2. Clinical Audit Jill Warn, Audit & IT Lead Dr John Guy, Clinical Lead

3. What ..... do you hope to achieve today? experience have you had of audit?

4. Today we will look at…... • Enhancing your understanding of Audit • Getting Audit right for Revalidation • The benefits of Audit in Primary Care • Implementing change Please ask questions / interrupt

5. A small change in practice is better than a major discussion of the possibilities

6. What is Audit?

7. Some Definitions • Audit is a process used by health professionals to assess, evaluate and improve the care of patients in a systematic way in order to enhance their health and quality of life. • OR • Deciding what you should be doing, looking at what you are doing, deciding whether you can do it better, implementing any changes and then making sure the changes have worked!

8. What do we audit? • Structure • Process • Outcome

9. Why do an audit? • Bring about change • Best use of resources • Improve standards • Stimulate education • Reduce errors (clinical and organisational)

10. GMC advice all doctors should take part in systematic audit and be familiar with the principles and practice of clinical audit

11. It is about Auditing your own practice!

12. What to consider when choosing a subject. Is your topic appropriate? Does it reflect the care undertaken by you the practitioner? Is it evidence based?

13. QOF areas will not be acceptable

14. Which topics to choose? For principals / static salaried doctors For sessional docs

15. Principals

16. Sessional

17. When Planning an Audit Measure care against a set standard or criteria Take action to improve care Monitor to sustain improvement

18. DDIAY

19. Consider • Being a Learning Organisation • Look at the skills within the team • Empowerment • How might this work?

20. Audit and Revalidation • At least one full clinical audit cycle during a revalidation period • Significant Events Audit • A GP’s portfolio is expected to contain an analysis of at least ten significant events over a 5 year period

21. Clinical Audit • At least one full audit cycle during a revalidation period • Initial audit results • Change implemented for the GPs’ patients • Re-audit – demonstrating improvement by the GP

22. The Audit Cycle

23. What is an Effective Audit? An educational activity Promotes understanding Resource effective Raises standards Promotes change Source of information

24. Writing up your Audit

25. The great coffee audit Found on Google: Gloucestershire PCCAG

26. Problem: The doctors feel that their coffee isn’t hot enough after slogging through morning surgery The great coffee audit

27. Problem: Criteria: The doctors feel that their coffee isn’t hot enough after slogging through morning surgery The coffee shall be hot and satisfying to the hard pressed docs The great coffee audit

28. Problem: Criteria: Standards: The doctors feel that their coffee isn’t hot enough after slogging through morning surgery The coffee shall be hot and satisfying to the hard pressed docs The coffee shall be served at a temperature of 85-90C on 80% of occasions and there will be 90% satisfaction level expressed by the docs The great coffee audit

29. Methods: The junior receptionist shall check the temperature of the coffee daily for two weeks and circulate a questionnaire to the partners asking them to score a coffee satisfaction level between 1 and 10. The practice manager shall visit Tesco’s and interview the manager about the availability, costs, quality and sell-by dates of the coffee brands available. The great coffee audit

30. Review: After a rather tense audit team meeting it was found that the coffee temperature fell below 37C on at least 33% of occasions and reached the standard on only 10% of occasions. The doctors scored the coffee at an average 3/10 and two expressed it undrinkable. The practice manager reported the results of her Tesco’s visit. The great coffee audit

31. Change: It was agreed to replace the aged coffee maker (after agreeing suitable redundancy terms for the senior receptionist) with a shiny new machine from Argos. As an additional ‘quality initiative’, cream cakes would be served after surgery. The coffee contract would be switched from the corner shop to Tesco PLC Trust. The great coffee audit

32. Re-audit: For a further two weeks it was agreed to measure the coffee temperature and re-circulate the questionnaire. It was gratifying to find 100% correlation with agreed standards with the exception of one partner who didn’t like coffee anyway. The great coffee audit

33. Re-audit: Future Audit: For a further two weeks it was agreed to measure the coffee temperature and re-circulate the questionnaire. It was gratifying to find 100% correlation with agreed standards with the exception of one partner who didn’t like coffee anyway. Cost implications of standard maintenance Cholesterol assays for partners The great coffee audit

34. KISS

35. Writing Criteria A criterion is a statement of what should be happening. Evidence based Measurable Clear, unambiguous

36. Setting the Standard • A standard is a number • Usually quoted as a percentage • One for each criterion • Where you think you should be • Use group discussion, journals and press, financial targets, last year’s results.

37. Collecting the Data • Consistent information • Dedicated time for audit • Team Approach • Sharing of information

38. Collecting Data • Be Organised. Collect essential information only. • Think of different possible sources of data.

39. Comparing the Results with the Standard • Straight comparison • If the standard is not met, what can be done to improve things?

40. We may not be quite as good as we think we are!

41. Onset of diabetes (a)

42. Onset of diabetes (b)

43. Onset of diabetes (c)

44. Onset of diabetes (d)

45. Making the Changes • Is this something you have direct control over? • Does patient opinion come into this? • Who needs educating? • Selling your changes to your colleagues • How long will the changes need?

46. What can we do to improve things? • ‘For every fatal shooting, there were roughly three non-fatal shootings. And, folks, this is unacceptable in America. It's just unacceptable. And we're going to do something about it.’ George W. Bush

47. Have the Changes Worked? • Collect a second set of data • Allow time for the changes to take effect • Have the changes made a difference? • Has the target now been reached? • Can further changes be put in place? • Is this going to be reviewed again in the future?

48. Presenting Results • Results must be clear and understandable • Present data in a visual way • Avoid complex statistical analysis • Quote the numbers before the % for less than 50 pieces of data • Be tactful with difficult results

49. Why do we use graphs? • The number of asthmatic patients attending for annual review varies according to age, with patients in the 16-24 age group least likely to attend.

50. Types of Graph: Pie Chart Percentage of patients discharged from hospital with either complete, incomplete or no discharge letter