Clinical audit in general practice - Kuwait Institute for Medical ...

BULLETIN OF THE KUWAIT INSTITUTE FOR MEDICAL SPECIALIZATION 2002;1:63-68Clinical audit in general practiceAbeer K. Al-Baho 1 , Maleka Serour 2CMEThe subject of Audit has been increasingly recognizedas an important topic in the medical profession.Audit had been officially introduced in theUnited Kingdom in the late 1985. It is recognized asa tool for measuring quality and improvements.This is a review article summarizing the definition,aims, and steps of audit, how to choose a topic, theaudit cycle and how to implement change, with finalrecommendations for trainees and physicians to facilitatethe process of auditing in their medical career.Key words: Audit, criteria, standards, data collectionG/P: General Practitioner, P: PatientBulletin of KIMS 2002;1:63-68Bulletin of KIMS carries some articles specifically designated asCME. They provide the opportunity for the reader to obtain creditpoints under the CME Program of KIMS. Clinical audit in general practiceis one in this category. Studying the article, answering the questionsrelated to it on page 68, and sending a copy of the Answer Sheet(page 80) to the CME Center of KIMS makes the reader eligible for 1CME credit in Category 1. To claim credit, the reader has to haveobtained registration in the CME Program of KIMS, the answer sheetshould be received by the CME Center before 31 st August 2003, andall questions should have been attempted. Readers who satisfy theabove requirements will receive a certificate from the CME Centerindicating the credit data.IntroductionAudit is such an unsatisfactory term that it ishard to understand how it ever becameadopted by the medical profession. Its derivationfrom the Latin audio which implies listeningrather than doing, passivity ratherthan an active role to change. In PrimaryHealth Care, Medical Audit developed a momentumonly during the 1970’s. Prior to 1966,facilities for general practitioners in the UKwere sparse that most doctors had little timefor anything other than reactive care on a dayto day basis. Until introduced by the RoyalCollege of General Practitioners in 1985,Medical Audit had not been formally recognizedin the UK. 1,21Director of Family Practice Specialty Training Program(FPSTP), Senior Trainer/Examiner2Senior Trainer/Examiner FPSTPCorrespondence: Dr. Abeer Al-Baho, Family PracticeTeaching Center, New Building, Qadsia, P.O. Box 1793,Safat,13018 Kuwait. Tel.: 965 2562372, Fax: 9652533134; Email: abeerkhaled@hotmail.comClinical audit ● Abeer K. Al-Baho, Maleka SerourDefinition of AuditA range of definitions exists. Audit is abouttaking note of what we do, learning from itand changing, if necessary, the improvementin the quality of care through standardsetting,peer review, implementation ofchange and revaluation. It is concerned withassessing and improving the delivery ofhealth care, the resources used, the caregiven, and the outcome. It is quite simply atool that enables you to monitor and then improvethe quality of care you provide to yourpatients. 1,2 Marinker defined Medical Auditas the attempt to improve quality of medicalcare by measuring the performance in relationto desired standards and by improving onthis performance. 2,3 Crombie et al. definedAudit as the process of reviewing the deliveryof health care to identify deficiencies so thatthey may be remedied. 2Why do AuditTable 1 shows a summary of the main reasonsfor performing an audit.Table 1. Summary of “Why do we audit?”• Development of professional education and self regulation• Improvement of quality of patient care• Increasing accountability• Improvement of motivation and teamwork• Aiding in the assessment of needs• As a stimulus to research63

BULLETIN OF THE KUWAIT INSTITUTE FOR MEDICAL SPECIALIZATION 2002;1:63-68What clinical Audit is NOTClinical audit is not a resource managementtool, although audit findings often inform resourcedecisions. It is never used to threatenan individual clinician suspected of poor practice,but is a neutral measurement process.Clinical audit is not a batch of computers or aset of statistics. Clinical audit is not aboutcompetition between clinical professionals. 4There is temptation to compare audit findingsbut never to judge good and bad professionalsbased on audit. It is improving patient carethrough ensuring consistent application ofstandards of care. 1,2,4Audit versus researchBoth contribute to clinical practice effectivenessbut they are not the same.Research is used to define good practicewhile audit measures the extent to whichgood practice (as defined through researchand expert opinion) is implemented on a dailybasis. Audit does not aim for a universaltruth about a practice, but focuses on the performanceof individual practitioners (or theworkplace) and the service to its patients. Auditis about what you do not find. Audit also isongoing, whereas research is a one-off activity.5 It is possible to generalize from researchbut not from audit findings. Audit can contributeto research by creating questions forresearch to address. 4 Observation or data collectionto determine current practice is anotherform of information gathering which issometimes used alongside research and audit.It is appropriate to be used when practice patternsare unknown or when the intent is tocatalogue prevailing practice patterns withoutmaking judgments about appropriatenessand effectiveness. 4Which one to use - Audit, research ordata collection and observationTable 2 shows when to use audit, research ordata collection and observation.Preparing the groundThe introduction of audit to the practice canbe fraught with difficulties. To maximize thechances of success an essential step is for thepractice team to take an inward look to see if64it is capable of and ready for the challenge.Successful Audit needs the members of theteam to be in the right mood, and to have confidencein each other with ability to work togetherin enthusiasm, accepting criticism andwishing to improve.Table 2. Scheme to choose the appropriate method for practiceevaluationMethodResearchData collectionor structuredobservationAuditWhen to use itGood practice is notdefined and comparisonsare neededPractice patterns areunknownGood practice is definedbut we want to check howmuch we are sticking to itBlocks to getting startedWhyTo define good practiceThe intent is to catalogueprevailing practice withoutmaking judgmentsTo improve the currentperformance1. TIMEEvery general practitioner is busy and so isthe staff. To overcome the time problem:Keep it small and simple, use a small sampleof a large topic. or tackle a small topic.Work together in a team.2. RECORDS AND COMPUTERSIt is good to have good records and to have acomputer. The topics that are suitable fordata collection may be important for the practice.A great deal of information needed for auditis not adequately recorded by computers, so anote search may still be required.3. LACK OF SKILLS AND PROTOCOLSThis can be overcome by searching, preparingand setting protocols by the staff before starting.4. THE PRACTICE TEAMNegative attitudes to audit and general lackof support from the practice team is one of theblocks to starting an audit. To overcome thisproblem, ensure team members understandaudit and the purpose of it and consider trainingin team building. You may even involvethe practice manager. 1,2Setting the aimsClear aims must be identified at the outset ofany audit project in order to define its purposeexplicitly. Self selected aims can be themost rewarding from the point of view of pro-Clinical audit ● Abeer K. Al-Baho, Maleka Serour

BULLETIN OF THE KUWAIT INSTITUTE FOR MEDICAL SPECIALIZATION 2002;1:63-68ducing behavior changes than empirical aims(derived from many other studies) or normativeaims (derived from standard text-booksand the writing of the experts). 7 Self-selectedaims should be chosen against the backgroundof other studies where statisticallysignificant results were obtained, i.e. evidence-based.The team should justify itschoice of the aims and be prepared to examinethose areas where the aims are included inthe audit project.The Audit cycleThe process of identifying areas of care to beaudited, implementing any necessarychanges, and then periodically reviewing thesame issues is known as the Audit Cycle(Figure 1). 4,7 After identifying the topic to beaudited, criteria will need to be agreed to decidewhat constitutes an acceptable standardof care. Current practice is then observed tocompare the care that is being deliveredagainst the standards that have been set.Once changes have been made, their effectscan be measured to see if they have the desiredoutcome. For audit to be effective thecycle needs to be repeated to see whether thechanges implemented have improved thecare. So perhaps an image of a gradually ascendingspiral is more appropriate than a circle.Identify thechangesrequired andimplement themFigure 1. Audit cycleChoose the topicDefine criteria and standardsAssess performance againstcriteria and standardsClinical Audit processCollect thedataBy National Center for Clinical Audit 41. DESIGN THE AUDIT• Who is involved? A team leader is better.The presence of a team leader is of greatimportance, with liaison with an auditcommittee and team members and otheruseful team supporters.• Topic: What to Audit (high risk practices,high volume practices, high cost care,topics of local concern).• Objectives: Measures of quality of careconsistent with evidence of good practice• Cases to be included.2. MEASURE DAY-TO-DAY PRACTICECollect and analyze valid and reliable data,following ethics and confidentiality principles.3. EVALUATE EVIDENCE OF DAY-TO-DAYPRACTICEIdentify areas of good and not so good practice.4. ANALYZE THE EVIDENCEDoes your practice equal good practice? If yes,feedback to your group; if not ,devise an actionstrategy and implement the action plan.Getting startedA practice meeting is needed to encourageparticipation and distribute tasks.When reviewing the topics for Audit, we canask three questions:• What facilities are there? (Structure)• What was done to the patient? (Process)• What was the result for the patient?(Outcome)Structure of the Audit refers to the physicalfeatures of the practice, the premises, theavailability of staff and their training, clinicbuilding, practice equipment, and records.Process refers to what the GP actually does,i.e. practice activity, e.g. prescribing habits,referrals, laboratory investigations, etc.Outcome refers to the results of health care,changes in patient’s future health status thatcan be attributed to health care, e.g. preventionof disease, prevention of premature deathand patient satisfaction with the care provided.The outcome is the ideal indicator forcare but the most difficult to measure.Choosing the topicThree fundamental questions to be answered:11. What kind of practice are we?2. What kind of practice do we want to be?3. How capable of change are we?The range of care given by primary healthcare teams is so broad that it is not possible toaudit everything.Clinical audit ● Abeer K. Al-Baho, Maleka Serour65

BULLETIN OF THE KUWAIT INSTITUTE FOR MEDICAL SPECIALIZATION 2002;1:63-68Table 3 demonstrates factors to considerwhen selecting a topic for audit and the consequencesof these factors. 2Table 3. Factors influencing choice of topic for auditing and theconsequences of these factorsTopics of major importance include chronicdisease management, preventive care, prescribing,Audits on childhood immunization,cervical cytology, referrals to hospital and useof laboratory services. 1,2Examples of topics for Audit• Structure Audit: Patient’s record cardsshould contain a summary card.• Process Audit: The BP of patients aged 20-65 years should be taken and recorded atleast every 5 years.• Outcome Audit: Patients with establishedhypertension aged 20-35 years will have adiastolic level below 90 mm Hg within thefirst year of treatment.Criteria and standardsCriteria are what you want to measure(yardstick). It addresses a definable andmeasurable item of health care which describesquality, and which can be used to assessit, e.g. patients with chronic asthmashould have their inhaler technique assessedat least once in 12 months.Standards are how well you should be doing.It describes the measurable level of careto be achieved for any single criterion. Table 4shows examples of some criteria and standards.2Arriving at Standards• Don’t get overly concerned - standard settingis flexible, can be revised upwards ordownwards66FactorCondition should have importantimpact on healthCondition should affect a largenumber of peopleGood reasons for believing thatcurrent performance could beimprovedConvincing evidence is availableabout appropriate careConsequenceLikely increase in morbidity and mortalityif care is poorImproving quality of care in commonconditions usually has more impact thanin rare conditionsConcentrates effort on optimum elementsof careOtherwise efforts to change currentperformance are difficult to justify• Those involved decide on the level of carethey find desirable• Guidance can be derived from the literature/textbooksbut ultimately you decide.• Can be based on your own work and observations• Best solution - Perhaps combine all three.Table 4. Examples of some criteria with standardsCriteriaChildren under 2 years should beimmunized against tetanus andpolioThe notes of those patientssensitive to penicillin should beclearly markedPatients should wait no longerthan 30 minutes in the surgerybefore consultationData collectionData collection should be restricted to aminimum, sufficient to fulfill the aims of theaudit. This will ensure that data collectiondoes not become so intensive that exhaustionovercomes enthusiasm. Data collectionis usually simplified by crafting a data recordingform. The form should be selfexplanatoryand easy to complete. It shouldhave a profound title, include dates and bepiloted. The task of data collection should bedelegated to the most suitable staff members.The duration of data collection shouldbe decided. It should be the minimum requiredto collect the essential information tokeep the eagerness. It can be done manuallyor using computer, depending on the availablefacilities.SamplingStandard90% of the registered 2 years olds areimmunized against tetanus and polioThe notes of 100% of patients sensitive topenicillin are clearly marked75% of patients should wait no longerthan 30 minutes in the surgery beforeconsultationThe number of the patients to be included inany audit can involve all potential patientsin the target population. This may be possibleif the total numbers are small or thedata required is easy to gather. In othersituations using a sample of the patientsrepresenting the target population can minimizethe total number of the patients. Optimalsample size can be calculated by usingrandom or systemic sampling. 2 Randomsampling can be done by using a computeror by using a random number table. Systemicsampling requires arranging the itemsClinical audit ● Abeer K. Al-Baho, Maleka Serour

BULLETIN OF THE KUWAIT INSTITUTE FOR MEDICAL SPECIALIZATION 2002;1:63-68to be audited in sequence and sampling everyn th item in a predetermined pattern.Presenting resultsOnce the data collection stage is complete,preserved time should be set aside for dataanalysis, summarizing and presenting theresults to the team. The aim of this process isto produce evidence, which will certainly influencethe next stage of the audit cycle – implementingchange. 2It is enough to use simple arithmetical calculationfor summarizing the results. The resultsmay be represented in the form of percentageof patients whose care complies withthe criterion so as to ease the comparisonwith the agreed standards.The results of the second data collectionmust be presented in the same way as thefirst to monitor the progress and to ease comparison.Key messages• Audit is a process of critically and systematicallyassessing our own professional activitieswith intention to improving personalperformance and finally the quality.• Audit is a cycle which consists of a seriesof particular steps which should be completedto achieve the desirable changes.• Selected topics should be relevant andshould address areas where improvementsare needed.• The identification of explicit audit criteriais the core feature of any systemic approachto audit.• Standards set should be realistic and attainable.• Data collection should be kept to the minimumnecessary to fulfill the aims of theparticular audit.• All participants should be prepared to implementappropriate changes.Implementing changesImplementing changes is the most challengingstage in the audit cycle. Once the resultsare presented to the team, it has to decidewhether it is satisfied with that performance,especially regarding those results that areclose to the standards set, or to continue withany necessary steps to achieve higher standards.This is particularly suitable if the initialstandards had been set at lower than100%. For low results sometimes it is reasonableto reset the agreed standards at realisticpercentages.The team has to discuss the ways throughwhich they have to work, make a change andachieve the agreed standards. It has to discussthe advantages and disadvantages ofeach one and choose the most appropriateones. It has to consider the most practicalmethods, and all involved in that stage mustbe familiar with the aims of doing that andtheir roles. The team has to decide about thedate of the second data collection and whenaudit should be repeated in the future. Theaudit leader has to monitor the process andget others to share the ideas, which is so importantin effecting change 8 and keeping theenthusiasm.References1. Lawrence M. What is medical audit? In: LawrenceM, Schfield T, editors. Medical Audit inPrimary Health Care. New York: Oxford UniversityPress; 1993.2. Fraser R, Lackani M, Baker R. Evidence-BasedClinical Audit. 1 st ed. Oxford: Butterworth-Heinemann; 1998.3. Marinker M. Principles in Medical Audit andGeneral Practice. London: BMJ PublishingGroup; 1990.4. Garland G, Corfield F. Audit, In: Susan H, GillC, Evidence-Based Practice: A Handbook forPractitioners. Edinburgh: Harcourt PublishersLimited; 2000: p. 129-48.5. RCGP. Information sheet module10. ClinicalAudit in General Practice. 2002 Jan. Availablefrom: URL: www.gpnetwork.net.au/eduseru/10-keyiss.htm/.6. Sheldon MG. Audit in General Practice. PracticeUpdate. 1989;5:1052.7. RCGP. Information sheet No.17. Clinical Auditin General Practice. 2002 Feb. Available from:URL: www.gpnetwork.net.au/eduseru/1-backgr.htm/.8. Stewart, R. Leading in the NHS, A PracticalGuide. London: Macmillan; 1989.Clinical audit ● Abeer K. Al-Baho, Maleka Serour67

BULLETIN OF THE KUWAIT INSTITUTE FOR MEDICAL SPECIALIZATION 2002;1:63-68CME QuestionsAfter you have completed reading the above article, take the test given below. Circle T (True) or F (False) in the answer sheet (page80) to show the correct answer to each question. Questions 1 to 10 are related to the content in this article.1. The term audit adequately reflects the concept of Audit as used in general practice.2. An example of the Audit of process is audit of referrals to hospitals.3. Audit usually consumes an extensive amount of resources (of time, money etc.).4. Rare conditions should be audited.5. The higher the standard the practitioner starts with, the stronger is the resulting audit.6. Maintaining clearly written notes of at least 20% of patients who are sensitive to penicillin is an acceptable standard in generalpractice.7. The higher the amount of data the practitioner collects, the easier is the decision making process in audit.8. The most challenging stage in Audit is implementing change.9. In data collection all in the target population must be included.10. The agreed standards can be reset at realistic percentages after the first round of data collection.□ □ □ □ □KIMS Training ProgramsKIMS supervises many postgraduate training programs leading to specialty certificates in several disciplines in medicine.The contact details of the directors of these training programs are listed below for any inquiries regarding them:DermatologyDr. Nawaf Al-MutairiTel.: 965 4832067Email: nalmut@usa.netFamily MedicineDr. Abeer Al-BahoTel.: 965 2562372Email: abeerkhaled@hotmail.comLaboratory MedicineProf. T. JunaidTel.: 965 5319476Email: tah@hsc.kuniv.edu.kwInternal MedicineDr. Moussa KhadadahTel.: 5319596Email: mousa@hsc.kuniv.edu.kwNuclear MedicineProf. Bert David CollierTel.: 965 5319592Email: bertdavidcollier@hotmail.comObstetrics & GynecologyDr. Eyad Al-SalehTel.: 965 3967649Email: dr.eyad@lycos.comPediatricsDr. Amal Al-EisaTel.: 965 5319486Email: amal@hsc.kuniv.edu.kwRadiologyDr. Tariq SinanTel.: 965 5317038Email: drtariq@yahoo.comSurgeryDr. Adel AyedTel.: 965 4843885Email: adel@hsc.kuniv.edu.kw68Clinical audit ● Abeer K. Al-Baho, Maleka Serour