Examples of clinical audit projects

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1 Examples of clinical audit projects INTRODUCTION This section was compiled from examples of clinical audit projects provided by members of the FOCUS network and other CAMHS professionals. The examples are not intended as ideal templates but as a source for learning about clinical audit in practice. The purpose of this chapter is to promote ideas about topic areas and designs for clinical audit projects in CAMHS. It was felt that it was important to provide examples of real clinical audits, rather than ideal recipes, since this enables readers to gain insight into actual benefits experienced, as well as the practical problems encountered, in conducting a clinical audit project. Ways of preventing/overcoming these difficulties in future similar projects are also suggested by contributors. The examples were chosen to reflect a range of topic areas, contexts and professional disciplines. They have been grouped together under subject areas, such as responsiveness of services and therapy process. For some of the examples, particular stages of the clinical audit cycle were not completed. Where this is the case, the stages omitted are shown clearly by the shaded clinical audit cycle diagram presented on the front page of the example. Where possible, data collection tools (record forms, questionnaires, etc.) have also been included. Once again, these are intended to generate ideas for a variety of collection methods. For use in a different setting, these tools would undoubtedly need to be tailored to the specific requirements of the service providers undertaking the clinical audit. Any other relevant tools (check-lists, protocols, template letters, etc.) have been included under Additional resources. References are cited for most examples, but it would be advisable for anyone considering replicating the clinical audit project to conduct their own literature search in order to ensure that more recent articles, guidelines, and research evidence are traced and used to inform the work. We would like to thank all of those CAMHS professionals who have been prepared to share their experiences of clinical audit projects with such honesty and enthusiasm in order that others embarking on a similar process may benefit. Without the help of these individuals this chapter could not have been written. Examples of clinical audits 29

2 ECTION A ACCESS SECTION CCESS TO SERVICES EXAMPLE A1: CLINICAL AUDIT OF COMMUNITY SERVICES PROVIDED TO CHILDREN WITH AUTISM 10 Re-audit 1 Select topic 9 Set/review standards 2 Review literature 8 Set/review 8 Change standards practice Number of times around clinical audit cycle = 1 = not completed in this example 3 Set standards 7 Feed back findings 4 Design audit 6 Analyse data 5 Collect data CONTRIBUTORS Dr V. Chandra Senior Registrar (Audit Project Lead) Ms S. Smith Clinical Effectiveness and Audit Facilitator Lifespan Health Care Children Services, Lifespan Health Care Cambridge NHS Trust, Cambridge Stage 1 Select topic BACKGROUND RATIONALE FOR CLINICAL AUDIT Autistic spectrum disorder consists of a triad of impaired social interaction, communication and imagination associated with a rigid, repetitive pattern of behaviour. Onset is usually during the first three years of life and problems can also begin in later childhood. It affects 3 4 per children, 75% of whom require special education. Early diagnosis and intervention is essential to ensure that families and carers have access to appropriate services and professional support (Rapin, 1997). Children with autism need support from professionals from a range of disciplines. It is, therefore, crucial for paediatricians to coordinate their services to support these children and their families and to identify gaps in the services. This clinical audit was conducted to examine services provided to pre-school and early school age children (<7 years) with autism, in Cambridge. The main objective of the clinical audit project was to ensure that children with autism and their families are being seen and assessed by the appropriate professionals from health, education and social services. 30

3 Stage 2 Review literature The most useful and relevant articles found were: Gillberg (1991), National Autistic Society (1995), Rapin (1997), Webb et al (1997), Wing (1996), Woodhouse et al (1996). Stage 3 Set standards SOURCE OF STANDARDS These standards were based on local guidelines. STANDARDS SET Prior to diagnosis % of children with suspected autism will be referred to the Child Development Centre by the general practitioner and be seen by a paediatrician before the age of three years standard not applicable to those cases referred which have no record of age in the case notes % of children with suspected autism will have their head measured by the paediatrician at their first assessment appointment % of children with suspected autism will have a full developmental assessment by the clinical psychologist % of children with suspected autism will be assessed by the speech and language therapist. After diagnosis % of children with autism will be referred to the Communication Disorder Clinic. 6. For 100% of children with autism, the health visitor or social worker will visit their parents at home to share information (e.g. benefits, respite, schooling etc.) % of children with autism will be assessed by the pre-school learning support teacher soon after diagnosis. Stages 4 and 5 SAMPLE Design audit/collect data The sample comprised children referred to the Child Development Centre and Communication Disorder Clinic between January 1993 and mid-june 1997 (n=30). DATA COLLECTION Examples of clinical audits The case notes of these children (from the Child Development Centre, Communication Disorder Clinic, Addenbrookes Hospital, the community child health service and any psychologists consulted) were retrospectively audited by a senior registrar using a data collection form (see Data collection tool ). Stage 6 Analyse data The completed forms were analysed by the audit department. Totals and percentages were calculated in order to establish overall achievement of each of the standards set. KEY FINDINGS Standards 3 and 4 were achieved fully. The remaining standards were not met achievement was poorest for standards 1 and 2. 31

4 Stage 7 Feed back findings The findings of the project were presented by the clinician responsible for the clinical audit project at a multi-disciplinary meeting of staff providing services to children with autism. At this meeting, suggestions for an action plan were proposed and discussed. Stage 8 Change practice The following changes were suggested and used to develop an action plan. Development of a system which would enable easier identification of children with autism soon after diagnosis. Development of a system which would facilitate communication between the Child Development Centre and the Communication Disorder Clinic, particularly regarding the position on the waiting list of those children to be seen. Identification of criteria for routine case conferences. Examination of the feasibility of health visitors using the CHAT check-list (which examines a number of aspects of the child s development e.g. social skills, imaginative play, handeye coordination etc.) on children with language delay before referring them to the speech and language therapist and to the Hearing Assessment Clinic. Stages 9 and 10 Review standards/re-audit A date for re-audit was not decided. COMMENTS ON THE CLINICAL AUDIT PROCESS Resources Additional points Hints from contributors Total staff time required to complete the audit was approximately hours. Additional assistance was required from an audit facilitator. Apart from staff time, there were no additional costs involved in this clinical audit project. Notes were often difficult to obtain because they were being used for clinics. Poor communication among professionals made the audit difficult. Data were often not documented in the notes Looking at five sets of notes for each child at different locations was time-consuming. If you are attempting a similar clinical audit project, talk to a range of other professionals to obtain the information you require, as some data may not be documented in the notes. 32

5 A1 DATA COLLECTION TOOL A1 -L AUTISM AUDIT CHECK HECK-L -LIST 1. Name 2. M/F 3. No. 4. DoB 5. Referred by: General practitioner Health visitor Speech therapist Psychologist Psychiatrist Registrar/CMO/SCMO Teacher Other 6. Age at referral: years months 7. Date of referral: 8. Date first seen at CDC: 9. Date of referral to CROFT/Communication Disorder Clinic: 10. Date first seen by CROFT/Communication Disorder Clinic: 11. What information was sent from CDC to CROFT/Communication Disorder Clinic? Examples of clinical audits 12. Letter from CROFT to CDC: Y / N 13. Date of letter: Comments contd... 33

6 A1 DATA COLLECTION TOOL A1 -L AUTISM AUDIT CHECK HECK-L -LIST (CONTD CONTD) Examination 14. Head circumference: 15. Centile: 16. Neurocutaneous marker: Y / N 17. Does the child have any associated medical conditions? Tuberous sclerosis Y / N Neurofibromatosis Y / N Epilepsy Y / N Hydrocephalus Y / N Down s syndrome Y / N Williams syndrome Y / N Rett s syndrome Y / N Fragile X Y / N Other Investigations 18. Were any of the following investigations performed? Chromosomes Y / N Results filed in notes? Y / N Fragile X Y / N Results filed in notes? Y / N Metabolic screen blood Y / N Results filed in notes? Y / N Metabolic screen urine Y / N Results filed in notes? Y / N CT brain Y / N Results filed in notes? Y / N MRI brain Y / N Results filed in notes? Y / N EEG Y / N Results filed in notes? Y / N T4 Y / N Results filed in notes? Y / N TSH Y / N Results filed in notes? Y / N Wood s lamp examination Y / N Results filed in notes? Y / N Comments contd... 34

7 A1 DATA COLLECTION TOOL A1 -L AUTISM AUDIT CHECK HECK-L -LIST (CONTD CONTD) Assessment/therapy 19. Was the child seen by a psychologist? Y / N 20. Was a full developmental assessment done by the clinical psychologist? Y / N 21. Does the child attend therapy sessions with the psychologist? Y / N 22. Was the child assessed by a speech and language therapist? Y / N 23. Does the child attend speech and language therapy? Y / N 24. Was the child referred to the Communication Disorder Clinic? Y / N 25. Do the child and family have input from the health visitor? Y / N Comments Social worker er input 26. Was the family seen by a social worker? Y / N 27. Was the child seen by the children s disability team? Y / N 28. Does the family get Disability Living Allowance? Y / N 29. Does the family get any respite? Y / N 30. Have the parents been introduced to the Autistic Society? Y / N 31. Have the parents been given booklets/information on autism? Y / N Comments Education 32. Has the child been assessed by the pre-school learning support teacher? Y / N 33. Has the child been seen by an educational psychologist? Y / N 34. Has the child been statemented? Y / N 35. Does the child attend mainstream school? Y / N 36. Does the child attend special class in mainstream school? Y / N 37. Does the child get support from learning support assistants? Y / N 38. Does the child attend special school? Y / N 39. Does the child attend assessment centre? Y / N 40. Was a case conference held? Y / N Examples of clinical audits Comments 35

8 EXAMPLE A2: CLINICAL AUDIT OF ACCIDENT AND EMERGENCY PRESENTATION AND PAEDIATRIC ADMISSION OF CHILDREN WHO MISUSE DRUGS AND ALCOHOL 10 Re-audit 1 Select topic 9 Set/review standards 2 Review literature 8 Set/review 8 Change standards practice Number of times around clinical audit cycle = 1 = not completed in this example 3 Set standards 7 Feed back findings 4 Design audit 6 Analyse data 5 Collect data CONTRIBUTORS Dr F. Subotsky Consultant Psychiatrist Dr A. Santhouse Registrar Belgrave Department of Child and Adolescent Psychiatry, King s College Hospital, Maudsley NHS Trust, London Stage 1 Select topic BACKGROUND RATIONALE FOR CLINICAL AUDIT In the UK, drug and alcohol use and misuse has increased among young teenagers (Miller & Plant, 1996; NHS Health Advisory Service, 1996; Coleman, 1997). In the USA substance misuse (alcohol or drugs) has been reported as commonly associated in teenagers with presentations in accident and emergency (A&E) departments or trauma admissions (Felter et al, 1987; Hicks et al, 1990; Loiselle et al, 1993; Bates et al, 1995; Mannenbach et al, 1997; Spain et al, 1997). However, in younger age groups this has been under-evaluated. Recommendations have been made to use screening more, and subsequently make referrals to appropriate services (Maio et al, 1994; Buchfuhrer & Radecki, 1996). A recent British inner-city casualty audit (Robson, 1997) revealed that about 200 people aged under 17 years were brought in under the influence of alcohol in one year. Anecdotally, the inner-city casualty department of the hospital in which the child psychiatry department is located reported an increase of children attending in intoxicated states. Very few, however, had ever been referred to child psychiatry. 36

9 The aim of the audit was to attempt: to establish the incidence of casualty presentations and admissions related to drug and alcohol misuse; and to examine whether young people misusing drugs and alcohol were being referred appropriately by staff for further psychosocial intervention. Stage 2 Review literature Potentially relevant material was identified and reviewed from Medline searches, the contributors own files and discussions with addiction consultants. Twelve of the most useful references are: Felter et al (1987), Hicks et al (1990), Loiselle et al (1993), Maio et al (1994), Bates et al (1995), Buchfuhrer & Radecki (1996), Miller & Plant (1996), NHS Health Advisory Service (1996), Coleman (1997), Mannenbach (1997), Robson (1997), Spain et al (1997). Stage 3 Set standards SOURCES OF STANDARDS Local discussions with A&E consultants and paediatricians, social services and child mental health staff were used to inform areas for data collection, as described below. STANDARDS SET For this audit project no specific standards were set. Information was collected on: 1. whether reference to drugs or alcohol was present or absent in the casualty notes and whether this was positive or negative 2. whether in the admission case notes of children admitted with alcohol intoxication there had been referral to social work, child psychiatry or another appropriate agency. Stages 4 and 5 SAMPLE Design audit/collect data Sample one Casualty notes of one week s attendance at A&E, of year olds (n= 73). Sample two DATA COLLECTION Case notes of one year s admissions of under-16s with alcohol intoxication identifiable through the hospital PAS system (n=10). Data were collected retrospectively from casualty notes and case notes. Examples of clinical audits Stage 6 Analyse data The number of young people presenting at A&E over a one-week period where there was reference to drugs or alcohol in the notes was recorded. The number of young people admitted for alcohol intoxication in one year was recorded. The number of young people admitted for alcohol intoxication who were referred on to social services and/or child psychiatry was recorded. KEY FINDINGS In the one-week sample of A&E presentations (n=73) there was no reference to drugs or alcohol in any of the cases. 37

10 Of the cases (n=10) identified from the PAS, the notes were unavailable for one, there were definite referrals in four, possible referrals in two and no referrals in three cases. Stage 7 Feed back findings The findings were fed back to and discussed further with the alcohol audit group, the adult addiction services, the main child mental health services, the paediatric department and the hospital social work service. Stage 8 Change practice For A&E staff, a protocol for dealing with possibly intoxicated children was agreed (see opposite). An information leaflet outlining local and national sources of help for young people with drug and alcohol problems was developed. It was recommended to paediatricians that all children admitted with intoxication should be referred to the child psychiatric service. Stages 9 and 10 Review standards/re-audit It was decided that a re-audit should be undertaken annually. COMMENTS ON THE CLINICAL AUDIT PROCESS Resources Additional points The following time was required for data collection: sample one, 4 6 hours; sample two, 3 hours. Additional assistance was required from the casualty nurse and the hospital information and audit departments. Additional costs included the opportunity costs of prior planning and later discussion time. The lack of identification suggested poor recording in other departments. The team tried to help remedy this by discussing ethical issues, such as confidentiality and consent, and by clarifying pathways for action. HINTS FROM CONTRIBUTORS Motivation of other departments is crucial. Hospital information systems vary enormously, as do casualty systems, but should be utilised to identify the key population before looking at case notes. 38

11 A2 ADDITIONAL RESOURCE A2 DRAFT PRO ROTOCOL OCOL FOR ACCIDENT AND EMERGENCY DRUG AND ALCOHOL MISUSE IN UNDER NDER-16 AND CHILD PSY SYCHIA CHIATR TRY -16S AND Presentation of possibly intoxicated under-16s Get history of injury. Always ask about and record contribution of drink or drugs. Note any signs of intoxication. Investigate as appropriate for medical management needs. Attempt to get hold of parent: tell parent of situation and record response. When should child psychiatry be contacted? Child psychiatry should be contacted if there is a possibility of self-harm or serious mental illness. Phone 3219 during weekdays 9 a.m. to 5 p.m. Otherwise, air-call the duty child psychiatry senior registrar/specialist registrar through the Maudsley switchboard. When should a child be admitted? Serious intoxication demands paediatric admission and subsequent psychiatric referral. Encouraging request for help Give parent appropriate leaflet regarding seeking help for problem (to be supplied). If the parent is not contactable Consider admission and/or referral to social services. Examples of clinical audits Afterwards Ensure full record. The GP should always be notified by letter, including a reference to the intoxication. 39

12 ECTION B RESPONSIVENESS SECTION ESPONSIVENESS OF SERVICES EXAMPLE B1: CLINICAL AUDIT OF RESPONSE TIMES IN A CHILD AND ADOLESCENT MENTAL HEALTH CLINIC 10 Re-audit 1 Select topic 9 Set/review standards 2 Review literature 8 Set/review 8 Change standards practice Number of times around clinical audit cycle = 4 = not completed in this example 3 Set standards 7 Feed back findings 4 Design audit 6 Analyse data 5 Collect data CONTRIBUTOR Dr J. Roberts Consultant Psychiatrist Hornsey Rise Child and Family Consultation Service, Camden and Islington Community Health Services NHS Trust, London Stage 1 Select topic BACKGROUND RATIONALE FOR CLINICAL AUDIT This was the fourth time that Hornsey Rise Child and Family Consultation Service audited the length of time professionals take to make contact with both those who are referred and with the referrers. The audit takes place annually over the first three months of the year. Responsiveness to referrers was viewed as extremely important by team members. In meetings held with referrers, the need to be kept updated about cases was emphasised and the importance of responsiveness was reinforced. Stage 2 Review literature No literature was reviewed at this stage, although a useful article by Mutale (1995) was found after the study was undertaken. 40

13 Stage 3 Set standards SOURCE OF STANDARDS The standards were developed by the team based on their clinical experience and views about what would be manageable, realistic and acceptable. STANDARDS SET No specific targets were set for the following standards, but the assumption was that they should be met 100% of the time. 1. Responses to referrers will be made either by phone or by letter within two weeks of the referral being received. 2. Responses to those referred will be made by letter within two weeks of the referral being received this standard did not apply to cases when families have moved out of the area or have been transferred, or cases when the referrer requests a consultation, rather than the family/child being seen directly. 3. The client(s) or professional will be seen by the department within six weeks of the referral being received this standard did not apply to cases when the families have moved out of the area or have been transferred. 4. A summary/letter will be sent to the referrer GP (whether or not the GP was the referrer) within eight weeks of the referral being received this standard did not apply to cases when permission to contact the GP was denied by the client. Stages 4 and 5 Design audit/collect data SAMPLE All referrals to the service were audited over the three months of January, February and March 1997 (n=93). DATA COLLECTION All professionals in the clinic, including trainees, completed forms (see Data collection tool B1 ) in which were entered the names of those referred and the referrer (both name and agency). Agreement was established with all staff involved in the audit that responses made by telephone would be documented in the case notes. All of the information was therefore collected from the case notes using a data collection form. It should be noted that psychiatrists do not formally need to seek permission to contact the GPs of those who are referred. All other professionals cannot contact the GP unless they have such permission. Stage 6 Analyse data Examples of clinical audits The percentage of cases meeting each standard, not meeting each standard and not applicable was calculated. For those not meeting a standard, percentages were calculated in weekly bands (e.g. for standard 1: less than three weeks, less than four weeks, greater than four weeks). This enabled staff to know how late the response time was, on average. KEY FINDINGS (COMPARING RESULTS OF CLINICAL AUDIT 1997 WITH CLINICAL AUDIT 1996) The responsiveness of the service to referrers had marginally increased since the previous audit, with 84% being contacted within two weeks of the referral. The responsiveness to those referred had decreased almost entirely accounted for by the higher non-applicable figure. The percentage of those referred being seen within the target time had decreased slightly, a reflection of increased pressure on staff when fewer professionals were working at the clinic. 41

14 There was a significant decrease in the percentage of cases for which a summary/letter was sent to the referrer/gp within eight weeks the 1997 figure was skewed by a larger percentage of cases classified as non-applicable. Non-health professionals (e.g. social workers) and new members of staff (e.g. registrars) were found to fail the set standards the most often. Stage 7 Feed back findings A report of the findings was written and circulated to all of the relevant people including members of the team, managers, lead clinicians, the local education authority, and the medical director. Stage 8 Change practice For standard 4, the non-applicable figure was found to be 33%. It was felt that this was possibly artificially high, in that the family may not have attended, and a letter back to the referrer saying that they had not attended was perhaps not counted as a summary. Further discussion of this matter within the team was suggested. The data collection forms were modified to make analysis easier (e.g. lines were inserted). Ways of improving the number of new staff achieving the standards were incorporated into practice, for example they were explicitly informed about the need to send summaries to GPs. Stage 9 Review standards Standards have been modified so that they can be operationalised more easily and consistently (e.g. how to count days (chronological or working) defining non-applicable cases). Stage 10 Re-audit It was decided that this clinical audit should be conducted annually. However, the Trust changed its data collection system, which meant that the clinical audit could not be repeated using the same design the following year. COMMENTS ON THE CLINICAL AUDIT PROCESS Resources Additional points The only costs entailed were staff time total staff time was approximately 23 hours. The data collection forms had to be completed by the clinicians each month and the data were analysed by the clinical audit lead. The audits of responsiveness have become more specific and focused over time. Collecting the forms from people can take some time. The clinical audit project has led to improved practice. The clinical audit project has proved to be politically very useful, for example in providing evidence that the service is accessible (report given to local health authority). HINTS FROM CONTRIBUTOR The contributor would endorse the usefulness and importance of auditing responsiveness to referrers. 42

15 B1 DATA COLLECTION TOOL B1 RESPONSE TIME CHART Name of worker: Month: Target = 2 weeks Target = 2 weeks Target = 6 weeks Target = 8 weeks Name of referred Referrer Time for contact Time for contact Time before Summary to (name or agency) to be made with to be made with appointment referrer or GP referred referrer offered to family individual or professional 43 Examples of clinical audits

16 EXAMPLE B2: CLINICAL AUDIT OF COMMUNICATION BETWEEN CHILD MENTAL HEALTH PROFESSIONALS AND GENERAL PRACTITIONERS 10 Re-audit 1 Select topic 9 Set/review standards 2 Review literature 8 Set/review 8 Change standards practice Number of times around clinical audit cycle = 4 3 Set standards 7 Feed back findings 4 Design audit 6 Analyse data 5 Collect data CONTRIBUTOR Mrs R. Harris Consultant Clinical Psychologist The Tavistock Clinic, Tavistock and Portman NHS Trust, London Stage 1 Select topic BACKGROUND RATIONALE FOR CLINICAL AUDIT One of the most often cited requirements of GPs is the need for improvements in communication following a referral to more specialist services. Effective communication is critical to good client management (Kentish, 1987), yet most studies conclude that such correspondence is woefully inadequate (McGlade, 1988; Penney, 1988; Westerman et al, 1990). In a recent survey of GPs views of the institution, feedback suggested that staff were often perceived as being poor communicators, in terms of the speed, frequency and content of individuals responses to their referrals. Whether or not this assertion was justified, it required attention. Not only would more effective communication improve patient care, but also GPs will increasingly be the purchasers and gate-keepers of services. This audit project was designed to explore and attempt to address this perceived problem. 44

17 Stage 2 Review literature A literature search and review was conducted when selecting the topic, and for setting the standards. The following references were selected as being useful and relevant: Hoffman (1981), Pullen & Yellowless (1985), Kentish (1987), McGlade (1988), Penney (1988), Westerman et al (1990), Parry (1992), Cornwall (1993), Firth-Cozens (1993), Jones & Jordan (1993), Campbell et al (1994), Cookson & Fuller (1995), Duff (1995). Stage 3 Set standards SOURCE OF STANDARDS Standards were developed from the following sources: review of the literature, discussions with local GPs, and informal and formal discussions with staff within the organisation. A meeting was also held with the head of contracting, to ensure congruence of standards with contracts. STANDARDS SET Standards were set for the frequency of written communications to GPs and the format/content of these (see Data collection tool B2 for the list of standards). Of the standards agreed, those outlined in the first section labelled frequency were considered to be particularly important. These were written into the majority of people s contracts as quality standards. A target of 100% was therefore set for these standards. The subsequent sections were seen as a model of good practice; although ultimately a target of 100% may be hoped for, 80% was considered to be an appropriate target in conducting this clinical audit project. Stages 4 and 5 Design audit/collect data The design of this clinical audit project is presented diagramatically in Figure 3.1. CLINICAL AUDIT A Sample 1 All new cases from 1 April 1997 to 15 May 1997 were included in the sample (n= 44). Sample 2 (re-audit) All new cases from 16 May 1997 to 30 June 1997 (n=43). Following the initial process of consultation with GPs and staff, it was agreed that the clinical audit would begin in the new financial year. At this point the communication criteria agreed were in place in the department. Given that one of the standards for good practice was that GPs/referrers would be responded to within two weeks of completing the assessment (maximum of six sessions) or three months from referral (whichever was sooner), all new cases from 1 April 1997 to 15 May 1997 were audited. A number of changes to practice were made as a result of the first clinical audit, and following these changes the standards were re-audited (Sample 2). Examples of clinical audits CLINICAL AUDIT B Sample 20 randomly selected case notes (every other new referral received) of new referrals from 1 April Since the standards set were of communications to GPs/referrers up to and including closure of cases, a longitudinal audit was also undertaken and audited against the standards at threemonthly intervals, that is six weeks after the standards were in place in the department (July and October 1997). DATA COLLECTION The data were collected from the case notes, using the audit tool, which consisted of a checklist with met, not met and not-applicable (see Data collection tool B2 ). 45

18 SELECTING THE TOPIC Review literature on audit Assess current needs and concerns of the organisation Discuss conclusions with staff SETTING THE STAND ANDARDS ARDS Literature search Meeting with GPs Discuss within formal and informal structures within the organisation (e.g.. staff meetings) Meeting with head of contracting to ensure congruence of standards with contracts CLINICAL AUDIT A CLINICAL AUDIT B All new cases from 1 April to 15 May Feed findings back to staff group agree to changes in practice Second clinical audit all new cases from 16 May to end June 20 randomly chosen new referrals received in April 1997 Re-auditing of the same case notes in July 1997 Re-auditing of the same case notes in October The clinical audit process for example B2 FIG IG

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