Dr. U.Murali. M.S ; M.B.A

SURGICAL AUDIT

& RESEARCH

Define surgical audit

Identify the explicit criteria in clinical audit

Discuss the differences between Research & Audit

(or)

Compare & contrast Research & Audit

Explain about Audit cycle

LEARNING OUTCOMES

“ … surgery without audit is like playing cricket

without keeping the score.”

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

FAMOUS QUOTE

Clinical audit is a quality improvement process that

seeks to improve patient care and outcomes through

systematic review of care against explicit criteria

and the review of change. (NICE 2002)

The word ‘auditing’ has been derived from Latin

word “audire” which means “to hear”.

DEFINITION - AUDIT

One of first ever clinical audits was undertaken by Florence Nightingale during the Crimean War of 1853-1855.

She and her team of 38 nurses applied strict sanitary routines and standards of hygiene to the hospital and equipment.

Kept meticulous records of the mortality rates among the hospital patients.

Following these changes the mortality rates fell from 40% to 2%.

AUDIT - PIONEER

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.

INTRODUCTION

Structure – what is in place

The people, their training, their knowledge, the way theyare led, the equipment, their organization, the way they arepaid, etc.

Process – what you do

How referrals are processed, what diagnostic tests aredone, the antibiotics that are used, the thromboembolicprevention that is customary, the use of intensive care, thepolicy of feeding & mobilization after surgery, the dischargepolicy, etc.

Outcome – the results you get

Wound dehiscence rate, readmission rates, mortality,freedom from progression, reduction in symptoms,improvement in quality of life, return to work, etc.

CARE ASPECTS

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 training

An instrument that needs replacing

At team level e.g. nurses undertaking procedures instead of,

or in addition to, doctors

At institutional level e.g. new antibiotic policy

At regional level e.g. provision of a tertiary referral centre

At national level e.g. screening programmes & health

education campaigns

EXPLICIT CRITERIA

National Audit

Local / Hospital audit

TYPES

Is Clinical Audit a research

?

A QUESTION HERE …

A systematic investigation undertaken to discover

facts or relationships and reach conclusions using

scientifically sound methods.

(Hockey, 1996)

DEFINITION - RESEARCH

Purpose – To provide new knowledge in order to set or change standards

Methods – RandomisedTrials etc…

Data Analysis –Extensive statistical analysis

Ethical & Trust Approval – Always required

Sample size –statistically powered calculation

RESEARCH – IDENTIFICATION

Significance –

Statistical difference

(hypothesis driven)

Outcome – Improve

knowledge

Results, publications

– Generalisable,

publishable in peer

reviewed journals

RESEARCH – IDENTIFICATION

Types

Observational –

Retrospective

Prospective

Case–control –

Cross-sectional -

Definition

Evaluation of condition or trt in a defined population

Analysing past events

Collecting data contemporaneously

Series of patients with a particular disease or condition compared with matched control patients

Measurements made on a single occasion,not looking at the whole population but selecting a small similar group & expanding results

TYPES OF RESEARCH STUDY

Types

Longitudinal –

Experimental –

Randomised –

Randomised controlled –

Definition

Measurements are taken over a period of time, not looking at the whole population but selecting a small similar group and expanding results

Two or more treatments are compared. Allocation to treatment groups is under

the control of the researcher

Two randomly allocated treatments

Includes a control group with standard

TYPES OF RESEARCH STUDY

THE DIFFERENCE IS SIMPLY

Research asks:

Are we singing the right song?

Audit asks:

Are we singing this song right?

Define the audit question.

Identify the body of evidence and current standards.

Design the audit to measure performance against agreed

standards.

Measure over an agreed interval .

Analyze results and compare performance against agreed

standards.

Undertake gap analysis :

- If all standards are reached, re audit after an agreed interval .

- If there is a need for improvement, identify possible

interventions such as training, and agree with the involved

parties.

Re audit.

AUDIT CYCLE

THE AUDIT CYCLE

Problem or

objective

identified

THE AUDIT CYCLE

Problem or

objective

identified

Criteria agreed and

standards set

THE AUDIT CYCLE

Problem or

objective

identified

Criteria agreed and

standards set

Audit (Data collected)

THE AUDIT CYCLE

Problem or

objective

identifiedCriteria agreed and

standards set

Audit (Data collected)

Identify areas for

improvement

THE AUDIT CYCLE

Problem or

objective

identifiedCriteria agreed and

standards set

Audit (Data collected)

Identify areas for

improvement

Make

necessary

changes

THE AUDIT CYCLE

Problem or

objective

identifiedCriteria agreed and

standards set

Audit (Data collected)

Identify areas for

improvement

Make

necessary

changes

Re-audit

THE AUDIT CYCLE

Problem or

objective

identified

Criteria agreed and

standards set

Audit (Data collected)

Identify areas for

improvement

Make

necessary

changes

Re-audit

Step-By-Step Guide for

Doing An Audit

From Bailey & Love’s Short Practice of Surgery

5 – STAGES OF AUDIT CYCLE

STAGE 1 – PREPARING FOR AUDIT

Think broadly . Audit can be used to monitor change, to ensurethat current best pract ice is being implemented, or to inform your ownpatients what the probabil i ty of good & adverse outcomes is l ikely tobe.

Funding . All audit takes t ime & consume resources.

Ownership . Try to involve all those part ies that may have somestake in the results of the audit . Consider involving patients at theoutset .

Skills . Many hospital provide courses or have units with staff whohave the necessary expert ise required to conduct an audit on a project.

Time . Be real ist ic about the t ime the audit is going to take.

Teamwork . You are unlikely to be able to do it al l . Most projectsneed a leader. A sense of teamwork with al l those concerned beingactively involved is a formula that is most l ikely to succeed.

STAGE 2 – SELECTING CRITERIA

Think big . Cr i teria being audited should be important.

It must be measurable . Criter ia should be explici t &amenable to measurement.

Check guidelines . I f possible, consult published guidel ines fromreputable sources.

Systematic reviews . In areas where guidel ines have not beenproduced, try consult ing systematic reviews.

Process or outcome . Think hard about the cr iter ia you aregoing to audit . Wil l your goals be best served by using processmeasures or outcome measures?

Case mix . Whatever cr iter ia are chosen, some form of adjustmentfor case mix wil l be required. Age, social class & mode of admissionare usual but think hard about co-morbidity & disease severity.

STAGE 3 – MEASURING THE LEVEL OF

PERFORMANCE

Routine data . I t is worth checking whether routine data in the areaof interest are col lected by your own inst i tution or any external agency.

Electronic data . I f avai lable these data are worth consideringbecause of ease of use.

Medical records . Patient registers are notor iously incompletebut should st i l l be consulted.

Abstract data . Before going to any data source decide what it isthat you want to know. Design a data abstract ion instrument, inessence a questionnaire, so that you wil l be able to determine whatdata was present & what was missing.

Legalities . Pr ior to abstract ing any data, check what yourlocal/nat ional arrangements are in terms of the ethical considerat ionsof the project & also issue relat ing to data protection.

STAGE 4 – MAKING IMPROVEMENTS

Barriers . Before trying to change anything, try & work out what

barr iers to change might exist .

Feedback . Feedback of results to the participants in the audit is

usually insuff icient, in i tself , to result in change.

Discussion . I t 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 br ing about change.

Clinical governance . I t is prudent to use established structures

to bring about improvements in surgical care.

STAGE 5 – SUSTAINING IMPROVEMENT

Re-audit . I t is usually not necessary to go through the whole

process another t ime. Instead, periodic review with some kind of

monitor ing may be suff icient .

Structural change . I t is important to make sure that the change

result ing in improved care is easier for the clinician to undertake than

the pract ice that i t replaces.

Cultural change . Sustained improvement is diff icult to achieve

unless it is something that the organization is str iving to do.

STAGE 1:PREPARING FOR AUDIT

Selecting a topic

Defining the purpose

Planning

STAGE 2:SELECTING CRITERIA

Defining criteria

Sources of evidence

Appraising the evidence

STAGE 3:MEASURING LEVEL OF

PERFORMANCE

Planning data collection

Methods of data collection

Handling data

STAGE 4: MAKING IMPROVEMENTS

Identifying barriers to change

Implementing change

External relationships

STAGE 5: SUSTAINING IMPROVEMENT

Monitoring and evaluation

Re-audit

Maintaining and reinforcing

improvement

REFERENCES

Bailey & Love’s - Short Practice of Surgery

26 th edition.

Internet websites .

Thank you