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Audit – how to do it. Dr Mark Levy FRCGP Member GINA Executive Clinical Research Fellow, Edinburgh University Editor-in-Chief, Primary Care Respiratory Journal. Implementing guidelines into practice – using Audit (Become a reflective practitioner). Dr Mark Levy FRCGP Member GINA Executive

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Audit – how to do it

Dr Mark Levy FRCGP

Member GINA Executive

Clinical Research Fellow, Edinburgh University

Editor-in-Chief, Primary Care Respiratory Journal


Implementing guidelines into practice – using Audit(Become a reflective practitioner)

Dr Mark Levy FRCGP

Member GINA Executive

Clinical Research Fellow, Edinburgh University

Editor-in-Chief, Primary Care Respiratory Journal

© Mark Levy www.consultmarklevy.com


How to do a Medical Audit:Lecture Plan

Experiential learning

The audit cycle

Create a new audit – example

‘Off the Shelf’ Audits

Respiratory examples – can apply the principles to other medical disciplines


www.animalswild.com


Experiencial Learning

Confucious 551 – 479 B.C.E

I hear and I forget

I see and I remember

I do and I understand


Experiencial Learning

  • Personal involvement

  • Self initiated

  • Sense of discovery

  • Makes a difference in behaviour

  • Evaluated by learner

Carl Rogers (January 8, 1902 – February 4, 1987)

“Everyone has the potential to grow”


Experiencial Learning :– First Medical Audit

Florence Nightingale

1820-1910

  • Crimean war 1853-1855

  • Scutari 1854 -unsanitary conditions /high mortality

  • Strict sanitary conditions

  • Records – mortality fell from 40% to 2%


History of Medical audit

Medical auditing by scientific methods; illustrated by major female pelvic surgery. Lembcke PA. J Am Med Assoc. 1956 Oct 13;162(7):646-55.

A scientific method for medical auditing. Lembcke PA. Hospitals. 1959 Jul 1;33(13):65-6

Evolution of the medical audit. Lembcke PA. JAMA. 1967 Feb 20;199(8):543-50.


NHS and Audit

1989 White Paper, Working for patients - standardise clinical audit as part of professional healthcare

...."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.“........

1992/3 GP contract

Evidence for appraisal and ? revalidation


The audit cycle

Identify Problem / Learning objective

Set standards for achievement

Reflect on results / identify learning needs

Agree Criteria (data to be collected)

Re-audit after appropriate interval

Collect and analyse data

Make changes

Reflect on achievement of standards / identify areas for improvement.


Underdiagnosis and undertreatment

1982 Prevalence <4%

  • 2700 children

  • 11% had asthma

  • < 1% previously diagnosed

  • 66% never had bronchodilators

  • 30 % lost > 50 schooldays

BMJ 1983;286:1253 - 6


Delayed diagnosis of asthma

Levy & Bell BMJ 1984 ; 289 : 1115 - 6


Methods: ‘Real world’ study comparing 1339 patients of all ages and severity of asthma managed by 77 self-selected highly motivated general practices in Scotland with 9617 patients from 319 practices from a national sample


Pragmatic real world study of the effect of audit of asthma on clinical outcome: Results

  • More structured reviews

  • More inhaler technique checks

  • Fewer unscheduled consultations

  • Fewer symptoms

  • No significant difference in BTS Step or A&E utitilisation

Neville R et al. Prim Care Resp J 2004;13:198-204


Types of audit – retrospective or prospective?

Retrospective: Classically, many people believe that audit should be done retrospectively, ie through analysing past clinical management behaviour. This is one of the acceptable methods for establishing a baseline, and should be done to establish current practice and generate new audit or research questions. This method is also used to repeat an audit (or close the loop or cycle after appropriate intervention following the baseline audit). However, this type of audit cannot always reflect actual practice, mainly because of limitations of collecting retrospective data which often has missing data.

Prospective audit is valuable to investigate implementation of new practice following a baseline audit, and also particularly useful for sessional/ freelance doctors and nurss who don’t have a regular place of work.


Can Sessional, locum or freelance Doctors do audit?

They certainly can

Retrospective (if they have a regular place of work, with their own computer log on)

or

Prospective audit which may be more practical


The audit cycle

Identify Problem / Learning objective

Set standards for achievement

Reflect on results / identify learning needs

Agree Criteria (data to be collected)

Re-audit after appropriate interval

Collect and analyse data

Make changes

Reflect on achievement of standards / identify areas for improvement.


Becoming a reflective practitioner – Audit is the tool

Consider a question (PUN/ Den)

Decide to audit our work


Planning an audit (1)

Decide on aims/outcomes (SMART Specific, Measurable, Achievable, Realistic, Timeframe)

Set standards (what are you going to measure)

Selection of patients (eg Age/presentation)

How many patients

Criteria


Criteria and standards

  • Criteria = are those aspects of care that you wish to examine

    • the data you will collect

  • Standards = levels of success that you wish to achieve

    • Eg – Acute asthma : patients treated with high dose bronchodilator – expect > 80% to also be prescribed oral steroids.


Asthma: Patient AMP, Female, Age 7, consults:

She has a cough and has been using a prescribed Ventolin inhaler – you assess her and decide that she has got a cold

You notice she hasn’t been put on the asthma register

Nor has she been given a self management plan

Nor has she been told she has asthma

You wonder if indeed she has got asthma ..


Signs,symptoms and findings which increase the probability of asthma in children

  • wheeze

  • cough

  • dyspnoea

  • chest tightness

  • Symptoms are frequent and recurrent

  • Symptoms are worse at night or in the early morning

  • Symptoms often occur in response to exercise and/or emotion

  • Symptoms may occur as a response to triggers such as pets, pollens, cold or damp air

  • Patients may have a history of atopic disease

  • Patients may have a family history of atopic disease and/or asthma

  • Widespread wheeze may be heard on auscultation

  • Variable airflow obstruction (PEF varies by more than 20%)

BTS/SIGN /www.sign.ac.uk/


Aim: To assess quality of my diagnosis of asthma in children; according to The British Asthma Guidelines

1)How do I define ‘diagnosis of asthma’ for the purpose of this audit?

2) What do I mean by ‘Children’?

Definition of Diagnosed Asthma : Prescription of asthma medication implies a provisional or confirmed diagnosis of asthma

Children = Patients aged 6 - 16


Aim: To assess quality of my diagnosis of asthma in children, according to The British Asthma Guidelines

Standards:

i) All diagnosed with asthma have at least one symptom (wheeze, cough, difficulty breathing, chest tightness)

ii) At least 70% diagnosed patients had night symptoms

iv) Over 60% of diagnosed children should have history of atopy

vi) > 70% should have proven variable airflow obstruction

( eg PEF > 20% variation)


Selection of patients and duration of audit

  • Who:

  • Which patients:

  • When:

  • How Many:


Selection of patients and duration of audit

  • Who: Myself and members of my peer group

  • Which patients: All patients 6-16 years who I diagnose with asthma or prescribe asthma medication for.

  • When: From 1/11/2010 to 1/2/2011

  • How Many: Until at least 10 patients are recruited


Criteria: data needed to collect info:

  • Name

  • Annonymous ID

  • Date presented

  • Variable respiratory symptoms (cough, wheeze, diff breathing, chest tightness ( - yes/No/ Not asked)

  • Night symptoms: ( - yes/No/ Not asked)

  • History of atopy (eczema, hay fever)

  • PEF readings: Previous best, highest, lowest


Make forms

  • Patient selection form

  • Data collection form

  • Results reporting form


Patient selection form


Data Collection Form


Data Collection Form


Report form


Reflection

? Peer meeting / self reflection

What went well

What went badly

Which Standards did I meet?

What do I need to do?

Plans to re-audit and complete the cycle


Report


www.guideline-audit.com


Guideline-audit.com - unique features

  • Online FREE system for audit

  • Immediate feedback

  • Comparison

    • individual clinicians' changes

    • other clinicians world wide

  • Anonymised

  • Only registered users, password protection see their own data for comparison with others

  • Unregistered users see the amalgamated data for everyone, without individual comparison


www.guideline-audit.com


Chest Infection Audit Standards

Nice Guideline 69 www.nice.org.uk ;

Prim Care Resp J 2010;19(1):21-27. DOI: http://dx.doi.org/10.4104/pcrj.2010.00014


CRB-65 and Mental Test Score

CRB-65 score : 0= low risk; 1-2 = increased mortality); 3-4 >9% mortality)


Patient Data collection Form


Easy Online Data Entry with drop down response choices


Results available immediately – with comparison with peers


Print out a report for appraisal


System for auditing management of uncontrolled asthma including acute attacks

Participants register

Patient consults for uncontrolled asthma

Baseline audit


Checked inhaler technique


Medical audit

An educational activity

Promotes understanding

Resource effective

Raises standards

Promotes change

Ensures reflective practice.....


Interrested??

www.guideline-audit.com


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