Audit
Principles
Background
Effectiveness
Impact
The audit cycle
Education / training
Support for audit
Audit techniques
Principles

"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."

Aims:
- Improved quality of care
- Improved outcomes of care
- Professional development / education

Develomental Goals:
- patient focus
- multiprofessional
- primary through tertiary
- linked with education
- integrated with effectiveness information
Background
Audit arose from M&M meetings.
- now mandatory in many centres.
- however variable results in improving quality of care.
Audit should remain clinically led, but involve managers to help organizational improvements.
Effectiveness

Practice should be based on effective interventions.
Effective interventions maintain and improve health.
- the greatest possible health from available resources.
Audit:
- assesses current practice
- identifies and introduces necessary change
- monitors to check for expected outcomes.
It should be evaluated against agreed clinical standards, evidence-based guidelines, systematic reviews.
- local or national guidelines are often available.
Impact

Audit is different from day-to-day activities by being systematic.
- it looks at patterns of care.
Useful if issue of:
- high cost
- high risk
- common
- local interest
- and not of an interesting case.
Evidence has showed effectiveness in such areas as reducing test requests, cost-effective blood supply use, lower infection rates.
The Audit Cycle

Effective audit leads to change.
A cycle.
- observe practice
- define standards
- compare with standards
- define needed change
- implement change
- review
Change is the most difficult bit
- most audits achieve small or modest change
- (based on systematic review of 160 audits)
Can help change by:
- doing outreach visits
- physician reminders
- opinion leaders
- patient-mediated interventions
Publication of guidelines changes practice and affects outcomes
- more effective if account for local circumstances
- if supported by education
- if pt-specific reminders are used (eg in notes)
- shd be reviewed regularly.
Education / Training

Audit activities are essential in education:
- peer review
- self-evaluation
- makes teaching more explicit
- shows areas where more research needed
Remember audit itself does not lead to new knowledge.
- research establishes the right thing to do
- audit checks if it is being done.
Support for Audit

Audit Staff
- most hospitals have them
- helpful
Audit committees
- multidisciplinary
- coordinated/foster audit
National Centers
Audit Techniques

Three elements of health care delivery (Donabedian)
1. Structure
The quantity & type of resources
- easy to measure
- not a good indicator of care.
- but take it into account.
2. Process
What is done to the pt
- from adequacy of notes to what operations performed to meds given.
- informed choice increasingly important
- this is most open to clinician change
3. Outcome
Represents success or failure of the process
- the most relevant feature
- but difficult to define
- eg mortality / hospital stay easily measured but not necessarily related to quality of the service.
- pt subjective perceptions about outcome are important
- quality of life
- duration of their survival

Audit techniques used:

Basic clinical audit
Analysis of throughput
Broad analysis of case type
Complications / morbidity / mortality.
Undertaken at regular intervals
- if deviating from norm, investigate

Incident review
Discuss strategies adopted in certain scenarios
- use of IV urography
- AAA actions
Leads to clear policies
- and local guidelines

Clinical record review
An outsider comes to review a random selection of case-notes.
Criteria should be established
Simple and cheap
- however might concentrate on record keeping and not patient care.

Criterion audit
A more advanced and structured form of incident audit.
Retrospective analysis of clinical records judged against carefully chosen criteria for key elements in managing a particular topic.
All cases that fail to meet criteria are brought forward for further clinical review.
Criteria may relate to
- adminstration (eg wait time)
- investigation
- treatments and outcomes
- follow-up strategies etc.
Clinical guidelines exist for most things.
Allows comparison between hospitals
New targets should be set to improve care.

Adverse events screening
Events that should be avoided are discussed
- details of occurrences are recorded
- complex or serious occurrences are reviewed.
- a database is compiled
- trends / comparisons are made
Also valuable in clinical risk management

Comparative audit
Collects and compares data across teams, regions.
- eg RCS collects confidential data from all surgeons and compares at regular meetings
Information is widely disseminated and discussed.

National studies
Studies in this category proved that training surgeons need adequate supervision.
- disaster frequently occurs when surgeons attempt procedures for which they have insufficient skill.
National annual reviews are conducted and can guide actions and local audits
Separate reports are sometimes produced on key issues.

Outcome audit
Outcome evaluates a whole spectrum of care.

NB Information must be used confidentially - for both pts and practitioners.