By: Dr. Nitin Srinivasan, Consultant, ENT cum CMO
Audit is well recognized as a fundamental and compulsory part of clinical practice for quality assurance to attain international standards. To achieve this there must be a well defined and smooth protocol in place comprising of on-going treatment starting from patient attending the hospital for the first time to discharge and further follow up. A multidisciplinary input and monitoring of outcome for all variables which could potentially affect the patient care should also be included. Important areas of assessment within this framework also include patient outcomes (treatment results), appropriateness of care, institutional performance, resource management and patient/health care provider satisfaction. The objectives of Audit can be summarized as
- To serve as a basis for continuous and sustainable improvement in patient outcomes. A systematic review of untoward results will allow s clinicians to monitor the clinical outcomes and to bring about improvement in service.
- To support research and development of clinical policies.
- To provide insight and feedback to clinician’s performance.
- To serve as a tool of accountability on clinical outcomes and use of resources.
History of Audit
Florence Nightingale was the first to initiate systematic audit during Crimean War of 1853-1855 with her team of 38 nurses. The results were excellent with her input resulting in mortality rates dropping down to 2% from an earlier of 40%.Ernest Codman (1869 – 1940) was the pioneer of modern Surgical Audit. His work anticipated contemporary approaches to quality monitoring and assurance, establishing accountability, and allocating and managing resources efficiently.
Staging of Audit Process-
Stage 1: Identification of problem or issue
This stage involves the selection of a topic or issue to be audited, and is likely to involve measuring adherence to surgical practices that have been shown to produce best outcomes for patients. Selection of an audit topic is important in:
- Where national standards and guidelines exist; where there is conclusive evidence about effective surgical practice (i.e. evidence based medicine).
- Areas where problems have been encountered in practice.
- Patient and public recommendations to be considered.
- Looking for improvement in service delivery.
- Improvement is needed in areas of high volume, high risk or high cost.
Stage 2: Defining criteria & standards
- Audit Criteria- Decisions regarding the overall purpose of the audit, either as what should happen as a result of the audit, or what question you want the audit to answer, should be written as a series of statements or tasks that the audit will focus on. Collectively, these form the audit criteria. These criteria are explicit statements that define what is being measured and represent elements of care that can be measured objectively. A criterion is a measurable outcome of care, aspect of practice or capacity.
- Audit Standards- The standards define the aspect of care to be measured, and should always be based on the best available evidence. A standard is the threshold of the expected compliance for each criterion (these are usually expressed as a percentage).
Stage 3: Data compilation
To ensure that the data collected are precise, and that only essential information is collected, certain details of what is to be audited must be established from the outset. These include:
- The user group to be included, with any exceptions noted.
- The healthcare professionals involved in the users’ care.
- The period over which the criteria apply.
Stage 4: Comparison of performance
This is the analysis stage, whereby the results of the data collection are compared with criteria and standards. The end stage of analysis is concluding how well the standards were met and, if applicable, identifying reasons why the standards weren’t met in all cases. These reasons might be agreed to be acceptable, i.e. could be added to the exception criteria for the standard in future, or will suggest a focus for improvement measures.
Stage 5: Implementation of change
Once the results of the audit have been published and discussed, an agreement must be reached about the recommendations for change. Using an action plan to record these recommendations is good practice; this should include who has agreed to do what and by when. Each point needs to be well defined, with an individual named as responsible for it, and an agreed timescale for its completion.
Action plan development may involve refinement of the audit tool particularly if measures used are found to be inappropriate or incorrectly assessed. In other instances new process or outcome measures may be needed or involve linkages to other departments or individuals. Too often audit results in criticism of other organisations, departments or individuals without their knowledge or involvement.
Re-audit: Sustaining Improvements
After a set period, the audit should be repeated. The same strategies for identifying the sample, methods and data analysis should be used to ensure comparability with the original audit. The re-audit should demonstrate that the changes have been implemented and that improvements have been made.