Basic Introduction to Quality Improvement through Clinical Audit

1. Basic Introduction to Quality Improvement through Clinical Audit Presenter: Debbie Davies Primary Care Quality Nurse Co-ordinator Introduction to Clinical Audit

2. Primary Care Quality The purpose of the Primary Care Quality Team ? http://howis.wales.nhs.uk/sitesplus/888/page/34030 Primary Care Quality Public Health Wales

3. Overall aim of the session is to support the theory of developing an audit from the beginning Areas to be covered • What is Clinical Audit • Quality Improvement Why? • 5 stages to audit • Defining and setting audit criteria and standards • Quality Improvement methodology (PDSA) Primary Care Quality Public Health Wales

4. What is Clinical Audit? Clinical audit is a systematic process of looking at your practice and asking: • What should we be doing? • Are we doing it? • If not, how can we improve? Primary Care Quality Public Health Wales

5. clinical audit? ‘Clinical audit is 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’ (NICE 2002) Primary Care Quality Public Health Wales

6. Why do Clinical Audit? • Identifies and promotes good practice • Leads to improvements in patient care • Provides information about the effectiveness of a service • Highlights problems and helps with solutions • Improves team working and communication Primary Care Quality Public Health Wales

7. Every clinical audit: • Looks at your own practice • Follows a systematic process • Has standards you can measure your practice against • Involves everyone in the team Primary Care Quality Public Health Wales

8. Quality ImprovementWhy? Primary Care Quality Public Health Wales

9. When audits were carried out, there was no robust mechanism to ensure that changes were implemented. • When re-audits were required, they were often not undertaken ‘ Primary Care Quality Public Health Wales

10. Drivers for Quality Improvement in Primary Care • National Audits • Quality and Outcomes Framework • Replacement of the QP domain with a new GP Cluster Network Development Domain * • Improving Clinical Governance (CGPSAT)* • 1000 Lives Plus • LHB priorities (Local / Directed Enhanced Services) • Revalidation and appraisal Primary Care Quality Public Health Wales

11. Clinical Governance Practice Self Assessment Tool (CGPSAT) • Aim: • Supports practices to undertake a systematic, comprehensive review of practice systems • A programme of Internal review, reflection and needs assessment • Practices are asked to consider how mature their systems are by means of a matrix • Benefits: • 30 points of the new 3 year GP cluster network domain • Provide evidence for revalidation • Contribute to the practice PDP • Inform GP cluster action plan as part of the cluster network domain Primary Care Quality Public Health Wales

12. Six domains of Quality What are considered the 6 domains of quality healthcare? Primary Care Quality Public Health Wales

13. 6 Domains of Quality • Person- centred-Patient partnership and respect patients’ needs and preferences • Effective-Providing services based on evidence • Safety-Avoiding harm to patients • Timely-Reducing waits and sometimes harmful delays • Efficient-Avoiding waste • Equitable-Providing care that does not vary in quality Primary Care Quality Public Health Wales

14. How can we improve safety? • Standardise processes • Improve teamwork • Communicate How can we ensure patient centred care? • Involve patient • Support self management • Involve patients • Listen and learn Primary Care Quality Public Health Wales

15. What are the Five stages of audit? Primary Care Quality Public Health Wales

16. Stage 1 – Preparation-Choose a topic:- A good audit topic: • Address a known quality issue • concentrates on an important area of practice • Has the potential to achieve and improve the quality of patient care • Address an area of clinical certainty and consensus Primary Care Quality Public Health Wales

17. Stage 2 – select criteria/standard You start with a broad audit topic • set specific audit criteria-which should ideally be developed from evidence Primary Care Quality Public Health Wales

18. Audit Standards • The audit target shows what percentage of patients / cases / records you expect to meet the standard. This is normally set to 100% because we want all patients to receive best care. You can set the target at a lower level that is: • Taken from a baseline audit • The most you can aim at in the current circumstances. Note: Exceptions are clinical reasons why the standard may not be met for a patient or record. Primary Care Quality Public Health Wales

19. Audit criteria- (a written statement) ‘All Patients with heart failure are prescribed an ACE inhibitor’ • Audit standard - usually a target (percentage). 90% ofPatients with heart failure are prescribed an ACE inhibitor Primary Care Quality Public Health Wales

20. Be realistic in what you audit • Specific: covers one topic only • Measurable: can be measured in a practical way • Achievable: is something that is reasonable for staff to achieve • Relevant is an issue that is important to patients and staff • Timescale can be measured within a reasonable period of time Primary Care Quality Public Health Wales

21. Stage 3 - measuring level of performance • Collect the data: • computerised records, manual collection, or both. • May be retrospective or prospective. • Analyse the data collected: • Compare actual performance with the set Criteria/standards. • Discuss how well the standards were met. • If the standards were not met, note the reasons for this (if known). Primary Care Quality Public Health Wales

22. Stage 4 - making improvements • Present the results and discuss them with the relevant teams in your organisation. • The results should be used to develop an action plan, specifying what needs to be done, how it will be done, who is going to do it and by when. Primary Care Quality Public Health Wales

23. Stage 5 – maintaining improvements • involves repeating the audit; hence the terms 'audit cycle' or 'audit spiral' Primary Care Quality Public Health Wales

24. Sampling • The sample chosen should be small enough to allow for rapid data collection but large enough to be representative • Be pragmatic • Use statistical software programme!! (run charts, pareto charts) Primary Care Quality Public Health Wales

25. Other Improvement methodologies Primary Care Quality Public Health Wales

26. Model for improvement (including PDSA) • This is an approach to continuous improvement where changes are tested in small cycles that involves using the PDSA model for improvement CYCLE Plan, Do, Study, Act (PDSA) Primary Care Quality Public Health Wales

27. What changes can we make that will result in improvement? Use the PDSA cycle (Plan, do, study, Act) to assist the practice with making changes Primary Care Quality Public Health Wales

28. Applying the PDSA Cycle Evidence (Early identification of AF will reduce ill health and death associated with stroke ) • Plan- To improve systematic opportunistic screening of asymptomatic AF • Do- Patients ≥ 65 year have had their pulse rate and rhythm checked and recorded • Study- Using audit + generate a list of the number of Patients ≥ 65 year who attended a practice consultation and not had their pulse rate/rhythm checked and recorded. Primary Care Quality Public Health Wales

29. Act- The practice could consider applying a system to check and record the pulse of all patients ≥ 65 year using the following arrangements: • Check and record pulse rate/rhythm during routine appointments • Check and record pulse rate/rhythm in diabetic and flu clinics • Monitor high risk groups patients (diabetes/hypertension) for yearly pulse check • Add a pulse check to chronic disease templates • Display IT alert message for pulse check for patients over the age of 65yrs. • Engage the district nursing service to check and record pulse rate and rhythm of patient caseload in patients >65yrs Primary Care Quality Public Health Wales

30. Making changes • Use robust methodology in your project - if people are confident in the validity and reliability of your results they will be more likely to make the changesindicated by the results (UBHT 2005) • Involve all the key players at the project design stage (people who will have the final say about any proposed practice changes) – this should mean they are more likely to ensure that change happens • Identify your drivers and resistors for change • Seek opinions and feelings beforehand Primary Care Quality Public Health Wales

31. What makes Quality and audit successful in primary care? • Important topic • A topic front line staff can make a difference • Involve stakeholder in choice and design • Teamwork • Simple concept • Simple criteria • Attainable standards • Data collected electronically • Team have protected time to consider results and suggest change Primary Care Quality Public Health Wales

33. Public Health Wales Primary Care Quality

34. Primary Care Quality Public Health Wales

35. Suggested audit topics Non clinical TOPIC: Waiting time in the surgery CRITERION: • All Patients should be seen within 15 minutes of their appointment time Clinical Topic Moderate to severe Heart failure care audit Criterion • Patients with moderate to severe heart failure are prescribed aldosterone anatagonist TopicUnscheduled hospital admissions audit Criterion • Follow up and review all diabetic patients who had an unscheduled hospital admission within the last 4 weeks. Primary Care Quality Public Health Wales

36. Contact Details debbie.davies9@wales.nhs.uk 01495-332313 Primary Care Quality Primary Care Quality Public Health Wales

37. References • Gibbons, A.J. Dhariwal, D.K. (2003) Audit for Doctors: How to do it? BMJ Career Focus; 327:1; doi: 10 • Principles for Best Practice in Clinical Audit (2002) National Institute for Health and Clinical Excellence • National Association of Primary Care Education (2007) Structured reflective template: The Leicester 2007 Conference statement on essential Evidence for Appraisal • UNITED BRISTOL HEALTH-CARE NHS TRUST (2005); CLINICAL AUDIT "HOW TO" GUIDES • Clinical Governance Support Team (2005); A Practical Handbook for Clinical Audit • GP-TRAINING.NET - A GP EDUCATION AND TRAINING RESOURCE (2006) • Clinical Governance Support & Development Unit Wales (2002) – An Introduction to Clinical Audit Primary Care Quality Public Health Wales

38. Helpful resources Ensuring Data Quality in Clinical Audits http://www.hqip.org.uk/assets/LQIT-uploads/Guide-to-ensuring-data-quality-in-clinical-audits-8-Sep-10.pdf How To: Set an Audit Sample & Plan Your Data Collection http://www.uhbristol.nhs.uk/files/nhs-ubht/5%20How%20To%20Sample%20Data%20Collection%20and%20Form%20v3.pdf Revalidation For further information about revalidation in Wales, please follow the link below:http://revalidation.nhswalesappraisal.org.uk/The new CPD e-learning webpages can be found via the link below:https://nhswalesappraisal.org.uk/cpd/The GP Appraisal & CPD website can be found here;https://nhswalesappraisal.org.uk/The Medical Appraisal website can be found here;https://medical.nhswalesappraisal.org.uk/ Primary Care Quality Public Health Wales