NPHS Primary Care Quality and Information Service

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Audit Training Programme for Primary Care

• NPHS Primary Care Quality and Information Service
• Debbie
• Jane

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• After today you will be able to-
• Understand the principles of Clinical Audit
• Appreciate links between Clinical Audit and
  Clinical Effectiveness
• Select an appropriate audit topic
• Develop specific aims and objectives
• Define and apply criteria and standards
• Understand some of the principles and processes
  of change management
• Undertake audit in your place of work

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• What is clinical audit?
• 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 implementation of
  change
• (NICE 2002)

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Florence NightingaleHospital acquired
Infection Audit high mortality rates among
injured or ill soldiersChanges strict sanitary
routines and standards of hygiene to the hospital
and equipment Resultsmortality rates fell from
40 to 2,
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Audit today!

• General Medical Council
• All doctors must take part in regular and
  systematic clinical audit
• Nursing and Midwifery Council
• clinical audit is the business of every
  registered practitioner

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Types of Audit in Primary Care

• Standards based audit a cycle which involves
  defining standards. Collecting data to measure
  current practice against those standards.
  Implementing changes
• Significant event audit individual episodes are
  analysed
• Peer review audit assessment of quality of care
  provided by the team
• Patient surveys patients views about the quality
  of care they receive.

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BUT.

• Isnt audit about saving money or best use of
  money?
• Is audit the same as research?
• Is audit just about collecting numbers?

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• Is it clinical audit or research?
• Research is about creating new knowledge
• (which treatment is better?)
• Clinical Audit is about taking that knowledge
  and making sure we are doing the things that work
  best and doing them effectively

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• Is it Audit or Research?
• Does your project have a clear idea about the
  quality of services we should be providing i.e.
  does it involve standards?
• Are you doing this piece of work to try and
• improve patient care?
• Will it involve anything being done to patients
  which would not otherwise have been part of their
  routine clinical management?

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• How does clinical audit help?
• It helps answer
• What are we trying to do?
• How well are we doing it?
• How do we know
• How do we do it better

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Why do audit? - benefits

• It can lead to .
• Improved quality of care .
• A sense of personal and professional achievement.
  Stimulation of Continuing Professional
  Development (CPD)
• Improved Team-Working
• Improved communication within an organisation
• A greater understanding of the structure and
  process operating within the organisation
• Improved practice based skills such as the
  identification, management and use of information
• Improved GMS Contract performance

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Attitudes and Criticisms
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Attitudes Criticisms

• Attitudes towards clinical audit are
  influenced by negative experience
• Lack of support and resources
• Lack of Impact
• Failure to change clinical practice
• No time to do audit
• The audit process too time consuming
• Findings rarely seen in practice

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Clinical Governance

• Clinical Governance is an umbrella term for
  everything that helps maintain and improve high
  standards of patient care. It encompasses a range
  of quality improvement activities.
• (RCN 2003)

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The elements of the clinical governance framework
are

• Clear lines of responsibility and accountability
• Quality improvement programmes, including
  clinical audit, evidence-based practice, standard
  setting and monitoring
• Public and patient involvement in Health
• Risk management, learning from incidents, helping
  staff to reflect on and develop their practice.

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• What makes a good audit?

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• Good choice
• Patient centred
• Possible to measure
• Resources allocated (time/funds)
• Important
• Frequently occurring problem
• Standards agreed
• Good team involvement
• Will be possible to change and improve

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• Poor choice
• Clinician centred
• Not possible to measure
• Resources not allocated
• Unimportant
• Only happens rarely
• No standards agreed
• Relies on one or two individuals
• Impossible to change even if needed

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Audit Puzzle
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THE AUDIT CYCLE
DEFINE/ REVIEW Criteria and Standards (Based on
the best possible up to date evidence where it
exists)
Design Audit Tool
Implement change
COLLECT Data on Performance
Record Analyse
IDENTIFY Need for change Involve everyone

ASSESS Data Performance against criteria
Standards
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Selecting an Audit topic

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A problem may be identified from every day
practice. Problems can be identified in 3 basic
areas Structure The input of care, e.g.
manpower, premises or facilities Process This
refers to the provision of care (looking at what
is done and how it is done) Outcome This
refers to the result of clinical intervention.
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• How to choose your topic
• National Priority
• NICE guidelines
• NSFs
• Royal College
• NPSA
• LHB Priority
• Practice priority

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• Aims
• Why are you doing this project?
• What are you trying to achieve?

Primary Care Quality Information Group
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• Group Task
• Choose an audit Topic
• Why have you chosen it?

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• Criterion
• an element of care or activity that can be
  measured

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• Try to keep the number of criteria to a maximum
  of 4 or 5
• (It is perfectly acceptable to have only one
  criterion for an audit)
• SMART

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Minor Surgery Audit

• Examples of criteria
• There is a record of the patient having
  provided written consent
• (GMS contract 2003)
• The site of the procedure is recorded
• (Sambandan 1999)
• The type of procedure is recorded
• (Sambandan 1999)
• Above are aspects of care that can be measured to
  assess quality.

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• Standard describes the level of care to be
  achieved for any particular criterion

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Setting your standards

• Minimum
• Ideal
• Optimum

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• Question
• Is 100 ever realistic?

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• To make the criterion (statement) meaningful a
  standard needs to be ascribed.
• For example - a standard may state
• 100 There is a record of the patient having
  provided written consent
• 100 The site of the procedure is recorded
• 100 The type of procedure is recorded

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Looking for evidence
NICE National Service Frameworks Cochrane
Library BMJ Clinical Evidence Clinical Knowledge
Summaries (formerly Prodigy) Scottish
Intercolligate Guidelines TRIP ATTRACT (Clinical
query answering service) Local policies
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Group Task

• Set your criteria and standards

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How do we decide what data to collect, where,
when how?

• Brainstorming, focus group, think tank
• What have others done?
• Retrospective or Prospective
• Who is to be included ?
• Who will do the data collection?
• When will you do the audit?
• How long will you collect data for?

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• Where do you find the data?
• Clinical Records
• Computer
• Activity analysis
• Questionnaire / Survey
• Interview
• Observation

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How good is your data?consider

• Is it really the information you need?
  (Relevance)
• How well has it been recorded and by whom?
  (Accuracy)
• Has all the data been captured? (Completeness)
• Is it easily retrieved? (Accessibility)
• Has anonymity been maintained? (Confidentiality)

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Gathering data can be difficult
Its the results that can be exciting
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Sampling

• Do you need to review all patient records will
  a sample suffice?

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Sampling

• The sample chosen should be small enough to allow
  for rapid data collection but large enough to be
  representative
• The final number may depend on the time available
  . If you take too long, you may lose interest.

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Sampling
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• Reviewing your data

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• Compare with standards at outset
• How well are you doing?

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Identify need for change

• Write up audit report
• Discuss share your audit results
• Involve as many people as possible
• Develop an action Plan

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Audit is a team effort
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• Making changes

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Making changesConsider your change management
skills

• Leadership, Delegation, Involvement skills

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Driving forces for change

• To improve patient care
• Patient pressure
• National policy
• Demands for better service
• Frustration
• Reflection

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Restraining forces

• Individuals
• Fear of increased workload
• Concerns about staffing levels and cuts
• Loss of control over work pattern
• Low tolerance for change
• Organisations
• Loss of power
• Loss of face
• Additional workload
• Loss of income
• Job insecurity
• Low tolerance for change

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Getting consensus

• Seek opinions and feelings beforehand
• Emphasise areas of common interest
• Be sensitive to anxieties of others
• Acknowledge drawbacks honestly
• Allow time for discussion

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THE AUDIT CYCLE
DEFINE /REVIEW Criteria and Standards (Based on
the best possible up to date evidence where it
exists)
Design Audit Tool
Implement change
COLLECT Data on Performance
Record Analyse
IDENTIFY Need for change Involve everyone

ASSESS Data Performance against criteria
Standards
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Contact Details

• debbie.davies_at_nphs.wales.nhs.uk
• 01495-332313
• jane.holloway_at_nphs.wales.nhs.uk
• 01443-824191
• Primary Care Quality and Information Team

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www.nphs.wales.nhs.ukClick on Primary Care
(Primary Care Quality Information)

• National / Directed Enhanced Services
• Quality Improvement Toolkits 
• The following quality improvement toolkits
  contain the specification requirements of the
  Enhanced Services and contain audit tools and
  Read Codes.
• Access quality improvement toolkit
• Minor Surgery quality improvement toolkit
• Anticoagulation Monitoring quality improvement
  toolkit
• Near Patient Testing - Methotrexate toolkit
• Near Patient Testing - Penicillamine toolkit
• Near Patient Testing - Auranofin toolkit
• Near Patient Testing - Sulphasalazine toolkit
• Near Patient Testing - Sodium Aurothiomalate toolk
  it
• NPT/DMARD resource manual
• Depression quality improvement toolkit
• Violent Patients quality improvement toolkit
• Sexual Health quality improvement toolkit
• Minor Injuries toolkit (coming soon)
• Influenza toolkit (coming soon) 

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Clinical Governance Practice Self Assessment
Tool

• Online Web Version 
• http//nww.nphs-cgtool.wales.nhs.uk/

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