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

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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
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