? 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 individualand 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 thecommunity 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 feedbackForms 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 theauspices 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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scopeprogress
Interpret
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Select
results with
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standardspeer 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 thateveryone 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 SurgicalAudit?
? 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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