Transcript POWERPOINT TEMPLATE

Clinical Audit
How to make it work
Clinical Audit Department
Last revised July 2009
An introduction to clinical audit
‘Clinical Audit is a quality process that seeks to
improve patient care and outcomes through
systematic review of care against explicit criteria and
the implementation of change. Aspects of the
structure, processes and outcomes of care are
selected and systematically evaluated against explicit
criteria. Where indicated, changes are implemented
at an individual, team or service level and further
monitoring is used to confirm improvement in
healthcare delivery’
‘Principles for Best Practice in Clinical Audit’
the National Institute for Clinical Excellence (2002)
Why undertake clinical audit?
• To ensure the best possible care for patients is
provided
• To ensure clinical practice is evidence-based
• Audit is an integral part of Clinical Governance
• Assist with the implementation of national initiatives
(NSFs, NICE)
• To improve working between multi-disciplinary groups
Essential Elements of Clinical Audit
•
It should be patient focused
•
It should have a direct impact on patient care
•
Audit assists to improve patients’ experience of NHS
•
It can highlight an area of concern
•
It should be based on evidence based practice
•
Helps to ensure an efficient use of resources
What can be audited?
•
Structure – The resources and personnel
available, e.g. skill mix of staff, patient access
to see GP
•
Process – Amount and type of activities of
clinical care, e.g. annual review for diabetes
•
Outcome – Result of an intervention, e.g.
pain relief, patient satisfaction
Clinical Audit Cycle
1. Select
topic
8. Re-audit
7. Implement
change
6. Make
recommendations
Action
Planning
Audit
5. Analysis and
Reporting
2. Agree
standards of
best practice
3. Define
methodology
4. Pilot
and data
collection
If you require help at any stage
• Gordon Lyth
Effectiveness and Audit Coordinator (Commissioning)
Belmont 01432 344344 ext 3839
• Susan Little
Clinical Governance Manager (Commissioning)
Belmont 01432 344344 ext 3845
Stages in completing the audit
Step 1 Select a Topic
Choose a topic or area of importance or concern
Useful questions to ask are:
• Is it measurable?
• Is it evidence based? Complete a literature search
• Is improvement achievable?
• Does the project have clinical/relevant support?
• Who is going to undertake the audit?
Be SMART!
Specific
Measurable
Achievable
Realistic
Timely
Stages in completing the audit
Step 1 continued…
Define your objectives for the audit
Give a clear outline / purpose of what you expect to
achieve from the audit, this will assist with step 3.
The following verbs may be useful:
To improve…..
To ensure…..
To enhance……
To change…..
Stages in completing the audit
Step 2
Define your criteria and then set your standard
Criteria
Defined & measurable statements about
healthcare which describe the quality and
can be used to assess it
Standard
The proportion of times the criteria can be
fulfilled to ensure the quality of care and is
measured as a percentage
Stages in completing the audit
Example
Topic – Annual Reviews for people with Diabetes
Criteria:
• Patients will have a blood test taken for their NbA1C
and the result is recorded in their medical notes
• Patients will have their blood pressure recorded
Standard – 100%
Stages in completing the audit
Step 3
Identify how you are going to collect the information or
data to measure against your criteria & standard
• Retrospective – focuses on the evidence of the care
or service that has been provided in the past
• Prospective – focuses on the care being provided in
the future
• Sources of data – patient record, computer system,
survey, focus groups, direct observation.
Stages in completing the audit
Step 4 – the data collection sheet/questionnaire
• Pilot - the data collection sheet
• This will ensure the DCS/questionnaire is workable
and highlight any areas that may need adapting. It
will also help to make sure you are collecting the data
you want to collect!
• Collect your data
• Collate the results – organise your data
Stages in completing the audit
Step 5 Analyse the results
• Compare the results with the initial criteria and
standards and examine the reasons for any deviation
• Write a report
Writing a report
What to include:
1. Title page
2. Contents Page
3. Executive Summary
4. Background/Rationale
5. Aims & Objectives
6. Standards/Guidelines/
Evidence Base
7. Sample
8. Data Source
Template Available on Intranet
9. Audit Type
10. Methodology
11. Caveat
12. Findings
13. Observations
14. Presentation/Discussion
15. Recommendations
16. Learning Points
17. References
Stages in completing the audit
• Step 6 Make Recommendations
• Recommendations for practice – how the outcome of
the audit will change practice
• Give feedback of the results to colleagues and
ensure an action plan to implement any changes is
developed alongside colleagues – ownership.
Stages in completing the audit
Step 7 Implement Change
• Share the information with colleagues
• Share the information with people who can influence
change
• Publish outcomes
Implementing Change
1. Involve all concerned in project
2. Ensure consensus to the changes – avoid conflict
3. Identify any resources / training needed
4. Ensure everybody understands why change is
necessary – helps build teamwork
5. Effective change takes time – don’t re-audit too soon!
6. Agree an action plan for how to implement change
Stages in completing the audit
Step 8
Re-Audit – to ensure change in practice has been
implemented
Close the Loop!
Clinical Audit Cycle
1. Select
topic
8. Re-audit
7. Implement
change
6. Make
recommendations
Action
Planning
Audit
5. Analysis and
Reporting
2. Agree
standards of
best practice
3. Define
methodology
4. Pilot
and data
collection
Confidentiality
Patients confidentiality is achieved by ensuring that
access to information is appropriately controlled.
Ways to achieve this:
• Ensure compliance with the six Caldicott principles
• Ensure compliance with the Data Protection Act
(1998)
For further information please refer to the Handling
information leaflet – Information Governance
available on the PCT intranet.
Annual Audit Plan
• Create an Annual Audit Plan
• Being pro-active
• Involves colleagues
• Demonstrates good practice
Any questions?
Please contact the Clinical Audit Department
on 01432 344344 x 3839