Clinical Audit and Quality Correlation - Report Example

Running Head: CLINICAL AUDIT AND QUALITY CORRELATION Clinical Audit and Quality Correlation [The Writer’s Name] [The Name of the Institution] Clinical Audit and Quality Correlation Introduction In the present day healthcare setting, governance and supervision of clinical audit and care service quality have gained a significant importance. Besides physician, a nurse can also play a vital role in this regard. Previously, patient do not keep in mind the cost effects of healthcare services, but now, due to competition in every service industry, patients keep in mind all the factors and then decide which healthcare service to avail of. Most of the patients prefer the healthcare service where they had to spend less and benefit more. This is possible only through maintenance of quality and keeping in mind clinical audit setting. Definition of Clinical Audit Clinical audit is the process formally introduced in 1993 into the United Kingdom's National Health Service (NHS), and is defined as "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". The key component of clinical audit is that performance is reviewed (or audited) to ensure that what should be done is being done, and if not it provides a framework to enable improvements to be made. (http://en.wikipedia.org/wiki/Clinical_audit) Implications of Clinical Audit and Quality Care Provision of safe, high-quality care is a statutory obligation for healthcare organisations under the Health Act, (www.opsi.gov.uk/acts/acts1999/19990008.htm) and clinical governance is a proactive means of minimising and preventing mistakes by learning from previous events. Clinical audit is central to these quality improvement principles. It provides the means to review: • The quality of care given to patients with common conditions such as asthma, diabetes and CHD; • Health screening activities such as cervical cytology; • Significant events. Clinical audit provides a mechanism to address quality systematically and highlight areas requiring improvement. The report of the public inquiry into children's heart surgery at Bristol Royal Infirmary during 1984 to 1995 clearly underpins the importance of clinical audit. ( www.dh.gov.uk) The new GMS contract for primary care services places audit at the core of the funding, as financial rewards are tied to reaching thresholds of interventions and patient contacts.( www.nhsconfed.org/gmscontract). It is important to understand that, while clinical audit and research share some common features, they are distinct disciplines and therefore not the same. Research is concerned with the creation of new knowledge. Clinical audit ensures this knowledge is being applied appropriately. (www.ubht.nhs.uk/clinicalaudit) Management of Clinical Audit Within Strategic Health Authorities the clinical governance lead is responsible for assuring that there is a clinical audit programme within local trusts, and that this reflects national audit priorities. The clinical governance lead ultimately retains accountability for clinical audit, but may choose to delegate this role to another, the clinical audit lead. At a local level this individual will then be responsible for creating a clinical audit strategy, setting audit priorities, agreeing the audit programme, implementing the strategy and implementing the audit programme. The clinical governance lead however retains responsibility for ensuring that these tasks are completed and that clinical audit remains integrated with the other aspects of clinical governance. The clinical audit lead has a clear role in creating the strategy for embedding clinical audit within the organisation, but the individual chosen must have more than just a nominal strategic role. The clinical audit lead should have a high profile within the organisation, and must champion clinical audit both to colleagues and management alike. The clinical audit lead should be actively involved in linkages to the other aspects of clinical governance to allow for the dissemination of clinical audit information and the setting of local clinical audit priorities. (http://en.wikipedia.org/wiki/Clinical_audit) The Audit Cycle The component parts of clinical audit make up the audit cycle: • setting standards (what are we trying to achieve?) • measuring current practice (are we achieving it?) • comparing results with standards (why are we not achieving it?) • changing or updating practice (what can we do to make things better?) • re-auditing practice to measure improvement (have we made things better?) Making Improvements Making improvements, especially when there is significant negative divergence from the audit standards is the most challenging part of clinical audit and will require attention and action planning. The audit will indicate where improvements are needed but not how to achieve them. An action plan that addresses the following will be needed: • What needs to be done? • Who will do it? • What are resources required? • What is the time-frame? Disseminating the results of your audit, by means of a report or presentation, will raise awareness but will not lead to a change in practice. To achieve the latter among a multidisciplinary group, a successful tactic might be to set up, with all members of the affected group, a meeting at which you can disseminate the findings and the group can plan a strategy to improve outcomes. Group ownership of the new strategy may help to achieve successful implementation. It must be made apparent that any shortfall from the audit standard is rarely the fault of one individual, and that you are promoting a no-blame, learning culture, where individuals are free to speak without criticism. Effective strategies for implementation include: (Bero 1998; 465-8) • Educational outreach visits; • Manual or computerised reminders; • Multifaceted interventions; • Interactive educational meetings. It is important to record the detail of the audit in a written record, so it can be repeated in the future, and to set a review date. Sustaining Improvements After the audit, it is essential to monitor the action plan for implementing change. It is easy to lose the thrust as the daily pressures of work run counter to service developments. Effective leadership is needed to maintain momentum. When the action plan is completed, it will be necessary to re-evaluate any changes, implemented in order to sustain improvements and raise standards. Audit is a continuous cycle and an essential component of high-quality care. Various Contemporary Frameworks of clinical Healthcare Quality and Audit National Service Frameworks (NSFs) set national standards and define service models for specific diseases, services or care groups. In addition, they are responsible for ensuring that the models are implemented in a coordinated fashion across the different sections of the NHS and for establishing performance measures against which progress can be measured. Explicit performance indicators will be a key component of each of the frameworks. The Commission for Health Improvement (CHI) is an independent ‘watch-dog’ which will be used to monitor the performance of health care provider organisations. It is proposed that the Commission will combine the roles of inspection and regulation with consultation and guidance. CHI will ensure that clinical governance processes are in place, carry out a rolling programme of inspections of NHS organisations and intervene if local quality assurance mechanisms have not been effective. Public performance data will be used, alongside other types of evidence, to make judgements about performance. The extent to which the medical profession accepts the principles and practicalities of public disclosure is central to its success. Using publication as a stick to beat the profession is likely to have significant adverse consequences, but encouraging the profession to take the initiative will increase the opportunity to use public disclosure as part of a quality improvement strategy. This might mean that the pace and the content of public disclosure is less than might be desired by government. Pushing the agenda too far or too fast may, however, result in loss of morale amongst an important but vulnerable part of the NHS workforce. Audit Process Sixteen practices participated in an audit facilitated by the Oxfordshire MAAG (Multidisciplinary Clinical Audit Advisory Group; www.oxmaag.co.uk) looking at care provided for people with asthma. The practices identified 1,346 patients with asthma, and a questionnaire looking at the patients' experience of their asthma achieved a 79% completion rate. The audit also investigated the drugs and guidelines used in management of the patients' asthma. As a result of the audit, the practices reviewed the standard of care that patients with asthma received. (Bero 1998; 465-8) A feature of the national service framework for coronary heart disease is that practices should hold an electronic register of all patients with a diagnosis of CHD, to enable appropriate targeting of evidence-based interventions. Practices need to verify their registers, ensuring that all patients are correctly diagnosed. Having established a valid register, it is possible to audit evidence-based interventions, such as prescription of statins or aspirin for suitable patients. The Role of Hospital Mangers There is obvious merit in including doctors in the management of health care resources, but this involvement significantly affects the traditional concept of the doctor-patient relationship. Clinicians now have managerial obligations to hospital managers as well as to patients, so that the director's own clinical practices, and those of the colleagues for whom he is responsible, may be modified. Some will ask: how far can considerations of management interfere with relations between doctor and patient? This is surely a matter driven solely by clinical considerations which provide the basis of the relationship of trust between doctor and patient. Clinical audit and clinical practice guidelines have provided a means of encouraging doctors to re-appraise their own practices and priorities. Logical Rationale of Clinical Audit Clinical audit can be defined as the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient. The logic of clinical audit is to encourage doctors to adopt a critical and evaluative attitude to medical decision making. If, as some research suggests, patients are sometimes treated more from habit than positive choice about clinical benefit, then the process ought to enable the light of experience to shine on those practices which are ineffective or inappropriate compared to others. Audit is a voluntary system of assessment which may be applied to the whole range of medical services, from the treatment offered to individuals to the large scale assessment of medical technologies. For example, the extensive research conducted into treatment regimes has demonstrated the value of low doses of aspirin to those at risk of heart attack, that amniocentesis carries a risk of miscarriage and may cause breathing difficulties, and that an extension of day-case services provides good quality services to patients and excellent value for money. (Audit Commission, 1990, 17-19) In future, hospitals will increasingly be expected to show what proportion of patient’s survived surgery so that comparisons between hospitals, and between surgeons, can be made. The principle of clinical audit appears to be extremely valuable. How effective has it been in practice? Although the large-scale studies carry persuasive authority, the value of audit when applied to individual doctors is more difficult to assess. Some regard the whole process with suspicion and consider it a waste of time and effort. (Black, 2003, 84-89)The extent to which doctors and other medical staff have become involved varies from place to place, as do the ways in which audit has been introduced. (Kerrison, 1994, 118-20) Research Overview A survey of audit procedures adopted in hospitals revealed that there is no consistency as to the composition of the audit team, except that consultants are generally included and patients are almost always excluded. Nor is there a common practice concerning the medical evidence on which the audit is conducted. Case note review is the most common, mortality and morbidity review less so, and patient surveys are used only rarely. One of the difficulties in comparing the results of audits from different hospitals or practices is that there are no uniform standards on which comparisons can be based. Proper measurement of the success rates of a particular hospital or surgeon requires knowledge of the health of patients before admission. Patients admitted to hospital in very poor health are less likely to do well, no matter who is responsible for their care. And hospitals in areas of relative affluence will generally expect better results than those situated in areas of poverty. But accurate measurement of 'inputs' is extremely difficult. For this reason 'objective' standards are unlikely to be achieved in the process of clinical audit. Inevitably, in the absence of persuasive research findings, doctors will continue to disagree about the significance of particular clinical results, about the risks and benefits of a treatment, and the relative value to be attached to different findings by the audit. Some will say that, notwithstanding the evidence of the medical audit, their experience of a particular clinical practice is good and that they will not abandon it on the basis of the findings of a limited medical audit. Clinical Audit: Legal and Ethical Perspectives Health care professionals are another challenge in the quality process. Deeply involved in the day-to-day activities of the hospital, and overloaded with legal and ethical responsibilities, they frequently expect the organization and leaders to make decisions for them, including leaders who are not engaged in activities that have a direct effect on the practices of these professionals. These leaders are often not hospital employees, but they have offices, call schedules to obey, and continuous education programmes in which to participate. Under pressures such as these it is not unusual to note less than full participation by the medical and nursing staff on hospital-wide voluntary committees. Usually very focused on learning, the staff's approach to quality is nothing more than to prescribe the correct medication or to successfully perform a procedure. No doubt, there are certain legal and ethical implications in maintaining quality issues and conducting clinical supervision and/or audit and to run all the process quite smoothly. Nursing Role in Clinical Audit and Healthcare Quality It has been claimed that clinical nurse specialists ‘know more and more about less and less’ (Wade & Moyer 2002, 11-16). The challenge to this statement is that there is more and more to learn about an ever-expanding field which has outgrown the generalist role. In fact, the specialty of wound management is expanding so rapidly that there are specialists within specialties. The latter relate to the individual clinical practices such as burns and plastics, draining complex wounds, stomal therapy practice and leg ulcer clinics. The specialist role is defined as having several sub-roles of advanced practitioner, educator, consultant, researcher and change agent (Storr, 2001, 265-72). To these must be added the sub-role of clinical manager for there is an expectation that resources used in practice will be managed cost-effectively and distributed equitably. It would be impossible for generalist nurses to fulfil all these responsibilities in addition to their usual burden. Frequently there is confusion about the defining of specialist and consultant roles. The former is perceived, at least in the British literature, as being an expert practitioner whose role could lead to fragmentation of care as specialisation lays claims to either more nursing care or anatomical functions (Bale, 2005, 86-87). The consultant role, on the other hand, is perceived to be supportive of the primary practitioner. Both interpretations are too pedantic and one must question more the way the specialist or consultant—whatever the title—efficiently fulfils all the sub-roles, rather than the title they possess. It is not possible nor is it desirable for a specialist nurse to be responsible for all the wounds within an agency. There is great promise for advancement in wound healing technology. There will be a greater focus on tissue engineering and the use of cytokine impregnated products and biological dressings which will eventually make most of the dressings we presently use obsolete. More importantly, there will be scientific advances in medical diagnostics, treatment and genetic manipulation that will eradicate many of the metabolic, vascular and auto-immune disorders that currently predispose to many wounds and delays in healing. Audit Commission Role In 1990 The Audit Commission examined the development of day case surgery provision in the UK and audited twenty common procedures. As a result the Commission Identified the financial gains of day case surgery for the National Health Service, and many new day case surgery units were formed. "Stanford (1998, 49-55)" reported that with reduced costs and improved visual rehabilitation in the early post-operative stages of ophthalmic patients, day case surgery has become popular with both budget holders and patients alike. As the demand for day case cataract surgery has grown, due to the increasing aging population and earlier referral of cataract patients the NHS has looked closely at ways of improving the efficiency of the service. Evidence Based Quality Care and Nursing Gray, M. J.A. (2001, pp.11-17) tells us that nursing practices are changing from opinion based to evidence based. This important change means that nurses that adopt these habits can provide the best available care, increase the choice of treatments and after discussing with the patient, decide what the best course of action to be taken is. If evidence based practices are used together with effective management, this will result in the best possible patient care, but brings the least hazards at the lowest costs. Other reasons for using practices that are evidenced based are, according to Gray (2001, pp37-41) that there are increasing numbers of elderly people who need specialist care, this is due to longer life expectancy because of better diet, standards of living and improved health services and medicines. New research is constantly discovering better, more effective and efficient methods of providing care. Patients are more assertive about their rights to good quality care and are more likely to question the care that the nurse provides for them. Expectations of the multidisciplinary team have also changed. This is influenced by all of the other factors; in fact all of these reasons influence each other. The Department of Health (2005, web source) states Clinical governance is the system through which National Health Service organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. Elcoat (2000, p10) adds evidence-based practice and evidence-based nursing have very strong positions in the Clinical Governance agenda of quality improvement. Evidence-based practice can be defined as using contemporaneous best evidence ensuring actions are clinically appropriate cost effective and result in positive outcomes for patients (Trinder & Reynolds, 2000, 89-93). Therefore every healthcare team member has to critique evidence, assess its reliability and application before combining it with their own clinical expertise. Conclusion Clinical audit is a framework through which health care organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. The aim is to create an environment in which excellence can flourish. The process is led in the main by health professionals but includes all relevant stakeholders. A variety of mechanisms can be used to implement and monitor clinical governance and the explicit use of performance indicators is likely to be one important tool. Outcomes data have been available in some limited fields for many years in the form of the Confidential Inquiries, but the detail of these inquiries has not been made public and there has been no rigorous evaluation of their impact. Throughout the 1990s the NHS has been encouraged to become more accountable to the public and more open with information. Initially the information provided had minimal direct relevance to quality. It included the provision of largely structural data on services available, the description of some processes and outcomes in annual reports, which in theory are public documents but in practice are not widely disseminated and did not encourage comparisons among different providers. There have been only a small number of examples of public disclosure of performance information in the UK in recent years. Most of these have attracted only minimal public interest, in part because they addressed much specialised areas of expertise, such as in-vitro fertilisation or renal transplant success rates. There is minimal risk adjustment of the data and the emphasis of the reports is very much on raising awareness of variation, rather than making judgements about performance. Waiting list data are also published widely and used to pursue government policy to reduce waiting times. The UK government intends to use the publication of quantitative information on performance as a key tool to improve quality. Public disclosure will therefore become an integral part of a coordinated and systematic approach to quality improvement in the NHS, including the following initiatives. The National Institute for Clinical Excellence (NICE) is responsible for identifying new and existing health technologies that would benefit from appraisal, collecting evidence to assess the clinical and cost-effectiveness of the interventions, producing and disseminating guidelines and coordinating a national strategy to ensure equitable and effective health interventions across the NHS. Explicit indicators of performance will be an integral part of the guidelines produced. It is inevitable that performance data will be of great public interest and may be misinterpreted or over-interpreted by the public, the media, health professionals and managers. This will have adverse consequences for the credibility and potential impact of future data. The risks could be reduced by accompanying performance reports with expert analysis and interpretation of the data. This commentary could then be used by providers as a catalyst for internal discussion and further action or could be used by government officials when addressing NHS resource allocation. A policy on public disclosure is likely to be most effective if guided by empirical evidence of the associated merits and risks. The evidence is currently lacking, particularly in the UK, and would benefit from a focused and adequately funded research and development programme. Information is needed about the content and presentation format of information most useful to consumers, providers and regulators, the impact of disclosure on professional morale and public trust in the NHS, the unintended consequences and the most appropriate risk-adjustment mechanisms. The introduction of the National Performance Assessment Framework provides a unique opportunity to provide experimental or quasi-experimental evidence of the relative merits of public disclosure versus the use of the same data for internal quality improvement purposes. References A Short Cut to Better Services: Day Services in England and Wales (Audit Commission, 1990). 17-19 Bale, S. (2005) ‘The role of the clinical nurse specialist within the health-care team’, Journal of Wound Care, vol. 4, no. 2, pp. 86–7. Bero LA, Grilli R et al. Br Med J 1998; 317: 465-8. Black N. and E. Thompson, (2003) “Obstacles to Clinical audit: British Doctors Speak", 36 Social Science and Medicine p.84-89 Department of Health. (2005). Clinical Governance. Retrieved June 09, 2007, from http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ClinicalGovernance/fs/en. DoH. Learning from Bristol: The Doll's response to the Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995. 2002. Available at www.dh.gov.uk Gray, M. J.A. (2001). Evidence-based health care.2nd ed.London: Harcourt publishers. pp11-17, 37-41 Health Act 1999. London: The Stationery Office 1999. Available at www.opsi.gov.uk/acts/acts1999/19990008.htm Irvine D, Irvine S. Making Sense of Audit. Oxford: Radcliffe Medical Press 2001. 23-29 Kerrison, S. T. Packwood, M. Buxton, "Monitoring Medical Audit", in R. Robinson and J. Le Grand (eds.), Evaluating the NHS Reforms ( King's Fund Institute, 1994). 118-20 Lefort W. Improving Patient Care through Clinical Audit. 2004. Available at www.cambcity-pct.nhs.uk Mosby Elcoat, D. (2000). Clinical Governance in action: key issues in clinical effectiveness. Professional Nurse.18 (10) NHS Confederation; The New GMS Contract: Investing in General Practice. 2003. Available at www.nhsconfed.org/gmscontract Norris. A. C. (1998). Care pathways and the new NHS. Journal of integrated care. 2 pp 78-83 Stanford. P. (1998). Pre operative assessment for ophthalmic patients. Nursing standard 12 (44) pp 49-55 Storr, G. (2001) ‘The clinical nurse specialist: From the outside looking in’, 2Journal of Advanced Nursing, vol. 13, no. 2, pp. 265–72. Trinder, L., & Reynolds, S. (2000). Evidence-based Practice. A Critical Appraisal. Oxford: Blackwell Science. 89-93 United Bristol Healthcare Trust Clinical Audit Central Office. What is Clinical Audit? 2005. Available at www.ubht.nhs.uk/clinicalaudit Wade, B. and Moyer, A. (2002) ‘An evaluation of clinical nurse specialists: Implications for education and the organisation of care’, Senior Nurse, vol. 9, no. 9, pp. 11–16. Read More