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Dr. U.Murali. M.S ; M.B.A
SURGICAL AUDIT
& RESEARCH
 Define surgical audit
 Identify the explicit criteria in clinical audit
 Discuss the differences between Research & Audit
(or)
 Compare & contrast Research & Audit
 Explain about Audit cycle
LEARNING OUTCOMES
“ … surgery without audit is like playing cricket
without keeping the score.”
(Hugh Brendon Devlin 1932-1998,
Founding Director of the Surgical Epidemiology and Audit
Unit, Royal College of Surgeons of England)
FAMOUS QUOTE
 Clinical audit is a quality improvement process that
seeks to improve patient care and outcomes through
systematic review of care against explicit criteria
and the review of change. (NICE 2002)
 The word ‘auditing’ has been derived from Latin
word “audire” which means “to hear”.
DEFINITION - AUDIT
 One of first ever clinical
audits was undertaken
by Florence Nightingale
during the Crimean War of
1853-1855.
 She and her team of 38
nurses applied strict
sanitary routines and
standards of hygiene to the
hospital and equipment.
 Kept meticulous records of
the mortality rates among
the hospital patients.
 Following these changes
the mortality rates fell from
40% to 2%.
AUDIT - PIONEER
Clinical audit is a process used by
clinicians who seek to improve patient
care. The process involves comparing
aspects of care (structure, process &
outcome) against explicit criteria.
INTRODUCTION
 Structure – what is in place
The people, their training, their knowledge, the way they
are led, the equipment, their organization, the way they are
paid, etc.
 Process – what you do
How referrals are processed, what diagnostic tests are
done, the antibiotics that are used, the thromboembolic
prevention that is customary, the use of intensive care, the
policy of feeding & mobilization after surgery, the discharge
policy, etc.
 Outcome – the results you get
Wound dehiscence rate, readmission rates, mortality,
freedom from progression, reduction in symptoms,
improvement in quality of life, return to work, etc.
CARE ASPECTS
If the care falls short of the criteria chosen, some change in
the way that care is organized is proposed, it may be
required at one of many levels:
 An individual who needs training
 An instrument that needs replacing
 At team level e.g. nurses undertaking procedures instead of,
or in addition to, doctors
 At institutional level e.g. new antibiotic policy
 At regional level e.g. provision of a tertiary referral centre
 At national level e.g. screening programmes & health
education campaigns
EXPLICIT CRITERIA
 National Audit
 Local / Hospital audit
TYPES
Is Clinical Audit a research
?
A QUESTION HERE …
 A systematic investigation undertaken to discover
facts or relationships and reach conclusions using
scientifically sound methods.
(Hockey, 1996)
DEFINITION - RESEARCH
 Purpose – To provide
new knowledge in order
to set or change
standards
 Methods – Randomised
Trials etc…
 Data Analysis –
Extensive statistical
analysis
 Ethical & Trust Approval
– Always required
 Sample size –
statistically powered
calculation
RESEARCH – IDENTIFICATION
Significance –
Statistical difference
(hypothesis driven)
Outcome – Improve
knowledge
Results, publications
– Generalisable,
publishable in peer
reviewed journals
RESEARCH – IDENTIFICATION
Surgical audit
Types
 Observational –
Retrospective
Prospective
 Case–control –
 Cross-sectional -
Definition
 Evaluation of condition or trt in a
defined population
 Analysing past events
 Collecting data contemporaneously
 Series of patients with a particular
disease or condition compared with
matched control patients
 Measurements made on a single
occasion,not looking at the whole
population but selecting a small
similar group & expanding results
TYPES OF RESEARCH STUDY
Types
 Longitudinal –
 Experimental –
 Randomised –
 Randomised controlled –
Definition
 Measurements are taken over
a period of time, not looking
at the whole population but
selecting a small similar group
and expanding results
 Two or more treatments are
compared. Allocation to
treatment groups is under
the control of the researcher
 Two randomly allocated
treatments
 Includes a control group with
standard
TYPES OF RESEARCH STUDY
THE DIFFERENCE IS SIMPLY
Research asks:
Are we singing the right song?
Audit asks:
Are we singing this song right?
 Define the audit question.
 Identify the body of evidence and current standards.
 Design the audit to measure performance against agreed
standards.
 Measure over an agreed interval.
 Analyze results and compare performance against agreed
standards.
 Undertake gap analysis :
- If all standards are reached, re audit after an agreed interval.
- If there is a need for improvement, identify possible
interventions such as training, and agree with the involved
parties.
 Re audit.
AUDIT CYCLE
THE AUDIT CYCLE
Problem or
objective
identified
THE AUDIT CYCLE
Problem or
objective
identified
Criteria agreed and
standards set
THE AUDIT CYCLE
Problem or
objective
identified
Criteria agreed and
standards set
Audit (Data
collected)
THE AUDIT CYCLE
Problem or
objective
identified
Criteria agreed and
standards set
Audit (Data
collected)
Identify areas for
improvement
THE AUDIT CYCLE
Problem or
objective
identified
Criteria agreed and
standards set
Audit (Data
collected)
Identify areas for
improvement
Make
necessary
changes
THE AUDIT CYCLE
Problem or
objective
identified
Criteria agreed and
standards set
Audit (Data
collected)
Identify areas for
improvement
Make
necessary
changes
Re-audit
THE AUDIT CYCLE
Problem or
objective
identified
Criteria agreed and
standards set
Audit (Data
collected)
Identify areas for
improvement
Make
necessary
changes
Re-audit
Step-By-Step Guide for
Doing An Audit
From Bailey & Love’s Short Practice of Surgery
5 – STAGES OF AUDIT CYCLE
STAGE 1 – PREPARING FOR AUDIT
 Think broadly. Audit can be used to monitor change, to ensure
that current best practice is being implemented, or to inform your own
patients what the probability of good & adverse outcomes is likely to
be.
 Funding. All audit takes time & consume resources.
 Ownership. Try to involve all those parties that may have some
stake in the results of the audit. Consider involving patients at the
outset.
 Skills. Many hospital provide courses or have units with staff who
have the necessary expertise required to conduct an audit on a project.
 Time. Be realistic about the time the audit is going to take.
 Teamwork. You are unlikely to be able to do it all. Most projects
need a leader. A sense of teamwork with all those concerned being
actively involved is a formula that is most likely to succeed.
STAGE 2 – SELECTING CRITERIA
 Think big. Criteria being audited should be important.
 It must be measurable. Criteria should be explicit &
amenable to measurement.
 Check guidelines. If possible, consult published guidelines from
reputable sources.
 Systematic reviews. In areas where guidelines have not been
produced, try consulting systematic reviews.
 Process or outcome. Think hard about the criteria you are
going to audit. Will your goals be best served by using process
measures or outcome measures?
 Case mix. Whatever criteria are chosen, some form of adjustment
for case mix will be required. Age, social class & mode of admission
are usual but think hard about co-morbidity & disease severity.
STAGE 3 – MEASURING THE LEVEL OF
PERFORMANCE
 Routine data. It is worth checking whether routine data in the area
of interest are collected by your own institution or any external agency.
 Electronic data. If available these data are worth considering
because of ease of use.
 Medical records. Patient registers are notoriously incomplete
but should still be consulted.
 Abstract data. Before going to any data source decide what it is
that you want to know. Design a data abstraction instrument, in
essence a questionnaire, so that you will be able to determine what
data was present & what was missing.
 Legalities. Prior to abstracting any data, check what your
local/national arrangements are in terms of the ethical considerations
of the project & also issue relating to data protection.
STAGE 4 – MAKING IMPROVEMENTS
 Barriers. Before trying to change anything, try & work out what
barriers to change might exist.
 Feedback. Feedback of results to the participants in the audit is
usually insufficient, in itself, to result in change.
 Discussion. It is far better to use the audit result as a basis for
discussion in order to explore ways of improving the service.
 Implementation methods. Other areas such as industry use
a variety of techniques in order to bring about change.
 Clinical governance. It is prudent to use established structures
to bring about improvements in surgical care.
STAGE 5 – SUSTAINING IMPROVEMENT
 Re-audit. It is usually not necessary to go through the whole
process another time. Instead, periodic review with some kind of
monitoring may be sufficient.
 Structural change. It is important to make sure that the change
resulting in improved care is easier for the clinician to undertake than
the practice that it replaces.
 Cultural change. Sustained improvement is difficult to achieve
unless it is something that the organization is striving to do.
STAGE 1:
PREPARING FOR AUDIT
 Selecting a topic
 Defining the purpose
 Planning
STAGE 2:
SELECTING CRITERIA
 Defining criteria
 Sources of evidence
 Appraising the evidence
STAGE 3:
MEASURING LEVEL OF
PERFORMANCE
 Planning data collection
 Methods of data collection
 Handling data
STAGE 4:
MAKING IMPROVEMENTS
 Identifying barriers to change
 Implementing change
 External relationships
STAGE 5:
SUSTAINING IMPROVEMENT
 Monitoring and evaluation
 Re-audit
 Maintaining and reinforcing
improvement
REFERENCES
Bailey & Love’s - Short Practice of Surgery
26th edition.
Internet websites.
Thankyou

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Surgical audit

  • 1. Dr. U.Murali. M.S ; M.B.A SURGICAL AUDIT & RESEARCH
  • 2.  Define surgical audit  Identify the explicit criteria in clinical audit  Discuss the differences between Research & Audit (or)  Compare & contrast Research & Audit  Explain about Audit cycle LEARNING OUTCOMES
  • 3. “ … surgery without audit is like playing cricket without keeping the score.” (Hugh Brendon Devlin 1932-1998, Founding Director of the Surgical Epidemiology and Audit Unit, Royal College of Surgeons of England) FAMOUS QUOTE
  • 4.  Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the review of change. (NICE 2002)  The word ‘auditing’ has been derived from Latin word “audire” which means “to hear”. DEFINITION - AUDIT
  • 5.  One of first ever clinical audits was undertaken by Florence Nightingale during the Crimean War of 1853-1855.  She and her team of 38 nurses applied strict sanitary routines and standards of hygiene to the hospital and equipment.  Kept meticulous records of the mortality rates among the hospital patients.  Following these changes the mortality rates fell from 40% to 2%. AUDIT - PIONEER
  • 6. Clinical audit is a process used by clinicians who seek to improve patient care. The process involves comparing aspects of care (structure, process & outcome) against explicit criteria. INTRODUCTION
  • 7.  Structure – what is in place The people, their training, their knowledge, the way they are led, the equipment, their organization, the way they are paid, etc.  Process – what you do How referrals are processed, what diagnostic tests are done, the antibiotics that are used, the thromboembolic prevention that is customary, the use of intensive care, the policy of feeding & mobilization after surgery, the discharge policy, etc.  Outcome – the results you get Wound dehiscence rate, readmission rates, mortality, freedom from progression, reduction in symptoms, improvement in quality of life, return to work, etc. CARE ASPECTS
  • 8. If the care falls short of the criteria chosen, some change in the way that care is organized is proposed, it may be required at one of many levels:  An individual who needs training  An instrument that needs replacing  At team level e.g. nurses undertaking procedures instead of, or in addition to, doctors  At institutional level e.g. new antibiotic policy  At regional level e.g. provision of a tertiary referral centre  At national level e.g. screening programmes & health education campaigns EXPLICIT CRITERIA
  • 9.  National Audit  Local / Hospital audit TYPES
  • 10. Is Clinical Audit a research ? A QUESTION HERE …
  • 11.  A systematic investigation undertaken to discover facts or relationships and reach conclusions using scientifically sound methods. (Hockey, 1996) DEFINITION - RESEARCH
  • 12.  Purpose – To provide new knowledge in order to set or change standards  Methods – Randomised Trials etc…  Data Analysis – Extensive statistical analysis  Ethical & Trust Approval – Always required  Sample size – statistically powered calculation RESEARCH – IDENTIFICATION
  • 13. Significance – Statistical difference (hypothesis driven) Outcome – Improve knowledge Results, publications – Generalisable, publishable in peer reviewed journals RESEARCH – IDENTIFICATION
  • 15. Types  Observational – Retrospective Prospective  Case–control –  Cross-sectional - Definition  Evaluation of condition or trt in a defined population  Analysing past events  Collecting data contemporaneously  Series of patients with a particular disease or condition compared with matched control patients  Measurements made on a single occasion,not looking at the whole population but selecting a small similar group & expanding results TYPES OF RESEARCH STUDY
  • 16. Types  Longitudinal –  Experimental –  Randomised –  Randomised controlled – Definition  Measurements are taken over a period of time, not looking at the whole population but selecting a small similar group and expanding results  Two or more treatments are compared. Allocation to treatment groups is under the control of the researcher  Two randomly allocated treatments  Includes a control group with standard TYPES OF RESEARCH STUDY
  • 17. THE DIFFERENCE IS SIMPLY Research asks: Are we singing the right song? Audit asks: Are we singing this song right?
  • 18.  Define the audit question.  Identify the body of evidence and current standards.  Design the audit to measure performance against agreed standards.  Measure over an agreed interval.  Analyze results and compare performance against agreed standards.  Undertake gap analysis : - If all standards are reached, re audit after an agreed interval. - If there is a need for improvement, identify possible interventions such as training, and agree with the involved parties.  Re audit. AUDIT CYCLE
  • 19. THE AUDIT CYCLE Problem or objective identified
  • 20. THE AUDIT CYCLE Problem or objective identified Criteria agreed and standards set
  • 21. THE AUDIT CYCLE Problem or objective identified Criteria agreed and standards set Audit (Data collected)
  • 22. THE AUDIT CYCLE Problem or objective identified Criteria agreed and standards set Audit (Data collected) Identify areas for improvement
  • 23. THE AUDIT CYCLE Problem or objective identified Criteria agreed and standards set Audit (Data collected) Identify areas for improvement Make necessary changes
  • 24. THE AUDIT CYCLE Problem or objective identified Criteria agreed and standards set Audit (Data collected) Identify areas for improvement Make necessary changes Re-audit
  • 25. THE AUDIT CYCLE Problem or objective identified Criteria agreed and standards set Audit (Data collected) Identify areas for improvement Make necessary changes Re-audit
  • 26. Step-By-Step Guide for Doing An Audit From Bailey & Love’s Short Practice of Surgery
  • 27. 5 – STAGES OF AUDIT CYCLE
  • 28. STAGE 1 – PREPARING FOR AUDIT  Think broadly. Audit can be used to monitor change, to ensure that current best practice is being implemented, or to inform your own patients what the probability of good & adverse outcomes is likely to be.  Funding. All audit takes time & consume resources.  Ownership. Try to involve all those parties that may have some stake in the results of the audit. Consider involving patients at the outset.  Skills. Many hospital provide courses or have units with staff who have the necessary expertise required to conduct an audit on a project.  Time. Be realistic about the time the audit is going to take.  Teamwork. You are unlikely to be able to do it all. Most projects need a leader. A sense of teamwork with all those concerned being actively involved is a formula that is most likely to succeed.
  • 29. STAGE 2 – SELECTING CRITERIA  Think big. Criteria being audited should be important.  It must be measurable. Criteria should be explicit & amenable to measurement.  Check guidelines. If possible, consult published guidelines from reputable sources.  Systematic reviews. In areas where guidelines have not been produced, try consulting systematic reviews.  Process or outcome. Think hard about the criteria you are going to audit. Will your goals be best served by using process measures or outcome measures?  Case mix. Whatever criteria are chosen, some form of adjustment for case mix will be required. Age, social class & mode of admission are usual but think hard about co-morbidity & disease severity.
  • 30. STAGE 3 – MEASURING THE LEVEL OF PERFORMANCE  Routine data. It is worth checking whether routine data in the area of interest are collected by your own institution or any external agency.  Electronic data. If available these data are worth considering because of ease of use.  Medical records. Patient registers are notoriously incomplete but should still be consulted.  Abstract data. Before going to any data source decide what it is that you want to know. Design a data abstraction instrument, in essence a questionnaire, so that you will be able to determine what data was present & what was missing.  Legalities. Prior to abstracting any data, check what your local/national arrangements are in terms of the ethical considerations of the project & also issue relating to data protection.
  • 31. STAGE 4 – MAKING IMPROVEMENTS  Barriers. Before trying to change anything, try & work out what barriers to change might exist.  Feedback. Feedback of results to the participants in the audit is usually insufficient, in itself, to result in change.  Discussion. It is far better to use the audit result as a basis for discussion in order to explore ways of improving the service.  Implementation methods. Other areas such as industry use a variety of techniques in order to bring about change.  Clinical governance. It is prudent to use established structures to bring about improvements in surgical care.
  • 32. STAGE 5 – SUSTAINING IMPROVEMENT  Re-audit. It is usually not necessary to go through the whole process another time. Instead, periodic review with some kind of monitoring may be sufficient.  Structural change. It is important to make sure that the change resulting in improved care is easier for the clinician to undertake than the practice that it replaces.  Cultural change. Sustained improvement is difficult to achieve unless it is something that the organization is striving to do.
  • 33. STAGE 1: PREPARING FOR AUDIT  Selecting a topic  Defining the purpose  Planning
  • 34. STAGE 2: SELECTING CRITERIA  Defining criteria  Sources of evidence  Appraising the evidence
  • 35. STAGE 3: MEASURING LEVEL OF PERFORMANCE  Planning data collection  Methods of data collection  Handling data
  • 36. STAGE 4: MAKING IMPROVEMENTS  Identifying barriers to change  Implementing change  External relationships
  • 37. STAGE 5: SUSTAINING IMPROVEMENT  Monitoring and evaluation  Re-audit  Maintaining and reinforcing improvement
  • 38. REFERENCES Bailey & Love’s - Short Practice of Surgery 26th edition. Internet websites.