Improving Standards of
Patient Care: Clinical
Audits
Sudigdo Sastroasmoro
(Vice Chairman, Medical Committee
Cipto Mangunkusumo Hospital)
Selected references
Starey N. What is clinical governance? Available at www.evidencebased-medicine.co.uk.2001.
National Prescribing Centre. The audit cycle.
Department of General Practice, Royal United Hospital. Study
guide Clinical audit. [email protected]
Allen P. Accountability for clinical governance: developing
collective responsibility for quality in primary care. BMJ 2000;
321:608-11.
Halligan A, Donaldson L. Implementing clinical governance:
turning vision into reality. BMJ 2001; 322:1413-7.
National Health Systems. Clinical governance. Available at
www.doh.gov.uk/pricare/clingov.htm
National Centre for Health Outcome Development. Coding issues
concerning clinical indicators. 2002.
National Institute of Clinical Excellence. Principles for best practice
in clinical audit. Redcliffe Medical Press, ltd. Oxon: 2002
A complete set of references is available upon request
Morbidity
Mortality
QoL
Value =
Patient Health
Satisfact Status
ion
Quality
Cost
Clinical Governance
"A framework through which NHS
organizations are accountable for
continuously improving the quality of
their services and safeguarding high
standards of care, by creating an
environment in which excellence in
clinical care will flourish."
Clinical Governance
A powerful, new and comprehensive
mechanism for ensuring that high
standards of clinical care are
maintained throughout the health
systems and the quality of service is
continuously improved
A system for improving the standard
of clinical practice
Important elements of
clinical governance
Education & training
Clinical audit
Clinical effectiveness
(EBM)
Risk management
Research and
development
Openness
Patient safety
Clinical
audits
Education
Education
&
& Training
Training
Risk
Risk
management
management
Clinical
Clinical
Governance
Governance
Clinical
Clinical
audits
audits
EBM:
Clinical
Clinical
# HTA
AccountAccountEffectiveEffective- # Clinical guidelines
ability
ability
ness
ness
# Clin pathways
Research
Research &
&
# Algorithms
development
development
# Protocols
# Procedures
#Standing orders
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,
followed by the implementation of
change. Aspects of the structure,
processes, and outcomes of care are
selected and systematically evaluated
against explicit criteria. Where
indicated, changes are implemented at
an individual, team, or service level and
Clinical audits
Formally introduced in 1989
Previous name: medical
audits
Moves from optional to
obligatory
The heart of clinical
governance
Clinical indicators
Performance indicators: overall
performance of hospital or department
More specific: clinical indicators
Outcomes of clinical indicators: certain
health outcomes, death, sentinel
event, etc
RSCM has implemented clinical
indicators in each department
Should be systematically reviewed and
broadened with better management
Examples of clinical
indicators
Hospital death
Unplanned re-admission
Compliance to treatment
regimen
Admission for certain health
problem
Surgery for certain conditions
Length of hospital stay
Clinical audits
Clinical audits refer to quality of care
evaluation method, a multidisciplinary
process of professional team
The usual approach: standard (evidencebased) identification, performance
evaluation, compare with standard,
problem identification, recommendations,
improvement implementation, re-audit
Audit may involve many hospitals in a
region, but can be implemented in
individual hospital or even department.
Audit is not .
Research. Research attempts to find best
management, audit reviews if patient care has
been done correctly
Blaming action or competition among
individuals or groups
Discipline mechanism. The main purpose of
audit is improving process and system, not
discipline
Complex statistical works. When statistics are
needed, focus is on the comparison to
standards
Database collection. Database collects all data
Clinical audits
Review of clinical performance,
the refining of clinical practice as
a result and the measurement of
performance against agreed
standard
A cyclical process of improving the
quality of care
What is clinical audit?
the systematic critical analysis of the
quality of clinical care, including the
procedures used for diagnosis and
treatment, the use of resources and the
resulting outcome and quality of life for
the patient (Secretaries of State, 1989)
the process of reviewing the delivery of
health care to identify deficiencies so
that they may be remedied (Crombie et
al 1993)
Clinical audit is at the heart
of clinical governance
It provides the mechanisms for reviewing
the quality of everyday care provided to
patients with common conditions, like
asthma or diabetes.
It builds on a long history of doctors,
nurses and other healthcare professionals
reviewing case notes and seeking ways for
better service
It addresses quality issues systematically
and explicitly, providing reliable
information.
Stage 1:
Preparing an audit
Stage 2:
Selecting criteria
Using the
methods
Stage 3:
Measuring performance
Stage 4:
Making improvements
Stage 5:
Sustaining improvements
Creating the
environments
Choosing an audit topic
An identified problem (e.g., increased
mortality of DHF/DSS patients)
High volume, high risk, or high cost
areas of practice
Areas with high variation in practice
Evidence of clinical effective
treatment
Availability of clinical guidelines
Develop a matrix to select the
priorities
Choosing an audit topic
Topic
Volume
A 10/10
B
Risk
06/10
08/10
08/10
Cost
PPK
Physyian Mngmnt
concern concern Concern
06/10
10/10
10/10
06/10
05/10
Pts
08/10 05/10
05/10
05/10 05/10
46/
C 05/10
05/10
05/10
10/10
06/10
08/10 08/10
47/70
D10/10
10/10
10/10
10/10
05/10
05/10 00/10
50/70
Developing audit team
Select the team leader
Should be multidisciplinary
Involve all area where the patients
journey
Consider patient / lay-man
involvement
Remember that you should be sure
that the work will be applied to
State your aims and
objectives
Write the background of doing audit
Write aims and objective as
statements or questions
Write in brief the methods are going
to use in the audit
Agree audit standards
Define the standards of aspects to be
measured
The standard should follow the aims
and objectives
Use local, national, regional, or
international standards as
appropriate
All standards should be evidence-
Setting standards
Evidence of setting standards can
be
obtained through:
Literature reviews
Comparison with other hospitals /
countries / benchmarking
Clinical judgment
Assessment of current practice
Types of standards
External
Medical literatures
World Health Organization
Academy / Colleges / National
guidelines
Internal
Local benchmarks
Modify external standards
Compare external with
internal standards
External
Internal
Imposed
Negotiated
Remote
Sense of ownership
Usually authoritative
Sometimes non-
Fixed
rigorous
No effort for local
Adaptable
group
Less incentive for
further improvement
Considerable effort
Evolve to pursue
higher standard
Technical process for health
care standards
Clinical practice guideline:
Recommendation for health care based on
current research
Clinical pathway: expected,
multidisciplinary daily plan of treatment
Algorithm: flow charts of decision grid
Procedures: how to, step by step instruction
Protocol: management of patient care
Standing orders: a pre-established set of
medical orders
Types of clinical indicators
Deaths in hospital and after
discharge
Emergency re-admissions to hospital
after discharge
Admissions to hospital for certain
conditions
Operations for certain conditions
Timely discharge after admission for
certain
Criteria & Standards
Kriteria: Semua pasien rawat inap harus
diperiksa oleh DPJP sebelum pukul
10.00 pagi
Standar:
90%
Kriteria: Kematian pada DSS
Standar:
<2%
Kriteria: Rawat ulang emergency
setelah pulang rawat status
asthmaticus
Consider ethics
Although not necessarily require
ethical approval, audit should be
done according to highest
professional standards
Data protection and confidentiality
In any doubt, consult the audit team
Select an audit sample
May be formally estimated by using
sample size formula, but more
practical sampling methods are
acceptable
In some instances a small number of
subjects is sufficient to draw
conclusion and establish
recommendation
May be retrospective, prospective,
concurrent
A pilot study may be necessary to
Data analysis
Compare that data you have with the
standards.
Make sure that you compare the correct
data and standards
All measurements and comparisons
should refer the aims and objectives of
the audit
Formal statistical analysis may be
needed but not a primary concern
May ask for consultation to the audit
Develop summary and
recommendations
Results of an audit should be
presented to those individuals
required to agree recommendations
and implementation plan
Then should be presented to other
colleagues
Submit to the Audit Team for further
deployment
Draft audit report
Should be well structured
Introduction justification for doing audit
Aims and objectives describe in brief but
clear
Standards used should be stated
Methods detail of data collection, etc
Results description and analysis of data
Conclusion objective statement supported
by findings
Recommendations based on audit results
Action plan action that should be
undertaken including time frame for re-audit
Implementing change
Making change as recommended in
timely and appropriate way
Combine with feed back, consensus,
opinions
Make sure that what you are going to
change will improve your practice
The Audit Team may observe and
gives suggestions during the
implementation process
Re-audit
Final stage of audit cycle
Should be carried out at appropriate
time
Repeat every stage of audit cycle
using the same methodology
Research vs. clinical audit
Am I singing the
right song?
Is X as effective
as Y?
X is always more
effective than Y?
To investigate
Am I singing this
song right?
Are we doing X,
not Y?
We did X in 75%
of cases?
To improve
Risk Severity
Risk
Frequency
Certain
Insignificant
Mild
1
Moderate
2
10
Severe
4
15
Very severe
5
20
25
Very likely
12
16
20
Possible
12
15
Unlikely
Rare
2
1
8
4
10
5
Physicians competence
Valid evidence
Patients values
Patient with
problem
Apply
the evidence
Critically
appraise
the evidence
Formulate
in answerable
question
Search the
evidence
Leadership
Edu
Commitment
CG - Committee
Audit
EBM
Openness
Risk Man
Clinical Practice Guidelines
Standards of Clinical Care (SPM)
Protocols
Clinical care pathways
Algorithms
Standard Operating Procedures (SOPs)
R&D
Culture
