2011

By: Hanevi Djasri, Osman Sianipar, dan Adi Utarini Centre for Health Service Management, Clinical Epidemiology & Biostatistics, Hospital Management Graduate Program, Faculty of Medicine, UGM

Clinical Audit
Preparation for the Practical Sessions The Practical Sessions

Medical/Clinical committee (Sub-committee on Clinical Audit) Clinical Audit Ad-hoc Team (Team work) Assistant to Clinical Audit (Medical Record)

Select topics for clinical audit Re-audit Determine criteria and standards

Make changes

Collect data

Analyse data

Topic is selected in a meeting, using the

following information:
Routine data Patient satisfaction survey Observation of care delivery Inputs from stakeholders Enthusiasm of a certain care groups

Criteria for selecting a topic:

Can be improved High risk, cost, volume, problem Support or concensus from clinician Clear clinical guidelines

Topics for practical session (2011)

Typhoid, ARI, diarrhoea

Topics 1. ARI 2. Diarrhoea 3. Typhoid ...

Risk Volume Cost Problem

*already decided for the practical session, but this process will still be conducted during the practical session. Bring data!

Background Rationale for the selected topics (epidemiology, burden of illness, relevance) Clinical guidelines Problems in case management

Ensure or improve quality Not only to measure or examine Example:

diabetic ulcer Improve diagnosis of childhood TB

Improve case management of TB Improve case management of patients with

 Appropriateness: Is the treatment according to guidelines? Timeliness : Is the treatment given in a timely manner? Effectiveness : Is the outcome as expected?

Topics:
Breast cancer

Objective:
To improve quality of services for patients with breast cancer

Specific objective:
Ensure care is provided according to guidelines Ensure the diagnosis is made timely

Select topics for clinical audit Re-audit Determine criteria and standards

Make changes

Collect data

Analyse data

What is criteria?

It is an evidence that must be present to prove that an optimum level of care is provided
Diagnosis, treatment, interventions, patient reaction etc. related to topics for clinical audit

Trigger questions to identify audit criteria:

Case management if considered high quality if..
.... is present

.... is present .... must not be present Etc.

Common criteria used: Process criteria: diagnosis, treatment, intervention, surgery, etc. Less common criteria used: Input: often linked to budget limitation, therefore the audit cycle often cannot be completed Output/outcome: complex, related to many factors (co-morbidity etc), eg: status on discharge, death, complication, LOS etc.

IMPORTANT MESSAGE!

Concensus toward the criteria from senior clinicians is important for later improvement Conduct panel expert or review of criteria and clinical guidelines to be used for the audit

Specific: not ambiguous, value-free Measureable: can be measured Agreed: concensus reached Relevant Theoretically sound: based on evidencebased clinical guidelines
www.sign.co.uk www.cochrane.org

Name of the Criteria

Standard Exception Instruction for CA assistant/data collectors

Must be present (100%) or must not be present (0%) for each criteria Example:
Use of prophylactic actibiotics for elective surgery: standard 100% Decubitus: standard 0%

Standard is used to evaluate a medical record whether a criterion is met or not

Presence of clinical conditions to justify that a medical record is not meeting the standard Therefore the exception can be used to explain why a standard is not met

Refering to which parts in the medical record that contains valid and reliable information needed to evaluate the criteria Written in an objective way and all related terms need to be listed

Criteria 1. Ulcer in the vein must be

Standard 100%

Exception ABPI < 0,8 (ankle :

Instruction for

data collector
MR Form no 002/RM

treated with multilayer compression periodically

brachial pressure index)

Criteria 1. 2.

Standard

Exception

Instruction for

data collector

3. 4. 5.

Select topics for clinical audit Re-audit Determine criteria and standards

Make changes

Collect data

Analyse data

Retrospective: data already collected routinely or available in a certain register Concurrent/Prospective: data collected during the process of care

Code for evaluating the criteria

Code 1: According to standards Code 2: Not according to standards, but meeting the exception (justified) Code 3: Not according to standards and not meeting the exception (unjustified)

Implementation Data collection can be carried out by CA assistant (eg medical record staff, nurse, doctor) using the audit instrument Separate MRs that are not meeting the standards Result is recorded using the code system for audit

Variables are selected to understand certain patterns or variations Source of variables: hospital, doctor, nurse, patient characteristics
Doctor Class Ward Patient age Etc.

Take all population if the topic is extremely important (surgery) Take a sample if the no of patients is large (eg 1000 patients) Pragmatic approach: 20-50 patients For scientific purpose: sample size calculation

MR 01 Variable
Class Age Dr. Criteria Criteria 1 Criteria 2 Criteria 3 Criteria 4 Criteria 5

MR 02

MR 03

MR 04

Etc.

Select topics for clinical audit Re-audit Determine criteria and standards

Make changes

Collect data

Analyse data

1. 2. 3. 4. 5.

Re-check: esp for deficiency

Ensure that deficiency is correct

Identify the sample, if it is represent the population Measure level of compliance Measure pattern of deficiency Identify cause of deficiency using quality tools

SS examination 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 5 6 7 8 SS examination

ISTC Standard 2. All patients (adults, adolescents, and children) suspected of having pulmonary tuberculosis should have at least two sputum specimens obtained for microscopic examination.

Measurement
Faulty testing equipment Incorrect specifications Improper methods

Human

Machines
Out of adjustment
Tooling problems Old / worn

Poor supervision Lack of concentration

Inadequate training

Quality Problem
Defective from vendor Poor process design Ineffective quality management Deficiencies in product design

Not to specifications
Materialhandling problems

Environment

Materials

Process

Measurement

Human

Machines

Quality Problem

Environment

Materials

Process

Select topics for clinical audit Re-audit Determine criteria and standards

Make changes

Collect data

Analyse data

Eliminate waste Improve work-flow Optimize inventory Change the work environment Enhance the producer-customer relationship Manage time Manage variation Design systems to avoid mistakes Focus on the product or service

What should be changed Timeline

Plan of action
Whose responsibility

Follow-up

Objec tive

Measureable indicator

Responsible persons

Timeline

Cost

1 2 3 4 5.

Select topics for clinical audit Re-audit Determine criteria and standards

Make changes

Collect data

Analyse data

See list of groups and audit topics selected Search references useful as a background for the topic and exercise for selecting the topic Search for clinical guidelines for that topics
Find and share the guidelines with the group Read the guidelines individually Look for potential criteria individually

Do informal group meeting to discuss topic selection and criteria (Recommended) Read the recommended readings for the practical sessions (2 downloadable refs)

 Pre-test (15 min)

PS-1

Select topics Determine criteria & standard

Data collection

PS-2

Data analysis Make changes

Group presentation (in ppt)

hanevi_pmpk@yahoo.com o_sianipar@indosat.net.id adiutarini@gmail.com