How to make clinical audit meaningful

Professor Ruth Chambers describes the audit process and making it a vital aid to enhancing healthcare.

Professor chambers: review is timely (Photograph: UNP)
Professor chambers: review is timely (Photograph: UNP)

Clinical audit was adopted in general practice as a quality improvement process in the 1990s, aiming to improve patient outcomes through a systematic review of care based on standards of best practice and explicit criteria.

Then, where indicated, changes should be implemented at individual team level. There should be further monitoring by re-auditing and more revisions as appropriate to delivering patient care.

Revalidation needs
But recently clinical audit has become more of a routine tick-box activity in general practice to fulfil QOF requirements.

As the forthcoming requirements for revalidation (as far as we know) include evidence of clinical audits of care that GPs individually provide - and the prospect of earning extra CPD credits by showing how each hour of education leads to improvements of care or practice - this is a good time to review your own approach. By doing this you can make sure clinical audit has resulted in improving the care you provide.

Clinical audit method
Select clinical audits because of high-risk, inconsistent or high-cost clinical activity. The essential steps of the audit cycle are shown in the diagram.

The clinical audit method should be as simple as possible, and set up so you can re-audit later. Data extraction and analysis can be done as far as possible by non-clinical practice staff.

GPs and nurses need to participate only where their clinical input is vital: agreeing the topic, standards and criteria; reviewing findings and deciding on, and implementing, agreed changes.

Individual team members are more likely to alter their professional behaviour in a consistent way if everyone is involved and they realise the need to alter the way they work.

PATIENT PATHWAY 'HOT SPOTS'

Prevalence Compare your practice prevalence for the condition with the PCT average, or expected prevalence.

Initial assessment/treatment Check diagnostics, treatment and interventions are all completed against practice protocol (and check your practice protocol is in date and matches best practice or local guidelines - for example, NICE guidance).

Clinical management of continuing care of long-term condition Check diagnostics, treatment and interventions are all completed against practice protocol; consider any aspects of co-morbidity.

Medicines management For example, focus on patient sub-groups where compliance may be more difficult, such as young people.

Self-care See if lifestyle habits are tracked consistently or that self care is positively promoted by GP/nurse.

Review clinical outcomes Compare clinical outcomes between clinicians in the practice or between your practice and others.

Track trends with re-audits.

Team discussion of clinical audit findings Agree an action plan.

Re-audit Review achievements of action plan and plan further service improvement(s) as appropriate.


Thinking more widely
Clinical audit is often focused at one point rather than throughout the patient pathway. So you could study 'hot spots' along the pathway (see box above) where it is more difficult to deliver consistently good care or where patients may not comply with treatment.

Clinical audit is a reflective process, so show that you take responsibility for your part in providing the care reviewed and improvements identified in your appraisal portfolio.

Each clinician in the practice might take responsibility for one of those 'hot spots' or stages. Alternatively, the audit may be designed so that each clinician's practice is distinguishable from that of the others', including any regular locum.

Audit example: chronic kidney disease (CKD)

CKD stages 3A and 3B as patients are under GP care.

Aim to improve management of patients on practice CKD stages 3A and 3B in disease register. Use as standards best practice in minimising deterioration of CKD: NICE or SIGN guidelines.

Audit criteria

  • Prevalence at least as good as PCT average.
  • Diagnosis: eGFR measured annually in patients who are in at risk groups, for example, diabetes or hypertension.
  • Clinical management: for example, controlled BP <140/90 mmHg (at least); and patients with diabetes or with ACR ≥70mg/ mmol <130/80 mmHg. ACR checked every six months.
  • Medicines management: ACE inhibitor/ARB in people with diabetes and microalbuminuria, with hypertension and ≥ ACR 30mg/mmol or equivalent (without diabetes).
  • Self care: completed AUDIT C in previous year.

Method
All patients 18 years-plus with a diagnosis of CKD stages 3A or 3B identified from the practice CKD disease register. You could take a random sample of the 30 to 50 patients. Or a practice with sophisticated computer search skills could include all patients on the CKD disease register with stages 3A or 3B.

Analysis
Look at percentage achievements against criteria for different points on pathway, comparing variation between clinicians. Present the results at a practice meeting and devise an action plan after discussion with timescale for re-audit.

 

CPD IMPACT: DOUBLE YOUR credits

Double your credits

These further action points allow you to double the credits claimed.

  • Re-examine the last clinical audit you did.
  • Having read this article, did you undertake the clinical audit in line with the advice here? Note down in your CPD folder at healthcarerepublic.com/CPD whether the audit conformed, any major variations/omissions and whether, on reflection, you think the audit was carried out adequately - that is, completing the clinical audit cycle and making changes as appropriate.
  • Check that all action points in the light of the clinical audit for improving patient care were in fact implemented and record what was done and/or omitted in your CPD folder.
  • If your clinical audit was unsatisfactory consider repeating it, making sure that any patient care improvements needed are put in place.

Record all your learning with your free online CPD Organiser

Professor Chambers is a Stoke on Trent GP and honorary professor at University of Stafford

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