The Key Elements of the Support Structure
Training ON
HEALTH CENTER CLINICAL
AUDIT,
GUIDE AND TOOLS
Bishoftu, 2022
Gold- mark hotel
Nov 11, 2023
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CONTENTS
Introduction/background
Definitions
Objectives
Scope
Conducting clinical audit
Stages of clinical audit
Audit monitoring process
Roles and responsibilities
Clinical audit tools
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[Link]/ BACKGROUND
Ethiopia has been working rigorously to ensure the
quality and safety of healthcare
Formulation and execution of the quality strategies,
Establishing of the quality management structure,
extensive capacity building in healthcare quality
improvement, and
creating public awareness on the high quality
healthcare system.
local and national level learning Platforms
National Healthcare Quality and Safety Summit
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INTRODUCTION/ BACKGROUND…………
1.1. Rationale
significant quality gap in the provision of health care
Require the introduction of a well-organized effective
clinical auditing program as one component.
absence of a policy and strategy at the ministry level that
defines the roles
1.2. Clinical audit:
The ultimate goal of conducting clinical audits is,
understanding the degree to which care provided comply
with the expected level of care and identify poor areas of
performance to make improvements in those areas
significant quality gap in the provision of health care along
one or more quality dimensions- people-centeredness, safety,
timeliness, effectiveness, efficiency, equity, and integration
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2. DEFINITIONS
2.1. Quality Improvement:
continuous process whereby organizations
iteratively test and measure changes in work
routines, set and achieve ambitious aims, shift
whole system performance, and spread best
practices for rapid uptake at a larger scale
2.2. Clinical Audit:
quality improvement process that seeks to improve
patient care and outcomes through a systematic
review of care against explicit criteria and the
implementation of change
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DEFINITIONS ……
2.3. Quality Committee/Counsel:
A committee that is composed of department heads and
selected experts in the health center that oversees the quality
improvement efforts of the health center and mainstreams
the QI concepts and activities in all departments
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DEFINITIONS ……
2.4. Quality unit/focal
A formally organized structure that is responsible for the
coordination and guidance of all QI activities in the health
center.
2.5. Quality improvement team:
Is a team that works in the specific unit/ward responsible
for designing, implementing, monitoring, and reporting
quality improvement activities.
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3. OBJECTIVES of clinical Audit
Establish/strengthen the clinical audit system.
To standardize the clinical audit in such a way that it’s an
integral part of QI activities.
Help facilities to effectively conduct a clinical audit on the
services they deliver.
Guide the development of audit criteria for local audit priorities
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4. SCOPE
intended to guide healthcare workers, quality improvement
teams, and unit leaders
practicing in health center set-up to understand the concepts
and methodologies of clinical audit and
conduct clinical audits as an integral part of mainstream
clinical activities.
It promotes awareness on clinical audit and guides to the
achievement of best practices in clinical audit in health
centers
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5. CONDUCTING CLINICAL AUDIT
An effective clinical audit requires a structured system
with competent leadership, involvement by all staff,
and stress on team working and support (3).
Therefore, Health center should integrate the healthcare
clinical audit to the larger improvement effort (if it
exists) or develop a clinical audit program
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6. STAGES OF CLINICAL AUDIT
A typical clinical audit has five
stages:
planning,
standard selection, and
criteria setting
measuring performance
against a standard,
making improvement, and
sustaining improvement
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STAGES OF CLINICAL AUDIT …
I. Planning:
preparation is key for a
successful audit
Preparation involves three
main components:
1. involving stakeholders,
2. determining audit topic,
and
3. planning the delivery of
audit field work
Planning:
with the view of improving
the quality and safety of care.
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Planning …….
Step 1: involving stakeholders
Three questions can guide to determine who should be involved
in clinical audits:
who is involved in the delivery of care,
who receives, uses, or benefits from the care or service,
who has the authority to support the implementation of any
identified changes
involve multi-disciplinary teams
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Planning…………………
Step 2: Determine the audit topic
The following factors should be taken into account when
prioritizing audit topics
costly practice areas
areas with a frequent patient complaint
high-volume practice areas risky practice areas
areas that show variation in clinical practice,
have evidence of poor quality (high rate of complication and
adverse outcome)
have a reliable data source
Audits that are part of national audits should be a top
priority
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Planning…………………
Step 3: Planning the audit delivery
A. Set the aim/objectives of the audit
B. Equip the audit team with the necessary knowledge
and skills
C. Providing the necessary structures
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Skills required in clinical audit process
Leadership, organizational and management skills
Clinical skills
Project management skills
Change management skills
Audit methodology expertise
Understanding of data protection requirements
Data collection and data analysis skills
Facilitation skills
Communication skills
Interpersonal skills
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6. STAGES OF CLINICAL AUDIT …
II. Selecting Quality Standards And Setting Criteria
Defining standards and criteria
Developing valid criteria
Setting target
Inclusion criteria/exclusion criteria
Exceptions
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II. Selecting Quality Standards And Setting Criteria
1. Standard
“An objective with guidance for its achievement given in the form
of criteria sets which specify required resources, activities, and
predicted outcomes” (Royal College of Nursing,1990)
2. Criteria
“An item or variable which enables the achievement of a standard
(broad objective of care) and the evaluation of whether it has been
achieved or not” (Royal College of Nursing, 1990)
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II. Selecting Quality Standards And Setting Criteria
These criteria are explicit statements that define what
is being measured and represent elements of care
that can be measured objectively
Criteria can be classified in to three
[Link] Criteria (refer to the resources required).
[Link] criteria (Action and Decision)
[Link] criteria (Status)
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II. Selecting Quality Standards And Setting Criteria
Developing valid Criteria
Once a topic has been chosen, appropriate criteria that are
explicit, evidence-based, measurable, and related to important
aspects of care must be developed
Methods for developing criteria
1. Using guidelines:
2. Prioritizing the evidence method:
3. Criteria based on professional consensus:
4. Involving users: (Service user)
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6. STAGES OF CLINICAL AUDIT …
III. Measuring Performance Against Standards
four steps:
Data collection,
data analysis,
drawing conclusions, and
presentation of results
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STAGES OF CLINICAL AUDIT …
IV Making improvements
Data analysis and interpretation which lead to a
conclusion will answer the question of degree of
compliance thereby pointing to areas of excellence
and areas of poor performance
come up with possible changes or recommendations
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STAGES OF CLINICAL AUDIT …
V. Sustaining the improvement
implementation progress should be monitored
regularly to ensure they are being implemented as
agreed plan and time frame (D part of PDSA)
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7. AUDIT MONITORING PROCESS
The recommended time to complete a clinical audit is three
months,
but this might depend on the problems the audit team
prioritized to address in one cycle.
The audit team should notify the QI focal if a need for
extension arises during the implementation of the clinical
audit project and this should be with sufficient justification
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7. AUDIT MONITORING PROCESS
Three phases along with an estimated period are identified to
help track the status of the audit
Phase 1 - comprises team establishment, planning the
delivery of audit, and data, collection. The estimated time is
two weeks.
Phase 2 - comprises data analysis and interpretation,
problem prioritization, root cause analysis, drawing a
conclusion, developing change ideas, presentation of
findings, and writing reports. The estimated time is three
weeks.
Phase 3 - comprises designing and implementing QI
projects, including testing change ideas (PDSA) for each
prioritized problem. It is best to complete the phase-in seven
weeks period.
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ROLES AND RESPONSIBILITIES
MoH, RHB, Zonal, district
Oversee the implementation of clinical audit
Update the guide regularly
Build the capacity of regions
Ensure coordination of the audit
Evaluate clinical audit program (bi-annual review meeting)
Mobilization and allocate budget for implementation of
clinical audit
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ROLES AND RESPONSIBILITIES
Health facility
Establish audit committee
Monitor the implementation of audits regularly
Integrate clinical audit as a regular activity
Ensure change is achieved as per the action plan
Ensure capacity building of their respective staff
Ensure availability of guidelines, protocols, and audit tools
to service delivery unit
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ROLES AND RESPONSIBILITIES…
Healthcare Providers
Involve actively in clinical audit
Perform regular audit with the audit team
Recording and documentation of audit
Identify topics for clinical audit
Maintain client privacy and confidentiality
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ROLES AND RESPONSIBILITIES…
Quality Improvement team
Plan for clinical audit
Support the quality unit in the coordination of clinical audit
Ensure the audit guideline is implemented
Undertake analysis, interpretation of clinical audit
Design the implementation of change as per the audit
finding (support linkage of audit activity with quality
improvement activity)
Ensure clinical audit is implemented by a multidisciplinary
team
Ensure presentation (dissemination) of clinical audit finding
Monitor and evaluate the performance of clinical audit
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CLINICAL AUDIT TOOLS
clinical audit tools for national priority conditions
ANC
Labour And Delivery
PNC
Postpartum Hemorrhage
Severe Preeclampsia
Fever With Child Birth
Comerhenisve Abortion Care
Family Planning
Emergency Contraception
Child Health
Esssential Newborn Care
Sick Young Infant (0- 2 month)
Sick Child (2 month- 5 years)
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CLINICAL AUDIT TOOLS
clinical audit tools for national priority conditions
Child Malnutrition
Children 5-15 Years (For Children Visiting Outpatient Department With
Any Symptom)
Malnutrition (age >15)
General Adult OPD
Communicable Diseases
Tuberculosis
Malaria
HIV/AIDS
NCD
Diabetes, HTN, Asthma
Mental health
Depression/Anxiety, Psychosis,
NovSurgical
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Service
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Audit tool
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Proposal form
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Report form
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Audtit monitoring form
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Audit status indicator definition
On track- project is progressing according to schedule
Delayed- project is running but falls behind schedule
Completed- each phase is completed according to the schedule
Abandoned- the project is not completed within the initial estimated period or
the extension period allowed.
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Newborns
The data for new-born care auditing will be collected from separate charts than
SYI register
Sample need to be the deliveries during the audting period
Piloting indicated poor documentation
Can be taken as a quality improvement problem
May come up with new approaches
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IMNCI registers
Data will be sampled from the SYI IMNCI register
As it is problem/symptom based
If the answer for symptom check is No on the specific illness check the auditor will
have to skip to next symptom considering fullfilled
If the answer is Yes then the audit team should check for
Circled symptoms/observation
Records of VS or any other
If there are no circled symptoms/records it implies that the clincal evaluation is inadequate
and evaluated as 0
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Continued
In some problems
Negative symptoms also need to be recorded and intervened accordingly
if the record shows that negative symptoms are documented/ circled/underlined
and the positive symptoms are not underline/ circled it indicates that the
provider has checked the symptoms/signs and were not present in that particular
child, and hence the standard measurement criterias considered full filled.
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Continued
SYI register has Yes/No onlly in diahrea symptoms, hence
each column or problem will have a positive/negative symptom that should be
assessed and classified
Once these data are collected,
using the symptoms circled/underlined the auditor will have to verify the
classifications using chart booklet.
Chart Booklet must also be used to verify that correct treatment is given for each
classification identified
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Continued
• Other Problem evaluations, classification of a problem, treatment for a problem,
immunization status assessment, counseling of mothers and follow-up care
(bolded items in the sick young infant and sick child section of the audit tool) are
standards to be measured and graded.
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Thank You!
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