Khaing Zay Aung2/7/2015

1) Definition2) Attitude to audit3) Components of audit4) Stages of single audit5) A successful audit6) Types of surgical audit7) Audit committee8) Functions of audit committee9) Audit cycle

'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‘.

An effective program of medical audit will also help to provide reassurance to doctors, their patients, and managers that the best quality of service is being achieved, having regard to the resources available

medical audit refers to the assessment by peer review of the medical care provided

by the medical profession to the patient.

clinical audit refers to an assessment of the total care of the patient by nurses,

professions allied to medicine (such as physiotherapists) as well as doctors.

1. Audit must be seen as a systematic approach to the review of clinical care to highlight opportunities for improvement and to provide a mechanism for bringing them about.

Audit investigation is also suitable for resolving issues of contention or

local interest.

2. The time spent on audit could be much better spent on other activities, such as treating more patients.

3. There is, none the less, general agreement that a regular review of your own practice against agreed standards of best practice can lead to improved care of patients, who must be the principal beneficiaries of the process.

4. Clinical audit improves patient care not only through direct changes in clinical practice but also through indirect effects such as professional education and team development.

5. An effective clinical audit programme can give the necessary reassurance to patients, clinicians and managers that an agreed quality of service is being given within available resources.

6. Clinicians and managers share audit information within agreed rules of confidentiality.

7. There is a growing need to base clinical practice on the knowledge obtained from rigorous research into the effectiveness of healthcare interventions.

8. The treatment offered to individual patient may need to be justified it as accepted or evidence based practice if there is an adverse outcome.

9. An important part of the national research and development strategy is to make information on research findings easily available to clinical and managerial staff, both in printed form, such as Effective Health Care bulletins, and electronic media

(i) Audit of a structure this refers to the organisation and availability of resources to deliver

the surgical service It is not a good indicator of the quality of care but should be taken into

account in the assessment of process and outcome E.g - whether each ward, clinic has a fully equipped and operational

trolley available for emergency access

(ii) Audit of a process this refers to the way in which the patient has been managed from

admission to discharge E.g. – regular review of a sample of case notes to check that the

information recorded on all patients admitted with H&M conforms to agreed local guidelines

(iii) Audit of an outcome This is the audit of surgical intervention Eg; systematic review of the incidence of wound sepsis in patients

undergoing emergency appendicectomy

1. Primary data collection Normally performed by medical stuff or an audit officer using specific forms

2. Verification of primary data by confidential peer view3. Subjection of data to analysis4. Presentation of results

Audit meetings should be held regularly and should be attended by all members of the surgical team including representatives from the nursing stuffs

Complete Honest and accurate Educational Confidential Objective Reproducible Cost-effective

1. Unit based or morbidity and mortality meetings (M&Ms)

2. Local, hospital based audit

3. National / International comparative audit

Most hospitals have their own audit committee Members from range of clinical background The chairman needs to be well motivated and prepared to devote time

on regular basis to the task The members should be representatives from GPs, nursing

professions, educational stuffs, doctors in training grades, clinicians and audit stuffs.

Coordinate and foster clinical audit for every doctors

Determine existing practice of audit and assist clinicians in the implementation of audit methods

Monitor the results and conclusions of the audit process and check validity of data and reporting

Ensure that changes where indicated by the outcome of audit, are implemented

Ensure that the outcome of audit is perceived as educational

Train and direct audit directors

Ensure effective liaison with GP and management

Maintain confidentiality

Estimate funding required for audit

Prepare annual report and forward programme

Decide which area your clinical care you intend to scrutinized Then set the standard of practice Comparison made that between the observed practice with standard A decision can then be made as to whether practice need to change Finally change is implemented This process is known as “cycle of audit” The achievement of change is termed “closing the audit loop”

Good surgery is 25 percent manipulative skill and 75 percent decision making.

(American surgeon F. C. Spencer )

1. Information 2. Joint decision making with the patient3. Cost-effectiveness4. Avoid obstacles to good decision making

Relevant and reliable Facts to be borne in mine Facts that can be left out of consideration Facts that can be rejected as invalid or irrelevant

No two patients are exactly the same and some factors may exclude your patient from being comparable with the tightly selected patients assessed in statstistical trials

Surgeon should first decide what is the professional opinion that will offer the patient after reviewing the possible methods of management, with the benefits and risks

In taking informed consent, avoid scientific terms that are likely to confuse patients rather than instruct them

Recognize the patients’ right to ask for the treatment that differs from that advised by you but do not agree to treatment that is harmful, ineffective or offends against the moral code

Consider what treatment is best for the patient’s need

In the mean time need to consider from the financial aspect

Need to consider patients’ socioeconomic status

Try not to attempt too many tasks at once

But in an emergency, be willing to abandon a less important one and undertake one that is urgent

Measuring individual aspects separately does not provide a complete picture. You must look at the patient as a whole

1. Codified decisions (codify….. organized into a system)

2. Personalized decisions

Facts and experiences can be measured and then compared with findings in other similar situations, it become possible to make decisions for future guidance when faced with similar problems

As a result of reviewing series of cases, various standardized methods of management have been devised

If the problem complies with previously assessed cases, a plan can be developed so that succeeding problems can be dealt with according to predetermined directions.

Codified decisions can be with

Algorithm Protocol Guidelines Decision trees

Many decisions are complex and cannot be made with standardized or codified manner

The condition may be complicated by cofactors or may have unusual features

The decision is unique and may be challenging or even controversial Some of the factors may be indefinable and difficult to weigh in the

balance. It is in such circumstances that opinions differ between specialists because of individual selection of evidence and the importance given to it.

Personal experience, especially of rare problems is a powerful influence on decisions, so that senior surgeons are usually trusted to deal with them

In conclusion, the decision making is critical importance for the patient and also for the surgeon to manage a disease.

There are many factors need to be consider in decision making. And the decision making comprises ¾ to become a good surgeon

rather than surgical skill.