Download MBBS General Surgery PPT 14 Surgical Audit Lecture Notes

Surgical Audit

Objectives

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? Describe the principle of process and outcome audit.
? Use audit to the benefit of your patients.
? Develop soundly based audit projects.
? Introduction to the basics of surgical research.
Introduction

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? We are continuously being scrutinized.
? Living in the era of evidence based medicine and accountability.
? Must show that our standard of practice is satisfactory.
? Research and audit are processes by which evidence is developed.

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? Audit generates information related to performance- both individual

and collective.

Case 1

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? You have discovered that over

? Key issues

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the last year there has been a 2

? Patient scoring systems.

fold increase in the mortality of

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patients operated in your unit.

? Case mix alterations process and

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outcome audit

? Structure.
Case 2

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? A hospital is 2500 bedded hospital
? Average hospital admission is 2500/day
? Cost of one i/v fluid is Rs 200
? Cost of one inappropriate i/v fluid is 200X2500=500,000/day
? Cost of one inappropriate i/v fluid in a month is

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200X2500X30=15,00,000/day!!!

Types

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vMedical audit :

An audit undertaken by doctors and consists of a review of clinical

events.

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vClinical audit :

A review of all potential medical events surrounding the treatment of

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a patient. This will include nursing, physiotherapy, social aspects, etc.
Surgical Audit ? What is it?

? To examine whether what you think is happening really , and whether

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current performance meets existing standards

? Quality improvement process
? Aspects of the structure, process and outcome of care are selected

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and systematically evaluated against explicit criteria.

? Changes are implemented at an individual, team, or service level
? Monitoring is used to confirm improvement in health care

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Surgical Audit ? Why do it?

? As a result of local clinical interests
? As a result of clinical incident reporting
? To comply with regional or national initiatives

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? To inform patients about surgical results
? To drive continuous quality improvement
? For health care regulation
Components

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? Structure :

The physical environment in which healthcare is provided.

? Process :

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The activity of providing care.

? Output :

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The outcome of that care for both the individual and for the

community as a whole.

3 Elements

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? Measurement-Measuring a specific element of clinical practice
? Comparison-Comparing results with the recognised standard
? Evaluation -Reflecting the outcome of audit and where indicated,

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changing practice accordingly.
The aims of audit are:

? To identify ways of improving and maintaining the quality of care for

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patients;

? To assist in the continuing education of surgeons;
? To help make the most of resources available for the provision of

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surgical services.

Advantages

? Identifies bad practice

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? Reduces unnecessary investigations, treatments and procedures
? Decreases hospital stay
? Allows continuous refinement of patient care
? Allows objective assessment of quality of care
? Improves efficiency

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? Improves education, training and feedback
Forms of Audit

? Total Practice or Workload Audit: covers all the surgical operations

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performed.

? Selected Audit from Surgical Practice: covers all patients who

undergo a selected procedure.

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? A Clinical Unit Audit: conducted by a clinical unit in which individual

surgeons may participate.

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? Group or Specialty Audit: an audit conducted by or under the

auspices of a group or Specialty Society.

? A Focused Audit: : e.g. what is the wound infection rate after large

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bowel surgery.

Audit parameters

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? Time utilisation
? Cost effectiveness
? Mortality/morbidity assessment
? Quality of diagnostic services
? Monitoring of performance

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? Assessment of newer technology
? Surgical outcome
? Patient satisfaction
The Surgical Audit Cycle

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? Surgical audit activities are based on a five-step cycle:

Make

changes and

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Determine

monitor

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scope

progress

Interpret

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Select

results with

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standards

peer review

Collect data

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? Step 1 Determine scope:

? A thoughtful decision about which area(s) of surgical practice to review.

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? Step 2 Select standards:

? A clear description of what is good practice in this area against which the results of the

audit wil be compared.

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? Step 3 Col ect data:

? The collection of relevant data.

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? Step 4 Present and interpret results with peer review:

? Comparison of results to standards , discussion with peers, decision about what changes

may lead to improvement e.g. learning new skil s, changes in practice, systems etc.

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? Step 5 Make changes and monitor progress:

? Alteration of practice in accord with the results and then checking that improvement has

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occurred.
Common topics for audit?

Any guessess

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Common topics for audit:

? 30 day mortality and significant morbidity;

? length of hospital stay;

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? unplanned readmission or re-operation rates;

? positive and negative outcomes;

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? operation-specific complications;

? process of care, such as pre-operative care;

? time on waiting list;

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? numbers waiting for outpatient appointment;

? use of investigations;

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? justification of management; and

? patient satisfaction.
How to select standards?

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? evidence-based research and guidelines;
? existing local guidelines;
? look to your specialty group to define standards.

Col ect Data

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? what data you wil collect, and how you wil collect it.

? The most important principle here is to ensure that you collect quality data.

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? Consider the following questions to help decide on the best quality assessment method:

? What information is necessary to answer the audit question(s)?

? From whom wil it be collected?

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? Should it be collected prospectively or retrospectively?

? How wil it be collected?

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? During or after the operation, on a PDA, on a computer, on a form, or by questionnaire,

and by whom?

? How wil follow up data be collected?

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? By record review, by patient follow-up questionnaire, through the GP, by phone cal , or

by review of routine data, and by whom?
? How will the cases for review in a prospective audit be identified or

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selected?

? All patients, random selection, consecutive operations, all patients on

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the same day each week, or checklist to determine eligibility?

? How will the cases in a retrospective audit be identified or selected?
? From a register, medical records data, review of referrals, or from

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previous appointment schedules?

Present and Interpret Results with Peer

Review

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? The results of your audit should be presented at a clinical meeting.
? Peer review is a learning exercise. It is not an opportunity to blame or

brag.

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? Involves an evaluation of one's work by one's peers.
? Peers are other surgeons with comparable training and experience.
Make Changes and Monitor Progress

? The next step is to implement any changes that are recommended.

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? Implementation involves not just making changes but ensuring that

everyone involved is educated/ informed as to what changes are

being made and why.

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? The impact/ effects of the changes made then needs follow up action.

What Makes for Effective Audit?

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? Promotion of a culture of audit
? Allocate time and resources
? Oversee and verify data collection
? Productive peer review
What Opportunities Arise from Surgical

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Audit?
? Educational opportunities
? Systemic improvement opportunities

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What Resources are Required for Surgical

Audit?
? Manual systems
? Computer systems

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? Logbooks


?

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Key points

? Clinical audit can be prospective and/or retrospective.
? Audit information can be obtained from national, hospital, and

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surgeon-specific data.

? Clinical department benefits from a clear audit plan.
? Clinical audit improves patient outcome.
Surgical research

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