Clinical audit - A literature review

Abstract

Clinical audit is a proven method of quality improvement. It gives staff a systematic way of looking at their practice and making improvements. Auditing can be done right from the record maintaining, diagnosis and treatment and postoperative evaluation and follow-up. Clinical audit may contain many components of clinical research but it is different from that. This paper reviews basis of clinical auditing, its role in dentistry and Indian scenario.

Full text

Journal of International Dental and Medical Research ISSN 1309-100X Clinical Audit
http://www.ektodermaldisplazi.com/journal.htm Darshana Bennadi, and et al
CLINICAL AUDIT – A LITERATURE REVIEW
Darshana Bennadi1*, Vinayak Konekeri2, Nandita Kshetrimayum3, Sibyl S4, Veera Reddy5
1. Reader, Dept. Of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, Tumkur, Karnataka, India
2. Senior Lecturer, Dept. Of Public Health Dentistry, Navodaya Dental College and Hospital, Raichur, Karnataka, India
3. Assistant Professor, Dept. Of Public Health Dentistry, Regional Institute of Medical sciences, Dental College, Lamphelpat, Imphal,
West Manipur, India
4. Senior Lecturer, Department of Public Health Dentistry, SRM Dental College and Hospital, Chennai, India.
5. Senior dental health officer, General hospital, Molkalamuru, Chitradurga District, Karnataka, India
Abstract
Clinical audit is a proven method of quality im
provement. It gives staff a systematic way of
looking at their practice and making improvements. Auditing can be done right from the record
maintaining, diagnosis and treatment and postoperative evaluation and follow-
up. Clinical audit may
contain many com
ponents of clinical research but it is different from that. This paper reviews basis
of clinical auditing, its role in dentistry and Indian scenario
Review (J Int Dent Med Res 2014; 7: (2), pp. 49-55
)
Keywords: Clinical auditing, Dentistry, Research.
Received date: 22 February 2014 Accept date: 03 March 2014
Background
“Health is a state of complete physical,
mental and social well being, and not merely the
absence of disease or infirmity” as defined by the
World Health Organization.1
As oral physicians all of us are concerned
about this wellbeing of our patients and strive
hard to achieve this state.
Many instances of national publicity and
criticism regarding patient care in hospitals were
seen commonly. Society has become very
vigilant and critical about the standard of patient
outcomes.
Clinical audit is a proven method of
quality improvement. It gives staff a systematic
way of looking at their practice and making
improvements. Clinical audit: 2-6
• identifies and promotes good practice and can
lead to improvements in service delivery and
outcomes for users
• can provide the information you need to show
others that your service is effective (and cost-
effective) and thus ensure its development
• provides opportunities for training and
education
• helps to ensure better use of resources and,
therefore, increased efficiency
• can improve working relationships,
communication and liaison between staff, staff
and service users, and between agencies.
Historically, audit has been recorded as
early as in 1066 in Domesday Book with the
development of national statistics of births and
deaths.7 In 1750 BC, King Hammurabi of
Babylon penalized clinicians on poor
performance in order to ensure adequate patient
care.2,8
However, Florence Nightingale is
considered as the pioneer of clinical audit, as her
assessment of the effectiveness of cleanliness
and its enforcement resulted in tremendous
reduction in mortality rates of hospitalized
patients during the Crimean war of 1853-5.
Ernest Codman is recognized as being the first
true medical auditor for his work in 1912 on
monitoring surgical outcomes of his patients.2,8–10
*Corresponding author:
Dr. Darshana Bennadi,
Dept. Of Public Health Dentistry,
Sree Siddhartha Dental College and Hospital,
Agalkote, Tumkur, India – 572107.
E-mail: darmadhu@yahoo.com
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In recent years, the concept saw light
when the United Kingdom pioneered the move to
integrate clinical audit in professional healthcare
with the introduction of the white paper.2,9 This
paper defined medical audit as “the systematic
critical analysis of the quality of medical care
including the procedures used for diagnosis and
treatment, the use of resources and the resulting
outcome and quality of life for the patient”.7, 9
The definition from National Institute for
Clinical Excellence (NICE) is: A quality
improvement process that seeks to improve
patient care and outcomes through systematic
review of care against explicit standards and the
implementation of change. “Principles for Best
Practice in Clinical Audit”, NICE, 2002 2-5
Clinical Audit and Research
Clinical audit may contain many
components of clinical research. Hence there is a
great deal of controversy in delineating the terms
audit and clinical research. Research seeks new
knowledge whereas Audit seeks to ensure that
existing knowledge is being put into practice.
Table 1 shows differences between
research and clinical audit. Adapted from
Madden (1991) and Firth-Cozens (1993) 3, 5, 6
Table 1. Table shows differences between
research and clinical audit.
Types of clinical audit
According to Sandhya K Lokuarachchi2
1. Standard based audits: A cycle
involving defining standards, collecting data to
measure current practice against these
standards and implementing necessary changes.
2. Adverse occurrence screening and
critical incident monitoring: Often used to
review cases with special concern or unexpected
outcomes. This reflects the way the team has
functioned and helps to learn for future.
3. Peer-review: Individual cases are
discussed by peers to determine whether best
care was given. Somewhat similar to type 2
above, but might include interesting or unusual
cases rather than critical incidents.
Recommendations are very often not followed as
there is no systematic method to follow.
4. Patient surveys and focus groups:
Carried out by obtaining views of patients,
regarding the care received.
European Society of Radiology
subcommittee on audit and standards audit
states two kinds of audits.4
Internal audit: which is more commonly
carried out, refers to audit carried out within a
department or institution
External audit: audit performed by
professionals from outside the department or
institution. Whether internal or external, audit
should not be carried out without the knowledge
of those involved in the delivery of the service
and should be a planned, scheduled process.
Frostick SP, Radford PJ, Wallace WA and
ESR also consider4,7
Structure audit
Which denotes resources found within the
operatory and hospital and also management of
structure and equipment, technology, staff,
training, investigations and administration of
these resources.
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Process audit
Which incorporates the efficient
functioning of the staff and involves in-toto
evaluation of all the processes involved in the
delivery of care from the time of referral through
diagnosis to treatment and handing over of a
report and the employment of capacities towards
this. Thus it is a quality management of the
processes, justifying waiting times and
examination practices and protocols.
Outcome audit
Which concerns the patient. It involves
the patient's perspectives, the doctor's as well as
the patient's expectation and the community's
expectation through community health councils
and legal channels. However, outcome does
crucially involve the patient's inclination, psyche,
determination, education and beliefs; how they
can articulate the outcome and how they
perceive it.
According to Copeland G it can be divided
into:2
Prospective clinical audit
This permits accurate real-time buildup of
data which mirrors current and prevalent practice
rather than the historical ones.
Retrospective clinical audit
Serves as a historical yardstick but is of
crucial use if a complaint, litigation or serious
adverse outcome arises and a review of practice
is required urgently.
Academy of Royal Colleges categorizes audit
into ;11
Local clinical audit
Focuses on aspects of care that have
been prioritized by the individual clinician, clinical
team or service provider
Non-local clinical audit
Focuses on those aspects of care that
have been prioritized at a regional, national or
specialty level and encompasses clinicians and
clinical teams from multiple service providers.
Who Should Be Involved In The Clinical
Audit:3
A clinical audit project is more likely to be
successful and beneficial to service users if all of
the key stakeholders are involved from the outset.
These may include:
• clinical and non-clinical staff providing
the service
• service users
• people whose support may be required
to implement resulting changes in practice
(e.g.managers, referrers, trust board members).
If individuals are unable to attend team
meetings, then they will need to be consulted and
kept informed about the clinical audit project
throughout the process.
A ‘clinical audit project team’ works
together from the early stages when decisions
are being made about what to audit and how to
design the audit. Roles and responsibilities within
the team will need to be identified, for example
audit project lead, data collector.
The stages in clinical auditing:2-6
Stage 1 – Identify topic / problem to be
audited
Topic chosen should be of obvious
importance to the team, department and patients.
When you are thinking about topics for audit,
consider areas where there is:
• Local concern
• Patients’ concerns
• Risk issues
• Trust priorities
• Wide variance
Finding your evidence
Evidence can come from a range of
areas. This list gives a good hierarchy for looking
for evidence:
• National guidelines (NICE, NSFs, Royal
Colleges)
• Research findings, particularly
systematic reviews
• Local policies, protocols and procedures
• Local consensus
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• But not because we’ve always done it
Be careful about using local consensus.
It’s not proven best practice – but sometimes it’s
all you’ve got.
Primary sources of information
include:
• Books
• Journal articles, reviews, letters, comments
and editorials
• Reports from DoH, Royal Colleges
• National guidelines, NSFs
• Local care plans, protocols, guidelines etc
• Patient information leaflets (NHS, charities
and self help groups)
Databases that guide you to evidence
include:
• The Cochrane Library of Systematic Reviews
• MEDLINE – Index Medicus
• EMBASE – European, excellent for drugs and
pharmacology
• HMIC – Health Management Information
Consortium
• CINAHL – Cumulative Index to Nursing and
Allied Health Literature
• CANCERLIT and other specialist databases
Stage 2 – Define criteria and standards
Criteria are explicit statements that define
what is being measured. It is a measurable
outcome of care. Standard is the threshold of the
expected compliance for each criterion.
Standards: Standards specify what
should be provided and how. They should be
developed from the evidence of best practice by
looking at specific areas of care. Audit standards
must be SMART.
Specific covers one topic only
Measurable can be measured in a
practical way
Achievable is something that is
reasonable for staff to achieve
Relevant is an issue that is important to
patients and staff
Timescale can be measured within a
reasonable period of time
You need to be realistic in what you audit.
You start with a broad audit topic, decide what is
most important within this to give you objective(s)
and then set specific standards from these
objectives.
Sources of standards: Standards
against which local performance can be
measured can be found from a variety of sources
1. Local, European or international
legislation. Compliance with these standards is
compulsory.12
2. Peer-reviewed research. These will
provide benchmark standards but may have to
be interpreted in the light of local facilities and
expertise.
3. Recommendations or consensus
statements from learned or national societies and
organisations. These will usually have been
developed to be applicable in routine practice13, 14
4. Where no published or recommended
standards are available, these may have to be
established by local agreement or consensus
before the relevant audit is undertaken. Under
these circumstances, locally sourced data from
comparative investigations, pathology, surgical
findings, peer group review or clinical follow-up
may allow the setting of local standards for
outcome audits.
High or low standards?: Standards,
other than those governed by legislation, are not
necessarily pass or fail. A very high or
aspirational standard may only be achieved by
the very few but could serve to encourage
maximum improvement. If the selected target
standard is based on the average expected
performance, then initially, 50% will be expected
to fall below it. A low or minimum target standard
may be regarded as the minimum acceptable
level of performance. The level of the standard
selected should be taken into account in
interpretation of results.
Stage 3 – Method and data collection
Method or type of audit process is chosen
depending on audit objectives. Data collection
should be precise and only the essential data
should be collected. Data collection may be
retrospective, concurrent or prospective.9, 15, 16
Data may be collected using computerized
information or done manually. Consideration
should be given to what data will be collected,
where data will be available and who will collect
the data. Your standards will help you decide
what and how to collect the data. Consider
• What data do you need to collect?
• Where is the data?
• Who will collect it?
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• How will it be collected?
• How much should you collect?
• How long will it take?
• What resources do you need? (time, people,
support)
Always do a pilot – look at 2 or 3
patients / cases / records
• Check whether your audit design works
by testing it on a few cases.
• If it doesn’t, re-design and pilot again.
The data should enable you to measure
practice against the standards.
Ways of collecting data
Data can often be collected from patient’s
notes, or by interviewing patients of staff, or by
using questionnaires.
Sample Size
You don’t need a big, or statistically
significant, sample for an audit, but you do need
a fair sample that represents all the patients /
cases / records. For example, if you choose the
notes that are most easily to hand, you may miss
the more complex cases.
Ethical issues should be given due
consideration. Data collected must relate only to
the objectives.
Patient and staff confidentiality need to be
respected.
Stage 4 – Comparison of performance
with criteria and standards
Data collected are analysed. Results are
compared with criteria and standards. How well
the standards were met is concluded. Reasons
for any deviation from standards and areas with
potential for improvement should be recognized.9,
15, 17 Analysis of data:
Use a tool to analyse the data. This may
be pencil and paper and a calculator or a simple
spreadsheet. You only need simple descriptive
statistics – averages and ranges, not complicated
statistical tests. Consider:
• Were the standards met?
• If not, why not?
• Does the data point to ways of improving
care?
• What do the results tell you?
Stage 5 – Implementing change
Once the results of audit are analysed
and discussed and areas for potential
improvement are identified, recommendations for
improvement are formulated.9, 15 Action plan
should be made for implementing changes.
Persons responsible and time frame and the
action to be taken should be clearly defined.
At this stage a report should be sent to
the clinical audit department where there are well
organized clinical audit departments.9, 15 In the
absence of a well organized system report
should be forwarded to administrators who are
responsible for overall patient care at local or
national level. Make an action plan with
recommendations, actions, responsibilities and
timescale for implementation. Identify who will
review how the action plan is going.
Re-audit and sustaining improvement
After an agreed period of implementing
changes the audit should be repeated.8, 9, 15
Same strategies used for the original audit
should be used to ensure comparability. The re-
audit should reveal that the changes have been
implemented and improvement has been made.
Depending on achievements further re-audits
may be planned. If acceptable quality of care is
sustained re-auditing can be replaced by some
form of monitoring and audit processes
reintroduced when indicated. Results of good
clinical audits should be disseminated locally,
nationally and internationally when relevant.8, 9, 15
Clinical audit in dentistry
The scope for clinical audit in the vast and
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Journal of International Dental and Medical Research ISSN 1309-100X Clinical Audit
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burgeoning field of dentistry is endless. Distinct
to other areas of healthcare, dentists generally
get to examine ambulant and asymptomatic
patients at varying intervals, who just consult for
a periodic review of their oral health. Thus,
dentists are blessed with an exclusive
opportunity to assess and record the normal and
establish the baseline measurements and
document the location and profile of lesions by
means of diagrams or photography.
It must be recognized that in a dental
setup, care of the patient is not restricted just to
the oral problem but also includes assisting and
empowering the patients in their healthcare by
instituting a regimen that is best provided by a
multidisciplinary team including the oral
healthcare provider.
Variability in patient care is confounding
and varies dramatically with doctors, specialties
and geographic region. This has been observed
even within the same institution where identical
problems may have been addressed with
different therapeutics.18
Auditing is being carried out on a small
scale in various facets of dentistry. Auditing can
be done right from the area of record
maintenance through the diagnosis and
treatment and till the postoperative evaluation
and follow-up. An audit to assess the standard of
clinical record-keeping by undergraduate dental
students reported that constructive changes can
be achieved by creating an understanding
amongst them on the importance of keeping
records.19 Audits involving the general dental
practitioners’ experiences and practices of
antibiotic prescription highlighted the need for
clinical audit, in conjunction with continuing
education in the prescribing of antibiotics.20, 21
A prospective oral mucositis audit
assessed the various facets of severe oral
mucositis in patients receiving high-dose
conditioning chemotherapy and concluded that
severe mucositis is a more common problem
than previously reported, thus justifying effective
preventative and therapeutic measures.22
A study conducted to audit and monitor
the uptake of national mouth care guidelines for
children and young people undergoing treatment
for cancer stressed upon ensuring effectual use
of oral assessment scales and aids for them to
receive suitable dental care throughout and after
their treatment.23 The value of patient feedback in
the audit of temporo-mandibular Joint (TMJ)
arthroscopy was assessed and a disparity
between the clinical evaluation and the patients’
perception of effectiveness was noticed thus
emphasizing the importance of patient
feedback.24
Another auditing recommended
arthrocentesis as an effective, minimally invasive
alternative technique for TMJ pain not
responding to conservative management.25 An
audit of the time of initial treatment in avulsion
injuries opined that improving public knowledge
about tooth storage in avulsion injuries is critical
to long-term prognosis of the teeth.26
A multi-centre audit conducted to assess
the best method for achieving a functional and
aesthetically acceptable appearance after
unilateral cleft lip repairs suggested the need for
an internationally agreed objective method of
assessment for this facial deformity.27
Clinical audit for dentistry in India:
Many questions have to be answered its
feasibility in India like;
• Do we have adequate resources to implement
audit system?
• Who will comprise the audit team?
• Who will be the central authority for
conducting dental audit ?
• Will the dental practitioners and concerned
authorities of dental institutions extend their
cooperation to carry out a systematic audit?
• What should be the time interval required for
conducting audit and how long should the
process continue?
• What is the acceptable standard or
benchmark level of dental care?
Conclusion:
• Clinical audit, the cornerstone of clinical
governance, ensures that the strategy is
executed as planned, and in the process
provides a framework to highlight and enable
changes to be incorporated ensuring
improved patient care. It must be reiterated
that research needs the word ‘investigate’ and
audit needs the word ‘improve’.
• The immense potential of clinical audit can be
utilized only when open-mindedness and
innovativeness are encouraged and evidence-
based work culture is cultivated.
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• An inquisitive and informed mind; rigorous,
vigilant and thoughtful planning; investigation
and documentation; positive and resourceful
organization are the lifeline of a clinical audit.
• Lobbying of policy-makers should be done to
implement mandatory dental auditing system
for all the dental practitioners and dental
institutions.
• Governmental and/or non-governmental
organization(s) and/or professional bodies
should recruit an auditing team to serve as the
third eye of dental care.
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