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Clinical Audit: a Simplified Approach Mansoor Dilnawaz, Hina Mazhar, Zafar Iqbal Shaikh

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Clinical Audit: a Simplified Approach Mansoor Dilnawaz, Hina Mazhar, Zafar Iqbal Shaikh Journal of Pakistan Association of Dermatologists 2012; 22 (4):358-362. Review Article Clinical audit: A simplified approach Mansoor Dilnawaz, Hina Mazhar, Zafar Iqbal Shaikh Department of Dermatology, Military Hospital (MH), Rawalpindi Abstract A clinical audit measures practice against standards and performance. Unlike research which poses the question, “what is the right thing to do?” clinical audit asks are we doing the right thing in the right way? An approach for understanding a clinical audit is provided. A basic clinical audit example of a case note audit is presented. A simplified template to help the beginners is included. Key words Clinical audit. Introduction and steps of clinical audit We should determine what we are trying to measure and define gold standards. The next Audit is a key component of clinical stage is about setting the standards. Criteria are governance, which aims to ensure that the those aspects of care that we wish to examine. patients receive high standard and best quality Standards are the pre-stated or implicit levels care.1,2 It is important that health professionals of success that we wish to achieve. The are given protected and adequate time to standards are based on the local, national or perform clinical audit.4,5,6,7 Clinical audit runs international guidelines. They should be in a cycle and aims to bring about incremental relevant to our practice. A couple of example improvement in health care. Guidelines and of the sources includes National Institute of standards are set according to perceived Clinical Excellence (NICE) and the British importance and performance is then measured Association of Dermatologists (B.A.D) web against these standards.8,9,10 . sites. When setting the standards remember the acronym SMART – Specific, Measurable, A clinical audit is NOT the same as research. Achievable, Relevant and Theoretically sound There are differences ( Table 1 ). – based on current research. A clinical audit usually starts by discussion at Next, methodology should be defined. Who an audit team meeting discussing possible will be involved? Who will collect and analyse topics and prioritising them according to data? What will be the sample size? What perceived importance applicable to the about the feedback of findings – to whom and practice. The golden rule is we should only how? When will the project begin and end? ever audit our own practice. If for some reason we need to gather data about the practice of The audits and the data collection can be others, then we should involve them in the prospective or retrospective ( Table 2 ) audit and obtain their permission. 11 Address for correspondence The audit once completed is presented at a Dr. Mansoor Dilnawaz meeting and recommendations are made with Consultant Dermatologist regards to deficiencies found and to identify Department of Dermatology Military Hospital (MH), Rawalpindi areas for improvement. The implementation of Email: [email protected] the changes cannot be over emphasized - What Ph: +92 342 421 0568 358 Journal of Pakistan Association of Dermatologists 2012; 22 (4):358-362. Table 1 Difference between audit and research. Research Audit Generates new knowledge Knowledge being used to the best effect Is initiated by the researchers Usually led by the service providers Is theory driver (hypothesis based) Is practice based (standard based) Is often a one-off study Is an ongoing process Large scale, prolonged periods Usually less so Lot of statistical analysis Not much analysis May involve allocating service users randomly to different Never so treatment groups May involve administration of placebo Never so Requires approval from ethical committee No such approval needed Table 2 Data collection. Categories Retrospective Prospective Definition Data collected by looking back Data collected from this point onwards, over your practice starting at a future date When to use When looking at what has been Data currently unavailable happening in a chosen topic area Data of poor quality Advantages Can be faster Avoids using poor quality data. Provides a baseline Allows design of a clear and concise data collection sheet Disadvantages Past service users do not benefit Provides no baseline for audit. Can be time-consuming since a no of individuals needed to collect data Clinical Audit Cycle 1. Select 8. Re-audit topic 2. Agree 7. Implement standards of change best practice Action Planning 6. Make 3. Define recommendations Audit methodology 4. Pilot 5. Analysis and and data Reporting collection Figure 1 Clinical audit cycle. needs to change? How change could be will be monitored and by whom to achieve the achieved – what actions need to be taken? desired outcome and then re-auditing to see if Who needs to take these actions? When will the desired outcome(s) has been achieved. the proposed actions begin? How these actions 359 Journal of Pakistan Association of Dermatologists 2012; 22 (4):358-362. A summary of the stages of clinical audit are 1. Clinical effectiveness This means presented in the form of audit cycle ( Figure 1 ) ensuring that everything we do is designed to provide the best outcomes Discussion for patients i.e. “doing the right thing to the right person at the right time in Clinical audit in simple words means are we the right place”. In practice this means doing the right thing in the right way? This is an evidence based approach, changing achieved by measuring our practice and practice if current practice is shown performance against standards. Doing regular inadequate, developing and clinical audits is essential. Audits improve implementing new protocols and patient care, identify and promote good guidelines, conducting research to practice, lead to improvement in service develop evidence, CPD, maintaining delivery, demonstrate to others that our service log books, time management, seeking is effective, provide opportunities for help where required, patient education and training and encourages satisfaction surveys, adequate teamwork. The overarching aim of clinical consultation time, information leaflets audit is to improve service user outcomes by etc. improving professional practice and the 2. Clinical audit The aim of the audit general quality of services delivered. 12 process is to ensure that clinical practice is continuously monitored There are three main types of clinical audit: and that deficiencies in relation to set standards of care are remedied. 15 1. Structure (what we need). This 3. Risk management This involves includes staffing and facilities. having robust systems in place to 2. Process (what we do). The examples understand, monitor and minimise the are checklists, protocols, guidelines, risks to patients and staff and to learn record keeping, waiting times, from mistakes. When things go wrong trainee’s attendance and treatment. in the delivery of care, doctors and 3. Outcome (what we expect) for other clinical staff should feel safe example satisfaction surveys. admitting it and be able to learn and share what they have learnt. In simple Clinical Governance terms this means to identify, assess, prioritise and prevent risk. 16 A clinical audit is an integral part and key Examples of risk management component of clinical governance. 13 Clinical include : complying with protocols, Governance is an umbrella term which learning from mistakes and near- encompasses a range of activities in which misses, reporting any significant clinicians should become involved in order to adverse events via incident forms, maintain and improve the quality of the care looking closely at complaints, they provide to patients and to ensure full promoting a blame-free culture. accountability of the system to patients. 14 4. Education and training This means enabling staff to be competent in There are basically seven pillars of clinical doing their jobs and to develop their governance: skills so that they are up to date. This involves attending courses and conferences – CPD activities, taking 360 Journal of Pakistan Association of Dermatologists 2012; 22 (4):358-362. Table 3 Clinical audit template. Project title Name of the audit Specialty Name Professor/HOD Name Project Lead(s) Name(s) Staff members involved Names Date of presentation Date Rationale Background/Reason for the selected topic Objective(s) Insert Project type Structure, process or outcome Basis of proposal Local, National, International guidelines Criteria Insert Standard(s) Insert Sample source Insert Sample size Insert Data collection/ analysis Retrospective/ Prospective Results Insert Recommendations/ Insert Areas for improvement RE-AUDIT Date/ Time frame Table 4 Case notes audit example. Project title Case notes audit Re-Audit Specialty Dermatology Professor/HOD Dr. Zafar Iqbal Shaikh Project lead(s) Dr. Mansoor Dilnawaz Staff members involved Dr. Hina Mazhar Date of presentation 5 October 2012 Rationale Meticulous record keeping is an integral part of patient care Objective(s) 1- To assess the quality of patient record 2- To seek incremental improvement Project type Process Basis of proposal Local guidelines Criteria The case notes should contain the relevant demographic and clinical details of the patients Sample source Case notes from the dermatology ward at Military Hospital, Rawalpindi Sample size 10 case notes selected at random Data collection/analysis Dr. Mansoor Dilnawaz, Dr. Hina Mazhar Standard(s) 1. Is there: a. A hand written record? b. Is the clinician identified? c. Is it legible? 2. Is patient identified on each page (name, personal number, age, disease)? 3. Is there clear diagnosis or clinical problem? 4. Is there a clear management plan? Results 1 2 3 4 5 6 7 8 9 10 1a 1b 1c 2 3 4 Recommendations/areas for 1- All the case notes had hand written, legible record of the patients with clear improvement diagnosis and management plan 2- To continue with maintaining good patient record Re-audit 6 months 361 Journal of Pakistan Association of Dermatologists 2012; 22 (4):358-362. relevant examinations, regular 2. Scally G, Donaldson LJ. Clinical assessment during training, appraisals, governance and the drive for quality improvement in the new NHS in England.
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