CLINICAL AUDIT

1 Sisay.D (MSc .PT)

LEARNING OUTCOME

At the end of this class, students will be able to:

 describe about clinical audit.

 Identify appropriate audit topic.

 Undertake clinical audit.

 Choose appropriate audit standards and methodologies.

 Review their own clinical practice and improve patient care. 2

BRAINSTORMING

1.What is Audit?

2. What is Clinical Audit?

3. How do you know you are doing a good job? level of

competency?

4. Why clinical Audit??

5. What is the difference between clinical audit and research?

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WHAT IS CLINICAL AUDIT ?

 Clinical audit is a quality improvement process that seeks to improve patient

care and outcomes through systematic review of care against explicit criteria
and the implementation of change.
(Principles for Best Practice in Clinical Audit (2002, NICE/CHI))

 was introduced to the NHS by the 1989 by White Paper Working for Patients.

 Previously known as medical audit until the name changed in the early 1990‘s.

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CONT.….

 clinical audit involves reviewing the delivery of healthcare to ensure that best

practice is being carried out.

 ―audit involves improving the quality of patient care by looking at current practice and

modifying it where necessary‖. (Working for Patients, White Paper 1989)

 Clinical audit is a way to find out if healthcare is being provided in line with standards

and lets care providers and pts know where their service is doing well, and where

there could be improvements. 5

CONT.…..

Systematic review of care against standards

change implementation

monitoring change

improvement
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WHY WE NEED CLINICAL AUDIT.

 ‗Physician and clinicians need to accept that they have a

moral and professional duty to ensure they know what
they are doing and how well they are doing it.

(Health Service Journal, 2008)

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WHY CLINICAL AUDIT?

 Provides the framework to improve the quality of patient care in a collaborative and

systematic way.

 identify emerging trends, which enables us to identify risks and implement actions before it

becomes a bigger issue.

 Auditing allows us to identify which services are performing well and promote good

practice.

 similarly to identify where services require improvement.

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CONT.….

 audits can help shed light on how clinician cope with external

factors (such as a pandemic). This allows us to be better prepared

going forward and provide the best care.

 aim is to achieve quality improvement and improve outcomes for patients.

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HOW DOES CLINICAL AUDIT HELP THE PATIENT?

o The audit process will enable us to access whether the patient is

getting the correct care.

o A good quality audit will often lead to a change a in the way we

work.

o This change may improve the patient‘s care, or experience, as

well as the patient’s outcome.
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IMPORTANCE FOR YOU
o Distinguishes you from your colleagues in a
competitive situation

o Win prizes in audit competitions

o Publications

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RESEARCH VS AUDIT
 Research creates new knowledge about what treatments work best,
asking:
―What is best practice?‖

• Clinical Audit takes that knowledge and makes sure

that we are doing the things that work best,
asking:
 ―Are we following best practice?‖
 But the are links with research 12
CONT.…

 Research and Clinical Audit projects:

have different purposes, and therefore…
use different methodologies
 Research requires ethics approval: clinical audit does not

 Clinical Audit and Research are managed and funded in

different ways 13
BENEFIT

 The audit cycle ensures that the auditing is carried out

smoothly and that no process leaks are involved.

 It gives the authority to the auditor to question the current

procedures and norms.

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CONT.

 The audit process can be tracked efficiently, ensuring no delay in

the activities and timely completion of the complete audit.

 Focuses on the systematic approach rather than many things at a

time.

 As a result, the outcome of the audit cycle is a reliable report.

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STAGES OF AUDIT CYCLE

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CONT.…..

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 Discuss in group

o What are the reasons of clinical audit?

o How to select a clinical audit topic?

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DETERMINING THE AUDIT TOPIC

 Is the topic a priority for the organization? For example, have

problems been encountered in any of the following areas?

 High volume—such as requests for chest x rays i n the accident and

emergency department

 High risk to staff—such as needle stick injuries in an HIV unit

 High risk to patients—such as certain postoperative complications

 High cost—such as radiotherapy for breast cancer.

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I D E N T I F Y T H E P R O B L E M ( TOPIC S E L E C T I O N )

 Choose audit topics based on high risk, high volume, or high cost problems.

 Potential benefit to the service.

 Focused on the process

 Areas of concern/ Areas where problems have been encountered in practice.

 What patients & the public have recommended that be looked at.

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CONT.…

 What patients & the public have recommended that be looked at.

 Where there is a clear potential for improving service delivery

 Common condition

 Index procedures

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CONT.…

 This is a very important step that must be given careful consideration.

 Subjects for clinical audit should be selected with a view to improving the

quality or safety of care or of service provision.

 Selection of audit topic mainly focuses…

 Structure

 Process and
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 Outcome
CONT.….

Structure

 The resources required to deliver care;

 environment in which care is delivered;

 facilities made available (e.g. availability of single rooms)

 equipment made available (e.g. tens ,ultrasound) and

 documentation of policies, procedures, protocols and guidelines. 23

CONT.….

Process

 the procedures and practices implemented by staff in the

 prescription, delivery and evaluation of care – these may be specific to

the clinical process or service administrative processes.

Outcome

 the effect of care received by service users as a result of healthcare

provision and the costs to the service of providing care
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 i.e. the result of clinical interventions.
PRIORITIZING POSSIBLE AUDIT TOPICS

Question that can help you Prioritizing audit topics.

 Is the topic concerned of high cost, volume or risk to staff or users?

 Is there evidence of wide variation in clinical practice?

 Is good evidence available to inform audit standards (for example,

systematic reviews or national clinical guidelines)?

 Is the problem measurable against relevant standards?

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CONT.….

 Is there evidence of a (serious) quality problem (for example, service user

complaints or high complication rates, adverse outcomes or poor symptom

control)?

 Is the topic of key professional or clinical interest?

 Are reliable sources of data readily available for data collection purposes?

 Can data be collected within a reasonable time period?

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CONT….

 Is auditing the problem likely to improve healthcare outcomes as well

as process improvements?

 Is the problem concerned amenable to change?

 Is the topic pertinent to national or local initiatives or priorities?

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EXAMPLES AUDIT TOPICS

 Have patient history and examination been properly

recorded following admission?

 Were appropriate investigations carried out?

 Was the treatment appropriate and timely? 28

AUDIT STANDARTS

 “A standard is an explicit statement describing the quality of care to be achieved,

which is definable and measurable”

 They are quantifiable statements detailing the specific aspects of patient care

and/or management that you intend to measure current practice against.

 They seek to ensure that the best possible care is provided, given available

resources, and they are based upon the best available evidence.

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 Standards should be ‗robust‘ and evidence based.
CONT…

 Using standards to define precisely the care that we are seeking to

provide means that we can:

 Accurately inform anyone who might want to use our service, what service it

is that we are offering.

 Identify the things we need to enable us to provide our service.

 Monitor and improve our performance.

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CONT…
 Your standards should be related to your audit topic and objectives, as
per the framework below.

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 Sources of clinical audit standards
 Publication of conclusive new evidence about clinically effective

healthcare.

 Local or regional treatment guidelines, protocols or

frameworks
These will ideally be based on best evidence (perhaps from

national guidelines), or maybe a local consensus of best practice

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 SOURCES OF CLINICAL AUDIT PROJECTS
 Literature Review
 If guidelines/ protocols do not exist, or existing ones are out of date, you
will need to undertake a literature search to identify best practice.
 User views or complaints

 Adverse incident
clinical/critical incident reporting
 Identified local priorities or concerns e.g. areas of risk or cost

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CONT….

 Standards should always be based on the strongest, most up-to-date,

evidence of what constitutes best practice.

 A generally accepted hierarchy for the strength of evidence to base your

standards on is:
STRONGEST (BEST)………….………….systematic review and meta-analysis of RCT

Weaker …………………………….. Personal experience and opinion

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WRITING AUDIT STANDARDS
 S………Clear, unambiguous and jargon-free. A standard should only mean one thing
to all people who read them.

 M………... is the information required to answer your standard available?

For example, ―information leaflet should be given to patients‖.

If data is collected retrospectively, how will you know if it‘s a failure of practice or a failure of documentation?

 A………Agreed - By all concerned with delivering that aspect of care.

 R………Relevant - To area of care being audited / concern that has been raised.

 T ……….. Theoretically sound –

 Based on evidence about best practice, reviewed and updated as new evidence becomes

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available.
AUDIT AIM AND OBJECTIVES
 Aim:
 clinical audit project consider what it is that you hope to achieve.

 the overall purpose of the project.

 It should be related to the rationale behind choosing your audit topic and

 should not merely be to ‗count the number of‘ or ‗examine‘ but should focus your audit

towards achieving improvements in practice where necessary.

 Statement should be phrased positively, to ensure that the audit brings about improvements in

practice.
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 Eg: To improve the care received by patients who develop LBP.
CONT…..
 Objectives:

 Objectives are the steps that need to be taken in order to assess whether or

not you have achieved your aim.

 Your objectives can be written as either specific tasks to be undertaken or as

the different aspects of quality that your project will address.

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CONT.….

How to Write: Clinical audit topic, aim and objectives

Topic: Low back pain

Aim:
 To improve the care received by patients with low back pain

Objectives:
 To ensure that patients with low back pain are treated appropriately.

 To ensure timely treatment of low back pain.

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STANDARD 8: EVALUATE THE EFFECTIVENESS AND EFFICIENCY OF PHYSIOTHERAPY INTERVENTION(S)

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CLINICAL AUDIT PROJECTS FOCUS ON ( ASPECTS OF QUALITY)

 Appropriateness: is the right treatment being provided to the right

patient?

 Timeliness: Was the treatment given at the right time?

 Timeliness is not exclusively linked to treatment.

 medical review of a deteriorating patient within 15 minutes, an

 arrival to bed allocation in A&E within 4 hours.

 Effectiveness: Was the treatment given in the right way? With desired effect?
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CONT.….

Standards Target Evidence Data source

100%

100%

100%

100%

100%

100%

100% 41
Standards Target Evidence Data Source
Club foot Clients should 100% NGL Physio-OPD Record
visit physiotherapy every
wk for 1 and ½ months

Manipulation of feet 100% NGL Physio-OPD Record

should be applied before
casting

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Supination and abduction 100% NGL Physio-OPD Record
should be applied on the 1st
visit
Supination with maximum 100% NGL Physio-OPD Record
abduction should be applied
on the 2nd visit

Sole abduction on the 3rd 100% NGL Physio-OPD Record

week
Abduction with minimal 100% NGL Physio-OPD Record
Dorsiflexion 4th week
 STANDARDS - IN SUMMARY

• Your standards are what you will measure to determine how

good practice actually is

• Aim to achieve the agreed standard 100% of the time unless

there is justification for less

• Keep focussed on your aim - you don‘t always need to audit

every standard or every aspect of the guidance related to
your topic 43
 STANDARDS - IN SUMMARY

• Your standards are what you will measure to determine how

good practice actually is

• Aim to achieve the agreed standard 100% of the time unless

there is justification for less

• Keep focussed on your aim - you don‘t always need to audit

every standard or every aspect of the guidance related to
your topic 44
 AUDIT METHODOLOGY
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AUDIT METHODOLOGY

 Identify your project team

Should include

 Audit supervisor (senior clinician/ manager)

 Audit lead (person undertaking the audit)

 Representative from those areas the results will

impact upon. 46
T EAM

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AUDIT METHODOLOGY – AUDIT POPULATION

 In order to decide on a population or a sample, it is first necessary to

define the population of concern (target population).

 Audit Population is the total population that meets your audit inclusion

criteria, within the audit time frame.

 A sample is a part of the population of interest.

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CONT..
In order to determine which is suitable for the purposes of the clinical audit,
the following should be considered:

 The audit‘s inclusion/exclusion criteria (in order to identify the relevant population)

 Timeframe/time interval, for example, the previous year, the next three months

 The size of the population.

 What resources are available for the audit?

 Whether sampling or population is most appropriate.

 What sample selection method should be employed? 49

INCLUSION/EXCLUSION CRITERIA

 In order to ensure that the audit sample is representative, it is necessary to define

what information should be collected and what information should not be collected.

Inclusion

 Identify a target population to whom a clinical guideline is intended to apply.

Exclusion

 Define areas outside the remit of the clinical guideline.

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SAMPLE SELECTION METHOD

 it is often not possible or necessary to gather data on all service

users, events or items for audit purposes; therefore sampling is often
required.
 It is important that any sample selected is representative, Convincing
and Current of the population under examination.
 There are numerous sampling methods which may be used; however
simple random sampling and convenience sampling tend to be the
most commonly used methods. 51
SAMPLE SIZE

 Clinical audit is not research, It is about evaluating compliance with standards

rather than creating new knowledge.

 therefore sample sizes for data collection are often a compromise between the

statistical validity of the results and pragmatic issues around data collection i.e.

time, access to data, costs.

 For many audit topics, a small amount of data may be sufficient for the purposes of

the audit; however, if a controversial issue is being audited a larger sample size
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may be required.
CONT.…
 The sample size should be sufficient to generate meaningful
results.

 The clinical audit should use pre-existing data sets where

possible.

 The sample should be small enough to allow for speedy data

collection but large enough to be representative.

 If the data collection takes too long, interest will be lost and data
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completeness issue will occur.
CONT…..

 It may not be practical to include every single patient

who meets your inclusion criteria.
 Representative

 Convincing

 Statically significant

 Current

 Considerations and Assumptions???

 Sampling techniques

 Other method

 http://www.raosoft.com/samplesize.html
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http://www.raosoft.com/samplesize.html

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