Clinical audit in emergency medicine

Transcription

1 Hong Kong Journal of Emergency Medicine Clinical audit in emergency medicine CH Chung Clinical audit is the review of clinical performance against agreed standards, and the refining of clinical practice as a result a cyclical process of quality improvement in clinical care. The different steps of the clinical audit cycle are discussed. Publications on clinical audit in connection with Emergency Medicine are scarce in the medical literature. Clinical audit should be made compulsory for all healthcare professionals providing clinical care, and emergency physicians are no exceptions. (Hong Kong j.emerg.med. 2003;10: ) Keywords: Health care quality, medical audit, quality control Introduction As clinicians, striving to provide optimal, effective and high-quality care should be the objective of our professional life. On the other hand, as our society is becoming more and more affluent and knowledgeable, expectations on the quality of clinical services provided are rising in parallel. Trust and respect of healthcare professionals is being slowly eroded by the negative sensationalizing publicity of isolated cases of adverse outcomes, patient complaints, and legal claims. Traditional professional discretion or clinical freedom has been increasingly questioned and challenged. Public pressure or concern groups have been set up to safeguard patients' rights and safety. Measures have to be undertaken to retain the confidence and respect from the public. As a quality improvement tool, clinical audit is one way to show that real efforts are being made by dedicated professionals to deliver highquality patient care. Other measures to gain confidence and build trust such as risk management Correspondence to: Chung Chin Hung, FRCS(Glasg), FHKAM(Surgery), FHKAM(Emergency Medicine) North District Hospital, Accident and Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong chunch@ha.org.hk systems and independent panels for adverse events belong to the domain of the administrators. In searching the medical literature through MEDLINE, EMBASE, CINADHL, HMIC and the Cochrane Database, only a handful of reports on clinical audit in Emergency Medicine have been retrieved. Definition of clinical audit In 1989, the White Paper 'Working for patients' published by the Department of Health of the United Kingdom (UK) defined medical audit as: 'the systematic critical analysis of the quality of medical care including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient.' 1 As it was later considered that audit should be extended to all healthcare professionals, medical audit evolved into clinical audit. A revised definition was announced by the National Health Service Executive in 1996: 'Clinical audit is the systematic critical analysis of the quality of healthcare, including the procedures used for diagnosis, treatment and care, the use of resources and the resulting outcome and quality of life for patients. It embraces the work of all health care professionals'. 2 The UK Department of Health's new

2 182 Hong Kong j. emerg. med. Vol. 10(3) Jul 2003 definition of clinical audit states that 'Clinical audit is a clinically led initiative which seeks to improve the quality and outcome of patient care through structured peer review whereby clinicians examine their practices and results against agreed explicit standards and modify their practice where indicated'. 3 In 2002, the National Institute for Clinical Excellence (NICE) in its publication 'Principles for best practice in clinical audit' defined clinical audit as '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. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery'. 4 Another definition is: 'Clinical audits monitor the use of particular interventions, or the care received by patients, against agreed standards. Any departures from 'best practices' can then be examined in order to understand and act upon the causes'. 4,5 In simpler terms, clinical audit is 'a structured process which ensures that we are carrying out best practice by reviewing what we are doing, compared with what we should be doing'. 3 Clinical audit is not research. Research is about obtaining new knowledge and finding out the most effective treatments. Clinical audit is about quality and finding out if best practice is being practised. 5 In simple analogy, 'research is to find out which is the right song to sing, and audit is to see if the right song has been sung well'. Obligations of healthcare professionals on clinical audit Clinical audit is increasingly seen as an essential component of clinical professional practice. In 2001, the General Medical Council of UK advised all doctors that they: 'must take part in regular and systematic medical and clinical audit, recording data honestly. Where necessary, you must respond to the results of audit to improve your practice, for example by undertaking further training'. 6 The UK Central Council for Nursing, Midwifery and Health Visiting stated that clinical audit is: 'the business of every registered practitioner'. 7 The #145 recommendation of the Bristol Royal Infirmary Inquiry 2001 stated that: 'Clinical audit should be compulsory for all healthcare professionals providing clinical care and the requirement to participate in it should be included as part of the contract of employment'. 8 Clinical audit provides an overview of the quality of clinical services provided to patients against agreed standards. Any departure from 'best practice' can then be examined in order to understand the causes and act upon for improvement in clinical effectiveness. 4,5 Clinical audit can improve patient care, enhance staff professionalism, increase resource utilization efficiency, aid continuing education, and demonstrate accountability to those outside the profession. 5 Clinical audit is the core element of modern day 'Clinical Effectiveness Units' and 'Clinical Governance' systems established by overseas institutions. The Hong Kong College of Emergency Medicine recognizes clinical audit activities as part of continuing medical education for its Fellows. Types of audit The different ways of carrying out clinical audit may be classified as follows: 9-1. Standards-based audit (criteria-based audit) This is the recommended process. Current practice is compared against defined criteria, standards or best practices, through the 'audit cycle'. (Figure 1) 2. Peer review audit With the benefit of hindsight, the quality of services provided is assessed by a team, reviewing case notes and seeking ways to improve clinical care. This is especially applicable in 'interesting' or 'unusual' cases.

3 Chung/Clinical audit in emergency medicine Significant event audit Adverse occurrences, critical incidents, unexpected outcomes, and problematic cases causing concern are reviewed systematically and solutions implemented. 4. Surveys Targets for opinions or suggestions may include patients or special focus groups. Information gathered is then analyzed and change implemented as appropriate. Stages of clinical audit the 'audit cycle' Clinical audit is the review of clinical performance, the refining of clinical practice as a result and the measurement of performance against agreed standards a cyclical process of improving the quality of clinical care. (Figure 1) 5,10 In other words, the stages of its process can be summarized as: What should be happening? What is happening? What changes are needed? As the process continues and repeats itself, each cycle aspires to a higher level of quality a spiral rather than a loop. Figure 1. The audit cycle. Stage 1: Prepare and plan for the project The principal aim of audit is to improve healthcare, and therefore the effectiveness of the proposed audit in promoting improvements should be the first consideration. There should be clear, realistic aims and timescale in place. Preparation and planning are essential elements for success in project management. Even before topic selection, an audit team unidisciplinary or multidisciplinary should first be formed to assess feasibility and identify requirements such as manpower, skills, participation, training, communication, resources, methodology, data issues, and implementability. Audit may be seen as a threat of criticism. It may be regarded as an unpleasant, time-consuming distraction from busy daily practice. 5 Successful clinical audit requires the organization to promote a culture in which audit is supported and actively encouraged by all relevant staff, especially the senior management. It would be best conducted within a structured programme, with effective leadership, commitment, transparency and teamwork, from the start. Organisations must recognize that audit requires appropriate funding and significant investment of resources, including skill training and time. They must also recognize that improvements in care resulting from clinical audit can increase costs. Stage 2: Select a topic To start the process rolling, the first step is to identify problems or issues relevant to the practice that you want to improve. 9 There is no point in auditing something that is already being done well. 5 Topics may be gathered through critical incident reports, adverse events, complaints, feedbacks, direct observation or direct conversation. Selection will be based on a number of factors: - 1. Impact e.g. high risk (to staff or patients), high volume, high cost, new policies or new protocols 2. Seriousness e.g. high complication rates, patient complaints 3. Good evidence available for standards e.g. systematic reviews, national clinical guidelines 4. Problem amenable to change 5. Improvement sustainable

4 184 Hong Kong j. emerg. med. Vol. 10(3) Jul 2003 It is only in the aspect of topics for clinical audit that Emergency Medicine may differ from other disciplines. Examples of quality indicators being practised by the Australasian College for Emergency Medicine 11 and the Central Coordinating Committee for A&E Service of the Hospital Authority in Hong Kong are shown in Table 1 and Figure 2. Table 1. Examples of quality indicators in Emergency Medicine Clinical performance indicator Recommended by Australasian College Implemented in Hong Kong Hospital for Emergency Medicine Authority Access Waiting time Triage waiting time Access block Consultation waiting time Safety Lost time to work related injury Occupational health and safety Body fluid exposures Patient falls Patient falls Acceptability Patient satisfaction survey ratings Patient satisfaction surveys Written complaint rate Patient complaints and appreciations Self-discharge (DAMA) Disappeared before consultation Death after arrival Trauma death Bereavement Effectiveness Admission rate by triage category Admission rate Time to thrombolysis Time to thrombolysis Unplanned representation within 48 hours Unscheduled return within 48 hours Short stay hospital discharge (24 hours) Efficiency Waiting time by Australasian Triage Scale Waiting time by triage categories Process time Medical staff productivity Continuity Provision of written health information Discharge information pamphlets for sentinel conditions: Discharge summary - Asthma - Wound care Provision of discharge summary Figure 2. Clinical audit on 24-hour discharge of medical emergency admissions in 15 Hospital Authority hospitals (April 2001, data on file).

5 Chung/Clinical audit in emergency medicine 185 Stage 3: Define criteria and set standards Explicit measurable criteria of the desired level of performance should be defined for later comparison with the observed level of performance. In general, 'an audit standard is a minimum level of acceptable performance for that criterion'. 5 It can be percentage of events that should comply with the criterion. References to best practice, clinical performance indicators, systematic reviews or national clinical guidelines should be made, if available. It may be necessary to have a balance relating to clinical effectiveness and cost-effectiveness. Clinical audits usually look at processes (e.g. record keeping, adequacy of documentation, use of investigations) but can also look at outcomes (e.g. surgical complications, deaths, patient satisfaction). Provided that research evidence confirms that clinical care processes have an influence on outcome, measurement of the process of care is generally more sensitive and provides a direct measure of the quality of care. Measurement of outcome can be used to identify problems in care, provided outcomes are clear, influenced by process and likely to occur within a short period e.g. surgical operation outcomes. Adjustment for case mix is generally required for comparing the outcomes of different providers. The National Centre for Clinical Audit (NCCA) Review identified nine disadvantages to the assessment of outcome alone: Outcomes are not a direct measure of performance 2. Adjustment for case mix is required 3. Some outcomes may be delayed 4. Evidence about the impact of some care processes on outcome is limited 5. Not all patients who experience poor process necessarily have a poor outcome 6. Many different factors contribute to eventual outcome 7. Outcomes cannot be improved unless clinicians develop an understanding of how process influences outcome 8. Process measures are less expensive to use 9. Outcome data can be subject to misrepresentation and misunderstanding by the public. If available, reference to the levels achieved in audits undertaken by other professionals is useful. In some audits, benchmarking techniques could help participants in audit to avoid setting unnecessarily low or unrealistically high target levels of performance. Stage 4: Collect data Information can be collected retrospectively or concurrently, although the former is more common. Data can be obtained from computers, clinical records, adverse incident reports, direct observation, questionnaire surveys, or data abstract forms. Multiple sources of data will improve their completeness and accuracy. Consider ethics, consent and confidentiality (including staff involved) before starting to collect the audit sample. Traditionally, relatively large amounts of data are collected over a long period, making the process of change slow. Rapid-cycle sampling has been recently introduced as an alternative. Small samples are collected repeatedly to monitor serious fluctuations or changes in care, improving efficiency and reliability. It can also be used for testing the effect of changes on a small scale before full implementation. 13,14 Information management and technology (IM&T) has revolutionized data management. Electronic data is likely to be much quicker and more accurate. Computerized patient records provide audit data automatically and continuously, allowing immediate and instantaneous access to current levels of care for monitoring performance and providing regular feedback. As an example, concurrent data collection and analysis have been used to improve the timeliness of thrombolytic therapy in patients presenting to the emergency department with chest pain. 15 The Accident & Emergency Information System (AEIS) and the Executive Information System (EIS) of the Hospital Authority are two good examples of electronic management tools, providing statistical data from specialties and institutions to those authorized. Examples relating to Emergency Medicine are attendance characteristics, unscheduled re-attendance rate, admission rate, short-stay

6 186 Hong Kong j. emerg. med. Vol. 10(3) Jul 2003 admission rate, waiting time, process time, medical staff productivity, drug expenditure and observation ward utilization. The Clinical Management System (CMS) is more operationally orientated, and provides instant data on patient discharge records, outpatient notes, medication, laboratory results and radiology results. Stage 5: Analyze results The collected data is then compared with the set standard, to see if improvement measures are necessary. Statistical analysis is usually not necessary. As mentioned previously, rapid-cycle data collection and analysis have been claimed to be very successful in monitoring and improving performance. 13,14 Stage 6: Identify solutions for improvement and implement changes A report should be generated, together with recommendations as appropriate. A multitude of options is usually available for improvement. The results and recommendations should be presented in an audit meeting. The traditional Morbidity and Mortality meetings are prototypes. Modern examples include trauma audit and triage audit meetings. The discussion should be frank and truthful, educational and constructive, and on both clinical and administrative issues. It has been reported that passive feedback of statistical information without any discussion or other activity is either ineffective or of limited effect. Active feedback with discussion of practice or standard setting can be useful, but the effects are said to be small to moderate. In order to reduce resistance to change, use the 'noname' or 'no-blame' approach to errors or substandard performance. 'Finger-pointing' or punitive action discourages reporting and many valuable learning opportunities are thereby lost. The aim should be preventing future errors rather than punishing past ones. 16 Most of the time, the fault lies in the system rather than on individuals. Frank discussion will facilitate generating options, identifying optimal solutions, and securing staff commitment to change. Strong leadership is important. As mentioned previously, commitment and participation of all staff, especially support from the senior management, are vital for success. There is a diversity of options for changing behaviour. Traditional continuing medical education (CME) has little effect in implementing change. 17 Formal CME employs a variety of methods, including conventions, conferences, courses, meetings, symposia, lectures and clinical rounds. Didactic sessions are not effective, although interactive sessions that provide the opportunity to practise skills can change professional performance, and occasionally outcomes. 18,19 The trend is now shifting to continuous professional development (CPD), which expands learning activities in nearly all formal and informal aspects. Printed educational materials such as guidelines alone have little effect, and the addition of feedback or workshops does not produce substantial changes, but opinion leaders are more likely to produce worthwhile improvements. 20 Methods to prompt physicians to follow the guidelines during the consultation are relatively powerful. 21 In improving the use of diagnostic tests, education is of little effect, audit with feedback relatively weak, but administrative interventions can be effective. 22 In short, system enhancement is more powerful and effective than individual improvement. Initial solutions should preferably be aimed at systems of care, which can also help to reduce human 'slips' and 'mistakes'. Examples include the electronic medical record and the computerized medication order entry (MOE) in our Clinical Management System, presumably developed after some form of audit, providing instantaneous support in clinical decisions and reducing adverse patient outcome. Stage 7: Re-audit to monitor the impact of the changes ('close' the audit loop) In order to sustain improvement, the cycle should be repeated from time to time as a spiral, until the target level is achieved satisfactorily. Emergency physicians should take a more active role in auditing both old and new clinical activities.

7 Chung/Clinical audit in emergency medicine 187 Conclusion Audit may be seen as a threat of criticism. It may be regarded as an unpleasant, time-consuming distraction from our busy daily practice. However, with a clear aim, transparency and supportive culture, it will be effective in improving staff performance and patient care. As a quality improvement tool, audit is one way to demonstrate our accountability to those outside the profession that real efforts are being made by dedicated healthcare professionals to deliver high-quality patient care. References 1. Department of Health. Working for patients. London: The Stationery Office, NHS Executive. Promoting clinical effectiveness. A framework for action in and through the NHS. London: NHS Executive, Leicestershire Primary Care Audit Group NHS: < Accessed on 18 April National Institute for Clinical Excellence. Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press, Department of General Practice, Royal United Hospital, Bath. Study guide - clinical audit. < eurobell.co.uk/whyaudit.htm> Accessed on 18 April General Medical Council. Good Medical Practice. London: General Medical Council, UK Central Council for Nursing, Midwifery and Health Visiting. Professional self-registration and clinical governance. London: United Kingdom Central Council for Nursing, Midwifery and Health Visiting, Department of Health. Learning from Bristol: the Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary Command Paper CM London: The Stationery Office, Surgical-tutor.org.uk What is clinical audit? <www. surgical-tutor.org.uk> Accessed on 18 April Gray MJA. Evidence-based healthcare: How to make health policy and management decisions. New York: Churchill Livingstone, 1997: Australasian College for Emergency Medicine. Policy document: quality management in emergency medicine. Victoria, Australia, Dixon N. Good practice in clinical audit. A summary of selected literature to support criteria for clinical audit. London: National Centre for Clinical Audit, Plsek PE. Quality improvement methods in clinical medicine. Pediatrics 1999;103(1 Suppl E): Alemi F, Neuhauser D, Ardito S, et al. Continuous selfimprovement: systems thinking in a personal context. Jt Comm J Qual Improv 2000;26(2): Kendall JM, McCabe SE. The use of audit to set up a thrombolysis programme in the accident and emergency department. J Accid Emerg Med 1996;13(1): Peth HA Jr. Medication errors in the emergency department: a systems approach to minimizing risk. Emerg Med Clin North Am 2003;21(1): Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995;274(9): Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282(9): Beaudry JS. The effectiveness of continuing medical education: a quantitative synthesis. Journal of Continuing Education in the Health Professions 1989; 9: Freemantle N, Harvey EL, Wolf F, Grimshaw JM, Grilli R, Bero LA. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2000;(2):CD NHS Centre for Reviews and Dissemination. Implementing clinical guidelines: can guidelines be used to improve clinical practice? Effective Health Care 1994; 1(8). 22. Solomon DH, Hashimoto H, Daltroy L, Liang MH. Techniques to improve physicians' use of diagnostic tests: a new conceptual framework. JAMA 1998;280 (23):