1. Clinical Audit for the
Ian Callanan MB FRCSI MBA
Group Clinical Audit Co-ordinator
St Vincent’s Healthcare
Medical Director
Aviva Healthcare Insurance
PCC Committee
Medical Council of Ireland
uninitiated
troubled
confused
harried
enlightened

2. Clinical Audit for the
Ian Callanan MB FRCSI MBA
Group Clinical Audit Co-ordinator
St Vincent’s Healthcare
Medical Director
Aviva Healthcare Insurance
PCC Committee
Medical Council of Ireland
uninitiated
troubled
confused
harried
enlightened

3. What does it mean for health staff?
CPD
50 points per year
Clinical audit
1 per year
(12 hrs suggested)
CPD
?
Accreditation
HIQA
JCI etc
Clinical audit
Healthstat
KPIs

4. Life, according to Librarians…..?

5. What is quality?

6. Clinical AuditClinical Audit
Systematic
review and evaluation
of current practice
with reference to research
based standards with a view
to improving patient care

7. Clinical AuditClinical Audit
It
does
exactly as it says
on the tin
“Ronseal”

8. Clinical Audit
Identify and
eliminate waste
Identify and promote
good practice
Identify and stop
bad practice
Promote MDT
working
Improve professional practice
Improve patient outcomes
Release money
to provide
better patient care
Select & support
highest quality
care Professional education

10. Identify Standard
Measure activity
Validate against standardMake appropriate changes

11. Standard
and
Criterion
What should happen
–98% of female population at
risk should be immunised against
rubella
–100% of children needing
attention for acute problems will
be seen on the same day
–All patients Rxed with statins
should have an LFT carried out
Criterion:
a definable and
measurable item
of health care
Standard:
a statement of
expectation

12. PDCA
ACT

13. Example of wrist bands
0 printed
428
handwritten
21 ABSENT
54 printed
360
handwritten
10 ABSENT
165 printed
214
handwritten
15 ABSENT
339 printed
55
handwritten
34 ABSENT
368 printed
10
handwritten
31 ABSENT
Aug 2006 Aug 2010 Oct 2010 April 2011 Sept 2012

14. Audit and Feedback
0%
+70%
-16%
Change in practice after clinical audit
– measured by adherence to specific guideline
Jamtvedt et al 2006,
Cochrane Database of Systematic Reviews

15. Plan
Do
Do
CHeck
Do
CHeck
ACT
Plan
CHeck
ACT
Plan
ACT

16. Source
Professional directions
Research
Benchmarks
Guidelines
Level of compliance
Is 100% achievable
Is 80% good enough
Progressive improvement
The First Rule of Aviation
More than my jobsworth

17. Source of Standards
• Pubmed
• Cochrane
• BMJ
• SIGN
• Clinical Evidence
• EBM online
• School of York reviews
• Best BETS
• Bandolier
• Centre for Clinical Effectiveness
• Centre for Evidence-Based Medicine
• Centre for Evidence-Based Mental Health
• Centres for Health Evidence
• Clinical Assessment of the Reliability of the
Examination
• Clinical Decision Rules, The Samuel Bronfman
Department of Medicine
• Clinical Examination Research Interest Group
• Clinical Resources, Clindx Update Listserv &
Bibliography
• Netting the Evidence
• NHS Centre for Reviews and Dissemination
• Ovid EBM
• Physiotherapy Evidence Database (PEDro)
• Resources for Practicing Evidence-Based
Medicine
• Department of Family & Community Medicine
• Trip Database
• EPIQ (Effective Practice, Informatics &
Quality Improvement)
• Evidence-Based Mental Health
• Evidence based Nursing
• Evidence-Based Paediatrics
• Evidence-Based Practice Centers
• McMaster Health Information Research Unit
• National Library of Medicine's Health
Services/Technology Assessment Text
(HSTAT)
+ Google

18. Research is
probably
the nemesis of
clinical audit

19. Information for research
Detailed, focussed and minutiae
Info not usually collected
EXCITES doctors
Information for monitoring / accountability
Technical data
Externally used (Lot of energy in getting agreement)
Not illuminating how outcomes achieved or processes
managed
Information for quality improvement
Quickly gathered
Rapid cycle
Identify problems / get baseline / measure
improvements
1
2
3
After Solberg et al
Jt Comm J Qual Improv. 1997 Mar;23(3):135-47.

20. Who does audit?
1. Self-audit
2. Peer audit
3. External audit
Part of professional’s regular questioning
Can be difficult to sustain (time, space, skills….
Private
Adv: Frank discussion
Disadv: Collusion, avoid the awkward
“It takes one to know one”
Likely to be
Appropriate to context
Acceptable to colleagues
Principal risk
May become collusive
Most rigorous
Most threatening
Require resources

21. • Numbers needed
• Clarity of gathering
the right data
• Using databases
– Paper tots
– Excel
• Analyses / Stats!!!!
Gathering the data

22. Framework for clinical audit
Structure
Process
Outcome
Physical attributes of health care
•Tangible, easily counted
•Presence increases the chance of good
quality care but does not ensure it (appropriate
use…..)
•Examples: equipment; medical records
Care given by a practitioner / service
•Health professionals identify process with quality
–It describes what they do
–Reflects their attitudes, knowledge & skills
•Examples: prescribing habits, hospital referral
rates, lab & x-ray use
Changes in patient’s current & future health
status as result of intervention
•Describe effectiveness of care
•Difficult to measure……
•Example – lower incidence of specific disease;
lower mortality; improvement of level of
function, patient satisfaction

23. Criteria and Standards
Criterion Standard
Structure Patient records will include hard
copy results (NHO audit)
Should apply to 80%
records
Process Patients aged 20-65 will have
their BP recorded at least once in
last 5 years
Should apply to:
50% records in Y 1
75% in Y 2;
95% in Y 3.
Outcome Patients with ⇑BP aged u 40 will
have diastolic < 90mm Hg within
1st
yr of treatment
Will be achieved in
80% cases

24. Gap models of service quality
(SERVQUAL)
Expected service
Perceived service
Service delivery
Service standards
External
communications
Company perceptions
of customer expectations
Gap 1
Gap 4
Gap 2
Gap 3
Gap 5

25. Good audit.....
• Topic is a priority
– Reflects local services
– Agreed by all as priority
• Measured against
standards
– Best available evidence
• Supported by
organisation
– Time and planning
• Engages with all
– Ownership
– Through to completion
• Patient involvement
– Patient priorities
• Target sample
appropriate
– Generates meaningful
results
• Data collection
robust
– Clarity on criteria
• Action plan
– Ownership
– Accountability
• Repetition

26. Performance
Davidoff, Ann Int Med 2011
Reflection
Hands on experience
Reflective observation
Abstract conceptualisation
Endless performance

28. 1. I am Clinical Audit….thou shall not wave a Research Idea
at me
2. Thou shall close all clinical audit loops… unclosed loops
are an abomination
3. Keep thine audits simple
4. Thou shall have a plan
5. Thou shall not bear false witness to statistics
6. Thou shall not collect needless data
7. Thou shall tell everyone about your audit
8. Tell “The Organisation” about your audit
9. Keep to thee all the data only for as long as it is needed…the God of
Information shall visit all manner of plagues upon ye
10. Re-audit, in the name of all that is good and right in clinical care

29. Any questions?
Now…..
Later…..
clinicalaudit@svuh.ie