Root-cause analysis system must be integrated within each audit cycle to improve performance of standards without delay

• The process must take advantage of people’s knowledge while preventing their biases.

Clinicians and QI staff – creating effective partnerships

Summary• Audit teams work together

- to draft audit standards based on clinical priorities and governance agenda,

- review previous audit results and recommendations, perform a random baseline audit, understand barriers to achieving target % by random surveys, develop and deliver short teaching sessions while on duty to improve knowledge of standards, work to remove barriers,

- finally perform final audit to recommend changes.