audit training ©
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Audit Training Presentation May 2011 © Tim CoupeTRANSCRIPT
Clinical Audit Workshop
May 2011
Today‟s schedule
• Housekeeping
• Objectives for the session
• Introductions
• Healthcare quality
• Clinical audit
• Designing and running an audit
• Exercise
• Action plans and change
• Summation/close
Housekeeping
Fire exits
Toilets
Breaks
Emergencies
Ground Rules
First names
Phones off (or on silent) please
You can ask questions at any time
Don‟t need to put your hand up
Objectives
By the end participants should:
1. Understand the principles of clinical audit.
2. Have some basic clinical audit design skills.
Introductions
In pairs – introduce your partner with
1. Their name and role
2. Where they live/work
3. Why they‟re here today
4. One thing they‟re very proud of
Three dimensions of healthcare quality
1. Structure - resources, physical settings.
2. Process - How knowledge is used (technical),
Relationships(the interpersonal).
3. Outcome - the change in service user‟s health.
(Avedis Donabedian,1966)
Why do we look at healthcare quality?
To improve how we deliver care: provide a better service
To improve how we practice : provide better care
Task - What is „Clinical Audit‟?
In your groups – write a definition of „clinical audit‟
Nominate one person to feed back
You have 3 minutes
What is Clinical Audit?
The „official‟ definition is
“A quality improvement process that seeks to improve patient care
and outcomes through systematic review of care against explicit
criteria and the implementation of change”
National Institute for Health and Clinical Excellence, 2002
Research, Clinical Audit or Service Evaluation?
Research generates new knowledge about an idea/theory
Result is abstract: “testing an idea”
Clinical audit generates information about clinical practice bymeasuring it against a standard.
Result is practical i.e. “measuring what‟s done”
Service evaluation generates information about a service by describing it without a standard.
Result is practical i.e. “describing what‟s done”
Select Topic
Set Standard/criteria
Collect dataIntroduce change
Re-audit
Analyse and derive action
points
The Clinical Audit Cycle
Task - The Clinical Audit Race
2 Teams.
15 cards show stages of the audit cycle.
Put them in order them on the floor - show the audit cycle
Task is over when the first team declares the (right)
answer.
Introduce change
Re-audit
Set Standard/criteria
Collect data
Analyse and derive action
points
Select Topic
The Clinical Audit Cycle
Four key things for your project
1. Aim
2. Objectives
3. Audit standard
4. Audit criteria
Writing an Aim and Objectives
One aim: To ensure procedure X is completed on admission to ward Y
Objectives should deliver the aim:
1. Develop a clinical audit of procedure X
2. Use this to measure to what extent X is done on ward Y
3. Write and implement action plan to ensure X is always done
4. Conduct re-audit of X in 2012
An audit standard is a statement of the level of care/practice expected.
All service users have a STORM suicide and self injury assessment within
12 hours of their admission to an adult ward.
It should be as unambiguous as possible:
“All service users are assessed for potential self harm on admission to a
hospital”
What kind of assessment, where and when?
Measurement of practice against a standard
1. What That is the exact process/outcome
2. How much 75, 95 or 100% of the time?
3. What not Exceptions and why they are
For quantitative audit, criteria will usually be
Numerical: Times, Doses, Scores
Categories: Yes/No/Don‟t know
Each audit standard is measured with criteria
All service users have a STORM suicide and self injury assessment
within 12 hours of their admission to an adult ward.
Audit Criteria: A complete STORM suicide and self injury assessment is done within 12
hours of admission
This should occur for 100% of eligible admissions to the adult wards
Exceptions – any service user discharged within 12 hours of admission
any service user who has was admitted to another ward and has been
inpatient for at least 12 hours
Data collected could be either categorical (Yes or No) or numerical (hrs to completion)
Example criteria
Methods of Data Collection
Quantitative
Data collection tool/proforma (or a spreadsheet)
Numerical data: results, dates, dosages, times.
Qualitative
Questionnaire, interview, focus groups.
Experiences, attitudes, beliefs, meanings, behaviours.
Take care about what you‟re asking - ethics
Designing data collection
Keep it simple
Paper audits - don’t exceed one sheet (2 sides) if possible
Or collect it directly onto a spreadsheet
or we will provide a SNAP web survey tool
Keep a list of all eligible and all reviewed cases
Minimise the amount of personal information you collect
Maintain the 6 Caldicott Principles
Ask us for help with design
23
Questionnaires
Postal, web or e-mailShort and simple as possible. Clear instructions for respondents. Question types - open/closed, scalar. Least intrusive questions first Layout – clear headings, minimum 10pt fontPlain English, avoid clinical/NHS jargonPilot
Interviews
Structured, semi structured or
unstructured
One to one or group
Face to face or „phone
Ethics may be an issue – what are you asking?
Need a detailed record of responses
Rich data but time/effort intensive
Design and execution is skilled task so please
ask for advice.
Pilot Studies
Do a small pilot study of 2- 3 cases before the main project :
It will:
a) Test your criteria
b) Show up any practical problems with data collection
Sampling
An appropriate sample is the number of cases needed to
ensure your audit is representative of practice.
Random – choosing x numbers from a list
Time Period – all cases from 1 week or 6 months.
Cluster – all cases from one team/ward/locality.
Rapid Cycle – small numbers (20 - 50), repeated quickly
Prospective or retrospective?
Prospective (collecting data on practice as it happens) avoids
bias from incomplete records but:
People may alter their behaviour if their being watched (known as
The Hawthorne Effect).
Retrospective (collecting data on previous practice) is often
quicker and easier but:
Open to bias from the quality/completeness of the records.
Is my audit design any good?
Is it valid?
Validity the extent to which the audit measures what it is
supposed to. Valid audit measures things accurately.
Is it reliable?
Reliability means you‟d get the same result if the audit was
repeated on the same sample. Reliable audit would get the
same result.
Re-audit
Once your audit is complete you should schedule a re-audit to
consolidate any action. This should be part of your action plan and
be fairly prompt, usually within 3-6 months.
Other prompts for a re-audit might include:
Your original audit/action plan hasn‟t worked
Significant alterations to your team/service
Significant staff turnover in your team/service
New standards published
Project Checklist
1. Choose your topic
2. Build your 4 elements –Aim, Objectives, Standard, Criteria
3. Register it with the Audit and Research Department
4. Collect the data
5. Analyse the data and report
6. Implement any action points
7. Re-audit when appropriate
Exercise
Scenario:
You are concerned patients with bi-polar disorder are not having their
physical health checks. You want to ensure they receive physical health
checks as detailed in NICE Clinical Guideline Number 38.
In your group, write the following
An audit aim and objectives to support it.
Audit criteria and any exceptions.
Methodology – qualitative or quantitative data, data source(s), sampling
strategy,
pro/retrospective.
Feedback in 25 minutes.
Thinking about change
What year did you get your first mobile phone?
Other people
Action plans
Analysing and presenting findings is the first step of any
action/change process. When you do this keep the following in mind:
Your results should make sense to the intended audience.
Avoid elaborate data analysis – this won‟t make your findings any more credible
Conclusions and actions should reflect and be proportionate to your findings.
Active dissemination/marketing of the results/report/action plan is essential
Data analysis and presentation
Successfully changing what healthcare professionals do is difficult and
requires both skill and commitment. Before writing action plans it‟s worth
considering what any change in practice actually entails:
Carl Lewin (c1947) used the following model for change:
This may help you think about how to plan both your project and any action
needed from it.
Unfreeze Change Re-freeze
Healthcare professionals are by definition skilled, knowledgeable and highly
autonomous people who work in organisations composed of their peers, other
professionals and service users. Responses to any proposed change are
personal.
Some things that inform how you or I might respond to change are:
Awareness and knowledge – Do they know what you‟re proposing and why?
Motivation – What would motivate people to change?
Acceptance and beliefs – Does this fit with their values/beliefs?
Skills/Knowledge – Can they actually do what needs to be done?
Practicalities – Do they have the resources to change?
External Environment – Are there other priorities/competing demands?
Adaptation of Innovation
E. Rogers c1967
Mobile phones – When did you get one?
1991 20112000 20051995
Action plans are widely used in the NHS.
Some suggestions for writing action point/plans include:
1. Consult as widely as possible before writing your action plan.
2. Consider the other people involved i.e. whose got an interest & what is that
interest?
3. Consider the resource implications – can the Trust afford your proposed actions?
4. Scale is significant – bigger changes may be harder to implement
5. Dissemination – your Business Unit, the A & R Committee and who/where else?
6. Review - Are the action points really feasible and implementable?
Action Plans
Clinical Audit Resources
http://www.rcpsych.ac.uk/pdf/clinauditChap1.pdf
http://www.nice.org.uk/usingguidance/implementationtools/auditadvice/audit_advice.jsp
http://www.hqip.org.uk/clinical-audit-handbook/
http://www.hqip.org.uk/clinical-audit-resources-3/
http://www.wales.nhs.uk/sites3/Documents/501/Practical_Clinical_Audit_Handbook_v1_1.p
df
Statistics resources - random numbers
http://www.randomizer.org/form.htm -
http://www.graphpad.com/quickcalcs/index.cfm
Change and innovation in the NHS
http://www.institute.nhs.uk/option,com_quality_and_service_improvement_tools/Itemid,501
5.html
http://www.sdo.nihr.ac.uk/managingchange.html
http://www.tin.nhs.uk/leadership/change-management-workbooks
http://www.nice.org.uk/media/D33/8D/Howtochangepractice1.pdf
Summation of today
1. Definition of clinical audit.
2. The clinical audit cycle.
3. Four things you need to build an audit
4. Design issues/skills.
5. Written a simple clinical audit.
6. Action plans and change
Suggested Personal Development Plan
linkages
Core Dimension 2: Personal and People Development
Levels
1 Contribute to own personal development
2 Develop own skills and knowledge and provide information to others to help their development
3 Develop oneself and contribute to the development of others
Core Dimension 4: Service Improvement
Levels
1 Make changes in own practice and offer suggestions for improving services
2 Contribute to the improvement of services
Core Dimension 5: Quality
Levels
1 Maintain the quality of own work
2 Maintain quality in own work and encourage others to do so
3 Contribute to improving quality
4 Develop a culture that improves quality
IK2: Information collection and analysis
Level
2 Gather, analyse and report a limited range of information
IK3: Knowledge and information resources
Level
1 Access, appraise and apply knowledge and information
G2: Development and Innovation
Level
1 Appraise, concepts, models, methods, practices, products and equipment developed by others.
Please tell the group one thing that you’ve learnt today
Thank you