Chairman: Dr. Kamal Ahmad SaeedPresentation: Meeran Earfan

meeran81@gmail.com

“We must formulate some method of hospital report showing as nearly as possible what are the results of treatment obtained at different institutions. This report must be made out & published by each hospital in a uniform manner, so that comparison will be possible. With such a report as a starting point, those interested can begin to ask questions as to management & efficiency.

In a similar way all the important by products depend in the end on demonstration that the patient can be helped.”

(Taken from a lecture by Ernest Amory Codman 1896-1940 to The Philadelphia County Medical Society just prior to the First World War)

“ … surgery without audit is like playing cricket without keeping the score.”

(Hugh Brendon Devlin 1932-1998, Founding Director of the Surgical Epidemiology and Audit Unit, Royal College of Surgeons of England)

Introduction;

Clinical audit is a process used by clinicians who seek to improve patient care. The process involves comparing aspects of care (structure,

process & outcome) against explicit criteria.

Structure – what is in placeThe people, their training, their knowledge, the way they

are led, the equipment, their organization, the way they are paid, etc.

Process – what you doHow referrals are processed, what diagnostic tests are

done, the antibiotics that are used, the thromboembolic prevention that is customary, the use of intensive care, the policy of feeding & mobilization after surgery, the discharge policy, etc.

Outcome – the results you getWound dehiscence rate, readmission rates, mortality,

freedom from progression, reduction in symptoms, improvement in quality of life, return to work, etc.

Explicit Criteria:If the care falls short of the criteria chosen, some change in the way

that care is organized is proposed, it may be required at one of many levels:

An individual who needs trainingAn instrument that needs replacingAt team level e.g. nurses undertaking procedures instead of, or in

addition to, doctorsAt institutional level e.g. new antibiotic policyAt regional level e.g. provision of a tertiary referral centreAt national level e.g. screening programmes & health education

campaigns

There are a number of types of audit that take place within an institution, including:

• morbidity and mortality meetings• local/regional audit• national or international comparative audit.

The debate between Surgical & Medical specialties:

We need to consider the differences rather than similarities between the so-called ‘Surgical specialties’ & those that are traditionally called ‘Medical specialties’. While the distinction between the two is becoming increasingly blurred (Physicians spend most of their times consulting & prescribing medications, surgeons undertake a large number of invasive procedures), it is nevertheless an important one.

The archetype of the non-surgical model of care is as follows:A large body of evidence exists to show that an intervention works.

This could be a meta-analysis of randomized trials that have shown that a reduction in mean arterial BP brought about by use of hypotensive agents results in significant reduction in the rate of strokes. In order for the physician to confer this benefit on the patient, all that he or she needs to do is prescribe the appropriate drug to the right patient. IT DOES NOT MATTER WHO GIVES THE DRUG TO THE PATIENT; THE EFFECTIVENESS OF THE DRUG IS ALREADY KNOWN & FAIRLY PREDICTABLE.

The Nice Thing about SurgerySurgical operations are different. If an operation is decided by a

surgeon for a patient, it probably does matter who performs it.Is a trainee likely to obtain the same results as an

experienced consultant?Does it matter that the operation is being done in a district

general hospital rather than a regional centre?Even if the operation is going to be done by one of two

specialists of equal experience, it is still likely that one surgeon will perform the same operation in a very different way.

The Audit Cycle

Step-By-Step Guide for Doing An Audit

From Bailey & Love’s Short Practice of Surgery

Stage 1 – preparing for auditThink broadly. Audit can be used to monitor change, to ensure that current

best practice is being implemented, or to inform your own patients what the probability of good & adverse outcomes is likely to be.

Funding. All audit takes time & consume resources. Ownership. Try to involve all those parties that may have some stake in the

results of the audit. Consider involving patients at the outset.Skills. Many hospital provide courses or have units with staff who have the

necessary expertise required to conduct an audit on a project.Time. Be realistic about the time the audit is going to take.Teamwork. You are unlikely to be able to do it all. Most projects need a

leader. A sense of teamwork with all those concerned being actively involved is a formula that is most likely to succeed.

Stage 2 – selecting criteriaThink big. Criteria being audited should be important.It must be measurable. Criteria should be explicit & amenable to

measurement.Check guidelines. If possible, consult published guidelines from reputable

sources.Systematic reviews. In areas where guidelines have not been produced,

try consulting systematic reviews.Process or outcome. Think hard about the criteria you are going to audit.

Will your goals be best served by using process measures or outcome measures?Case mix. Whatever criteria are chosen, some form of adjustment for case mix

will be required. Age, social class & mode of admission are usual but think hard about co-morbidity & disease severity.

Stage 3 – measuring the level of performanceRoutine data. It is worth checking whether routine data in the area of

interest are collected by your own institution or any external agency.Electronic data. If available these data are worth considering because of

ease of use.Medical records. Patient registers are notoriously incomplete but should

still be consulted.Abstract data. Before going to any data source decide what it is that you

want to know. Design a data abstraction instrument, in essence a questionnaire, so that you will be able to determine what data was present & what was missing.

Legalities. Prior to abstracting any data, check what your local/national arrangements are in terms of the ethical considerations of the project & also issue relating to data protection.

Stage 4 – making improvementsBarriers. Before trying to change anything, try & work out what barriers to

change might exist.Feedback. Feedback of results to the participants in the audit is usually

insufficient, in itself, to result in change.Discussion. It is far better to use the audit result as a basis for discussion in

order to explore ways of improving the service.Implementation methods. Other areas such as industry use a

variety of techniques in order to bring about change.Clinical governance. It is prudent to use established structures to bring

about improvements in surgical care.

Stage 5 – sustaining improvementRe-audit. It is usually not necessary to go through the whole process another

time. Instead, periodic review with some kind of monitoring may be sufficient.Structural change. It is important to make sure that the change resulting

in improved care is easier for the clinician to undertake than the practice that it replaces.

Cultural change. Sustained improvement is difficult to achieve unless it is something that the organization is striving to do.