Overview of the principles of Surgical Audits

1. SURGICALAUDIT
Akinbode O.O.
LUTH

2. Outline
• Introduction
• Historical Perspective
• Aims of Surgical audit
• Commonly audited Parameters
• Principles of Clinical Auditing
• Types of audit
• Conduct of surgical audit
• Value of audit
• Disadvantages and limitations of audits
• Conclusion

3. Introduction
• The systematic, critical analysis of the quality of surgical
care that is reviewed by peers against explicit criteria or
recognized standards, and then used to further inform and
improve surgical practice with the goal of improving the
quality of care of the patients.

4. Introduction
• It is a process by which groups of professionals agree
upon the required levels of excellence in practice, monitor
whether they are being achieved and then resolve
deficits found
• It covers all aspects of surgical care including procedures
used for diagnosis and treatment; the use of resources
and the resulting outcomes and quality of life for patients
• The purpose is to bring about improvements in clinical
practice and patient outcome

5. Historical Perspective
• Has existed since antiquity
• References to similar concepts seen in the Edwin Smith
papyrus (2000 BCE) and the Code of Hammurabi (1700
BCE)
• Modern surgical auditing began with Groves (England) in
1908 and Ernest Armory Codman (Boston) in 1912 who
independently reported systems of reporting outcomes of
surgical care.
• In 1912-American College of Surgeons reported the need
to standardize hospitals and they set five minimum
standards

6. Aims
• To identify ways of improving and maintaining the quality
of care for patients
• To assist in the continuing education of surgeons
• To help make the most of resources available for the
provision of surgical services.

7. Advantages of Audit
• Identifies bad practice
• Reduces unnecessary investigations, medications and
treatment
• Decreased length of admission
• Allows continuous refinement of treatment modalities
• Allows objective assessment of quality of care
• Improves efficiency and guides resource allocation
• Improved education, training and feedback
• Healthy competition

8. Types of Audit
• Retrospective or Concurrent
• Individual, Unit, Hospital, State, Regional, National

9. Audit vs. Research
Audit
• To inform delivery of the
best care
• Measures against a
predetermined standard
• Usually involves analysis
of existing data or simple
questionnaires
• No allocation of patients
• No randomization
Research
• To produce generalizable
new knowledge
• Tests a hypothesis
• Usually involves collection of
new data e.g.. additional
Investigations
• Patients may be allocated to
test and control groups
• May involve randomization

10. Audit vs. Research
Audit
• Only used to assess
modalities currently in use
Research
• May be used to assess
new or experimental
modalities

11. Principles
• Objectivity
• Honesty
• Accurate and standard forms
• Complete medical records
• All that happened to the patient
• Result of investigations
• Post Op Notes
• Follow up
• Autopsy findings
• Records should be filed in an accessible manner

12. Principles
• Confidentiality, patient privacy
• Relevance to common clinical problems.
• Clear standards set by peer assessment
• Education not punishment
• Audit should lead to appropriate action

13. Audit Parameters
• Time utilization
• Cost effectiveness
• Mortality/morbidity assessment
• Quality of diagnostic services
• Monitoring of performance
• Assessment of newer technologies
• Surgical outcome
• Knowledge of patient satisfaction
• Legal implications of surgery

14. Audit Parameters
• Audit of Structure
• Audit of Process
• Audit of Outcome

15. Audit of Structure
• Concerned with amount and type of resources available
• No of hospital beds, staff numbers, nurse to patient ratio,
theatres suites, wards, equipment
• Easy to measure
• Does not necessarily correlate with quality or
effectiveness of care

16. Audit of Process
• Concerned with the amount and type of processes carried
out
• Time utilization, time to surgery (in specific emergencies),
operating time, down time
• More relevant than audit of structure
• Identifies problems in surgical practice and proffers
solutions
• Can be difficult to quantify

17. Audit of Outcome
• Most relevant indicator of quality of care
• Intra and post op mortality, success rate, morbidity, wound
infection rate, specific complication rates, re-operation
rate, duration of hospital stay, re-admission rate, cost of
care, long term survival, quality of life
• Can be difficult to measure or quantify
• Requires adequate and long-term follow up
• Not always favoured by surgeons
• Doesn’t always tell the whole story

18. The Audit Cycle

19. Determining Scope
• Should be clearly defined
• Time bound
• Easy to measure
• Relevant to performance and outcome

20. Selection of Standards
• Clear cut standard for what is considered acceptable
clinical practice
• Should be evidence based
• Relevant to local trends
• Relevant to specialty and types of patients seen
• Should define adverse events
• Should define sentinel events

21. Data Collection
• Determine source of information
• Identify relevant information
• Assess accuracy of data
• Assess need to modify data
• Determine minimum acceptable quantity of data

22. Interpretation of Results
• Results should be presented regularly (e.g. monthly,
biannually)
• Results are evaluated by peers (e.g.. other surgeons or
other centres)
• Results should be compared to those of similar
centres/surgeons
• All sentinel events must be reviewed
• Quality issues should be identified
• Peer review is a learning process not for punishment or
bragging

23. Appropriate Action
• Recommendations and changes should be made based
on audit findings
• Staff should be educated on reasons behind each change
• Follow up
• Audit cycle should be repeated to assess effects of
changes

24. Disadvantages of Audit
• Takes considerable time and effort
• Highlights bad practice and “bad doctors”
• Exposes doctors to punitive action
• Doesn’t always tell the full story
• Pointless if no ability to make changes
• Promotes reliance on protocols and guidelines above
clinical judgment

25. Computers in Clinical Practice
• The availability of computers has significantly changed
the process of surgical audit
• Advantages: Easy storage and analysis of large amounts
of data
• Disadvantages: Translating and entering data to usable
formats, staff training, electricity
• Future trends: Electronic medical records

26. Local Experience
• Very little audit at individual and hospital level
• Morbidity and Mortality meetings
• Little training or emphasis on audit
• Poor and inconsistent data gathering
• Punitive mentality

27. Summary
• Surgical audit is a continuous quality improvement
process which systematically reviews surgical care
against explicit criteria to guide the implementation of
change
• It is a non- punitive, educational process aimed at
improving the outcome of patients
• Locally relevant criteria should be compared against
appropriate local standards to guide resource allocation,
surgical practice and decision making

28. Conclusion
• A good surgeon must never hide his/her faults, but should
learn from them in order to better serve his patients and
improve his practice

29. THANK YOU