CLINICAL AUDIT PROGRAM - A FEEDER AND A MODEL FOR THE NATION

CHRISTIAN MEDICAL COLLEGE (CMC), VELLORE

Project LeaderDr. Sunil Chandy

DirectorChristian Medical College,

Vellore - 632004

Dr. Oommen George, Deputy Director (Quality)Christian Medical College,Vellore - 632004directorate.qmc@cmcvellore.ac.in

Ms. Lallu Joseph Quality ManagerChristian Medical College,Vellore - 632004directorate.qmc@cmcvellore.ac.in

Project Co-ordinators

CMC VELLORE

• An educational institution and tertiary care hospital• Founded by Dr. Ida Sophia Scudder in 1900• 2678 beds – 67 wards• 7000 Out patients per day – 72 OP clinics each day• Consistently ranked among the top five medical colleges in India• The first’s

– College of Nursing in India (1978)– Reconstructive Surgery for Leprosy in the World (1948)– first Open Heart Surgery, Kidney Transplant, Bone Marrow

Transplantation and ABO incompatible Kidney Transplant in India

• CMC has the longest fully functional network of chute system in South Asia (7000 meters)

VISION STATEMENT

• The Christian Medical College, Vellore, seeks to be a witness to the healing ministry of Christ, through excellence in education, service and research.

PURSUIT OF EXCELLENCE India’s Best Employer by National Citizens Award in 2003.

MM Award for Excellence in Healthcare.

Gurukul Jyoti Award in 2007.

Best Multi-Specialty (non-metro area) Award by the ICICI Lombard General Insurance Company in 2011.

Best Cardiology Care in India Award by CNBC-TV18 in 2011.

5 - Star rating to CMC for the quality of education imparted awarded by the National Assessment and Accreditation Council (NAAC)

The Investment Information and Credit Rating Agency (ICRA) Ltd. categorized CMC as a super specialty teaching hospital of the highest quality and gave an A1 grading.

International Living Award by LeBonheur Healthcare, USA in 2008.

Largest hospital in the country to be accredited by the NABH in 2013.

CMC received 11 awards in 2014 from the prestigious SKOCH group of the national level

ACCREDITATION JOURNEY

•Having grown too large, there was a felt need to embark on accreditation •The Quality Management Cell was set up in 2007•Quality Manager reporting to the Director of the Institution, through the designated Deputy Director for Quality. •Liaison staff from every department called “Department Quality Managers (DQMs)”. I•Intensive training was imparted to the DQMs and continuous audits were conducted •Subsequently, a group of Department Safety Advisors were also added to take on the job of Safety•The strategic planning was initiated in 2009•“Quality” and “Safety” as the main points of discussion and decision making. •Decided that the hospital should go in for NABH accreditation with specific action plans and timelines drawn up.•The Consultation 2010 also stressed on the need to setup a separate Audit Facilitation Cell

THE CORE AREAS OF FUNCTIONING OF THE QUALITY MANAGEMENT CELL WERE REFINED

Quality Management Cell

Audits / Audit cycle completion

Training

Performance Indicator

Research System Study

Accreditation

Documentation & Process

development

CONSULTATION 2010 GRID FOR QUALITYNo ACTION

PERSON RESPONSIBLE

YEARBEGIN

YEARCOMPLETE

ESTIMATE AS OF 2009

1 Set up Quality Audit Facilitation Cell Director/Deputy Director (Quality)

2010

2010 2 Lakhs

2Evaluate the existing patient feedback system and make changes. ” 2011 -

3 Set up the Patient Grievance CellMS/NS/ Director/Deputy

Director (Quality)2011 3 Lakhs

4 Apply for accreditation and pre-assessment

Director/Deputy Director (Quality)

2011 5 Lakhs

5Set up internal reporting system for Audits

Director/Deputy Director (Quality) 2010 2012 -

6Conduct training programs in audits and standards

”

2011

Ongoing 5 Lakhs

7Complete the documentation of departments/ hospitals processes and policies

” 2012 -

8Develop Key Performance Indicators(KPIs) and establish the reportingMechanism.

” 2012 -

9Get NABH Accreditation for the main hospital ” 2012 20 Lakhs

10 Develop a system for Audit Compliance ”

2012

2013 -

11Set up the scorecard and management dashboard

” 2014 -

12 Get the NABL accreditation for all Labs ” 2014 25 Lakhs

13Establish systems for resources optimization

Director/Deputy Director (Quality)

2013 2014 -

14 Establish EQAS for all labs ” 2014 2015 10 Lakhs

CONSULTATION 2010 GRID FOR SAFETYNo ACTION

PERSON RESPONSIBLE

BEGIN COMPLETEESTIMATE AS OF

2009

1 Establish the Hospital Safety Cell GS / Director

2010

2010 5 Lakhs

2 Provide safety training to all staff ” Ongoing 2 Lakhs/year

3

Prepare the CMC Hospital Emergency Response Plan and develop the Emergency Response team

” 2011 2 Lakhs

4 Establish mechanisms to disseminate HICC Surveillance information

MS / NS / Director 2011 1 Lakh

5 Evaluate the effectiveness of the safety cell every year GS / Director

2011

Ongoing 1 Lakh/year

6

Educate the public of Vellore on Safety and assess the effectiveness of the program every year

GS / Director Ongoing 2 Lakhs

7 Establish the system for periodical preventive maintenance of equipment

GS / MS / NS / Director 2011 10 Lakhs

8 Strengthen HICC and make it as an Unit NS / MS / Director 2011 5 Lakhs

9 Assess the hospital safety systems and the emergency response plan using an external agency

GS / Director 2012

2012 5 lakhs

10 Develop the CMC Hospital customized Hospital Safety Index ” 2013 -

11 Conduct training courses in hospital safety ” 2013

Ongoing 2 Lakhs

12 Survey the hospital safety using the customized safety index ” 2014 2 Lakhs

NABH pre-assessment - September 2010 NABH final assessment - October 2011 NABH verification assessment - December 2013

THE JOURNEY

CLINICAL AUDIT

• A quality improvement process that seeks to improve patient care & outcomes through systematic review of care against explicit criteria and the implementation of change1

• 1 – NICE definition

IDENTIFICATION OF NEED

• Audit Facilitation Cell was set up in 2009• Initial audits focused on reviews

• completeness of consents, medication orders, discharge summaries, care plan

• NABH final assessment NC“The organization does not have a structured system for conducting clinical audits, presently, chart reviews are being done”.

• Decided to use this NC as the main quality improvement project for CMC

IMPLEMENTATION STAGE

Knowing Thyself

• Baseline survey there was lack of understanding in the part of the clinicians about the concept of actual clinical audit.

MAKING IT LOOK SIMPLE

• Standard presentation on conducting clinical audit was prepared

• Identifying the topic/problem• Defining criteria, defining standards• Measurement- Inclusion, exclusion, sampling, time

frame, data collection• Comparing the performance with the benchmark• Recommendations/ Implementations and re-audit

• Simple examples of clinical audits.

COMMUNICATING TO THE CORE GROUP

• Department Quality Managers and HODs/HOUs were trained on conducting clinical audits

• The presentation was also uploaded on to the CMC intranet

THE FACILITATION

• Circulars from Quality Management Cell (QMC) to all clinical units to start selecting topics and to initiate the audit

• Charts if required are provided by QMC through Medical records department

• Data entry by QMC staff• Few departments started doing it

• General Surgery• Ophthalmology

CONVINCINGLY MANDATED

• The root cause for non-compliance were analyzed and found that

• Clinical audit was not a priority in the already busy work schedule of clinicians• However, they all felt that this was the best way to

improve clinical care

• Written a letter to Dr. M.G.R University and made see if it could be mandated for PGs and Interns

LETTER TO UNIVERSITY FOR INCLUDING CLINICAL AUDITS

SAB MINUTES (Dr. MGR Medical Universitysenatus minutes- 10/08/2012)

THANK YOU NOTE TO UNIVERSITY

THE AUTHORIZATION FROM THE TOP

• The Principal gave the responsibility of co-ordinating this with Quality Management Cell through the Post Graduate Co-ordinators of the clinical units and the Vice Principal (Post Graduate).

MENTORING

• Clinical audit was included as a topic in Mandatory Training programs for

• PGs• MBBS interns

• PG co-ordinators helped the PGs to refine their topics of interest and the methodology

• Quality Management Cell ensured that the audits were completed and submitted along with the Post Graduate thesis

• Follow ups of the implementation of recommendations were carried out by QMC.

THE BOOSTER

• Quality Journal of CMC was introduced• Clinical audits are published after proper

review by the experts• First issue –August 2013 with 20 audits

covered

THE QUALITY JOURNAL

THE QUALITY JOURNAL

HEADING TOWARDS QUALITY DESPITE HURDLES

• The Tamilnadu MGR University has not been actively mandating the submission of the audits.

• This has acted as a deterrent to the submission of audits

• The institution felt the need for continuing the clinical audits and mandating the same at the institutional level

• CMC Vellore made it as responsibility for PGs and Interns to conduct the clinical audit

• This encouraged them to publish the same in the CMC Quality Journal

KUDOS FROM THE NABH ASSESSORS

• The efforts of the institution in promoting clinical audit was well received by the NABH assessors during

• NABH verification assessment in Nov 2013• NABH Focused assessment in July 2014

NABH VERIFICATION ASSESSMENT - NOV 2013

NABH FOCUS ASSESSMENT FOR ECHS EMPANELMENT – JULY 2014

IMPACT OF CLINICAL AUDIT TO THE INSTITUTION

• Better understanding of the scientific methodology of conducting audits

• Serve as a learning exercise for the clinicians• Exploration and awareness of the best

practices followed across the world• Serve as an impetus towards research in

future• Treating team of the institution in future will

be much better than the existing “best”.

IMPACT OF THE CLINICAL AUDIT PROGRAMME OF CMC TO THE NATION

• On an average about 30% of the students stay back in CMC for a few years and the others (about 70%) leave and join mission hospitals or corporate hospitals.

• They carry with them a rich heritage and the first hand experience of conducting clinical audits and their benefits

Sl. no Total No. of PGs’ 2012 2013 2014

1 Total No. of PGs’ (DM/MCh. MD/MS/ Diploma) pass out of CMC 195 217 251

2 Number of CMC PGs joining CMC after finishing the course 77 71 47

3Total number of CMC PGs joining other hospitals after finishing the course

118 146 204

60.5 % 67.29% 81.28%

IMPACT OF THE CLINICAL AUDIT PROGRAMME OF CMC TO THE NATION

• This ripple effect will encourage others also to join the movement and create a culture of openness to self examine the existing protocols set benchmarks as per good standards and implement changes required to improve.

• Develop a culture of continuous quality improvement in their respective Institutions

• This will ultimately result in good patient care.

APPENDIX

EXAMPLES OF AUDITS BY PG REGISTRARSAudit Topic Department Standard Result

Audit on hospital stay after laparoscopic sterilisation

Department of Obstetrics and Gynaecology

According to ACOG criteria, laparoscopic sterilisation, 1. Can be done as a day care procedure. 2. Patients can be discharged on the day of the surgery after a few hours of monitoring

The average number of days the patients in our hospital were admitted for laparoscopic sterilisation was found to be three. Patients admitted in general, semi-private and private wards for laparoscopic sterilisation could have saved Rs.1947, Rs.2450 and Rs. 2857 respectively for bed charges alone if day care system had come into existence.

Waiting time for emergency surgery in open long bone fractures over five months surgical audit

Orthopaedics, CMC

The American College of Surgeons Committee on Trauma, in its resources for optimal care of the injured patient, indicates 6 hours as the benchmark for time from injury to debridement of open fractures in trauma centers

In our hospital, the average time a patient has to wait before undergoing first debridement is 17.9 hours, which is significantly greater than the recommended waiting time

To determine the rate of conversion of laparoscopic cholecystectomy to open procedure.

Surgery

As per the study by Livingston, et al in 2004, published in the American Journal of Surgery, the laparoscopic to open conversion rate for cholecystectomy should be between 5-10 %.

The conversion from laparoscopic to open cholecystectomy was high (18%), as compared to international standards.

An audit of blood culture contamination rates in a tertiary care centre

Microbiology

The American Society for Microbiology (ASM) guidelines suggest that for all blood cultures drawn in a hospital, the blood culture contamination rates in a hospital should be <3%.

The blood culture contamination rate in our hospital was found to be 8%, much higher than the recommended standard. Therefore measures to reduce the contamination rate need to be implemented.

Audit on pre operative audiogram for the month of November 2012

ENTBenchmark - 100% of patients undergoing any middle ear surgery should have a pre-operative pure tone audiogram done within 6 months of surgery.

Approximately 9% patients included in this audit did not have an optimal audiogram as per the departmental policy

Example for Audit and Re- Audit (Audit completion cycle)

• January 2010 - audited the availability of surgical consents for the patients who are wheeled into operation theatre for surgery. Only 56% had the consent for surgery.

• The report was presented to the clinicians in the Medical board meeting.• It was decided that the holding bay nurses will not permit the patients to be

wheeled into OT without the consent for surgery. • A number of circulars and training sessions were conducted and various departments

were refined to meet the legal requirements.

• After the interventions, re-audited the consents for surgery in the month of October 2010.

• The result of the re-audit was overwhelming as the compliance improved to 99.30% from 56 %.

• Every year an audit on the same is conducted and the results are put in the intranet to follow up and ensure that it is meeting the requirements.

• The recent audit was conducted during the month of November 2014 and it was found to be 97% compliance.

Example for Audit and Re- Audit (Audit completion cycle)

THANK YOU