The Clinical Audit

                        CLINICAL AUDIT

 
Covers all aspects of clinical care including that provided by nursing and paramedical staff.
       

Purpose of Clinical Audit

• To plan future course of action, it is necessary  to obtain baseline information through evaluation of achievements
• For comparison purpose with a view to improve the service
• It is regulatory in nature ensuring full and effective utilization of staff and facilities available.
• Access the effectiveness and efficiency of health programme and put services in to practice.
• Describe and measure present performance.
• Help  developing explicit standards.
• Suggest what needs to be change
• Review the past and modify the present resources.

 

Types of Clinical Audit

1. Concurrent audit- care is evaluated at the time of it taking place.
2. Retrospective Audit- care evaluated after it has been completed through records.

 

Stages of clinical Audit

• Preparing for audit
• Selecting criteria
• Measuring performance
• Making Improvement
• Sustaining Improvement
• Re audit

 

Preparing for audit

1. User information-

• The concerns of user can be identified from various sources, including
• Letters containing comments and  complaints
• Critical incident reports
• Individual patient stories or feedback from focus groups
• Direct observation of data
• Sources of data

2. Selecting a topic

• Careful thought and planning
• Try to select a topic directly influencing quality care

3. Measure for priorities

• Is the topic concerned of high cost or risk to staff .
• Is there evidence of a serious quality problem ( Patient complaints or high infection rates)
• Is the topic a priority for organization
• Is good data is available to compare standards,

4. Defining the purpose

• Purpose must be established before appropriate methods for audit can be consider.
• The following objectives may be useful in defining aims of an audit.
• To improve quality
• To enhance performance
• Increase efficiency
• Change procedure
• Ensure patient satisfaction
• To reduce cost

5. Planning audit

• Involve all the people concern
• Fix time and plan resources
• Access the evidence/data
• Methodology to be followed for data collection
• Audit report for action.

 

Selecting criteria

1. Which area

• An individual, a team or an organization
• This can include assessment of the process and outcome of care
• The choice depend on the topic and objectives of the audit.
• They should relate to important aspects of care and measurable

2. Sources of evidence

• Systematic methods should be used
• Good quality data
• Reviews of the past audit
• Previously audit  criteria for same purpose
• Measurement of outcome in the past
• Need to develop new criteria

3. Appraising the evidence

• Evidence need to be evaluated to find out if it is valid, reliable and important.
• Meeting aim and objectives
• Study methodology
• Past results/conclusion
• Extent of applicability to your present study

 

Making Improvements

1. Identy barriers to change

• Fear
• Lack of understanding
• Low morale
• Poor communication
• Individual culture
• Doubt of outcome

2. Implementing change

• Systematic approach
• Identification of local barriers to change
• Change culture
• Provide support for team work
• Use specific methods like delegation and accountability.

 

Measuring level of performance

1. Planning data collection

• The data collected are to be precise
• Completed data
• Adequate data
• User group to be studies (Ex- Immunization status of pregnant women)

2. Methods of data collection

• Collect data should be simple, short and relevant to present study
• Compute red stored data, case notes/ medical records
• Local survey through questionnaire interviews focus groups
• Compare performance against the criteria
• Keep focused on the objective of the audit

 

Sustaining Improvement

1. Monitoring and evaluation

• Systematic approach to changing professional practice should include plans to-
• Monitor and evaluate the change
• Maintain and reinforce the change

2. Reinforcing Improvement

• Reinforcing and motivating factors by the management
• Integration of audit as part of regular practice
• Strong leadership and high motivation

 

Re audit

• Review evidence
• Measure effectiveness
• Decide how often to re audit
• Ongoing process monitoring
• Adverse incidents
• Significant event audit

 

Types of clinical Audit

• Statistical Audit
• Audit of disease cases
• Audit of operated cases
• Audit of obstetric cases
• Audit of random cases
• Audit of death cases
• Nursing Audit

 

Statistical Audit

• First step of medical audit.
• Data on  different indicators set by audit committee are prepared unit wise on monthly basis.
• A standard norm is evolved taking in to consideration of available services, facilities, resources by an expert committee.
• The data so obtained critically examined and compare against  the standard norms.
• Deviation from standard norm dictates investigation to find out possible cause and its remedial measures.
• The data are generated, complied and supplied by MRD.

 

Audit of disease cases

• Second step of medical audit.
• Start with the case record  examination of a particular disease. (  Thyroid)
• All case sheets are arranged unit wise and monthly wise
• A group of physician are asked to lay down certain norms with respect to
• Investigation to be done
• Line of treatment
• Average length of stay
• Likely complications
• Then the case sheets are examined as per the above norms to find out  difference
• This helps in earning, education and improvement in quality care.

 

Audit of operated cases

• In this group patient operated for similar surgical method are identified.
•        ( Laparoscopic, chole- cystectotomy)
• The cases are grouped as unit wise and month wise.
• The group experts are asked to lay down certain  norms in respect of the following-
• Methodological approach
• Percentage of pre-operative diagnosis confirms the surgery
• Types of pre anesthetic check up
• Types of post operative complications
• Anesthetic complications
• Patient consent and safety check list
• Use of antibiotics
• Then the case sheets are examined  in light of above norms

 

Audit of obstetric cases

• The indicators same as used as operation cases and addition.
• No of cs done with indicators
• No of forceps/ vacuum  applications
• No of material complication
• No of maternal or neonatal death.

 

Audit of Random cases

• In this method some case sheets of discharged patients randomly selected during a month.
• The objective of this type off audit is to study the quality of record maintenance , diagnostic deficiency, treatment and outcome.
• The various parameters used-
• History, physical examination, diagnostic skill
• Investigation done, treatment given, progress note
• Nursing care chart
• The initial diagnosis is compared with final diagnosis
• Treatment given is judged against correctness, accuracy  according to norms
• The end result of treatment is compared  with patient condition at discharge.

Audit of death case

• This is also called death review.
• All deaths occurring after 48 hours of admission should be subject to medical audit.
• The death case sheets are examined in terms of qualitative and quantitative adequacy.
• The various parameter used are-
• The diagnosis, investigation, treatment given in comparison to normal standard.
• Delay in examination, investigation or  initial treatment.
• Types of consultation obtained and reordered.
• Daily monitoring of progress.
• The various  inadequacies find out the committee are communicated to respective  units for taking preventive measures and improvement in future.

 

Nursing Audit

• Nursing audit is a review of patient record designed to identify and examine or verify the performance of certain  specified aspect of nursing care by using established criteria.
• The clinical audit process seeks to identify  areas for service improvement, develop and carry out action plans to rectify or improve service provision and then to re audit to ensure that these changes have an effect.
• In this case the medical records examined with respect to type of nursing care given.
• The audit may be retrospective or introspective.

 

Role of Hospital Administration in Audit

• To facilitate and provide good working environment
• To provide physical facilities, resources and smooth supply.
• To motivate to enable the medical care  provides to works enthusiastically.
• To attend patient complain, grievances by grievance redressal committee.
• To edit and monitor media coverage/press notes
• Patient satisfaction surveys  to reveal the grey areas.
• To conduct exit interview and make changes as suggested.
• To frame clear cut objectives and policies.