Vetlearning

2. Maximising clinical effectiveness Bradley Viner BVetMed MSc(VetGP) DProf MRCVS

3. The six ‘pillars’ of clinical governance

4. Narrowing it down….

5. Definition of clinical effectiveness   ‘The application of the best available knowledge, derived from research, clinical experience and patient preferences to achieve optimum processes and outcomes of care for patients.’ Royal College of Nursing (1996)

6. Clinical effectiveness Peer review: An assessment of the quality of care provided by a clinical team with a view to improving clinical care, including interesting or unusual cases. E.g. Regular practice meetings to carry out morbidity and mortality reviews. Critical Incident review: In specific cases which have caused concern or from which there was an unexpected outcome, such as an anaesthetic death in a patient that was considered to have been at low risk. Discussion and reflection should enable the team to learn from what has happened and to improve in future, but it is important that this can take place in a no-blame environment where all team members feel free to open up about what took place. Client survey and focus groups: These are methods that can be used to obtain users’ views about the quality of care they have received and thus inform the manner in which clinical care is provided and the areas where there is most room for improvement. Clinical guidelines Clinical Audit Cycle Benchmarking

7. Clinical audit

8. Clinical audit cycle

9. THE CLINICAL AUDIT CYCLE

10. Kolb’s learning cycle (reflective practice) Reflection on action key to good practice. Blame-free work environment. Ethos of continual improvement. Hand in hand with audit.Reflection on action key to good practice. Blame-free work environment. Ethos of continual improvement. Hand in hand with audit.

11. Clinical audit- why bother? Quality control – optimization of provision of veterinary careQuality control – optimization of provision of veterinary care

12. THE CLINICAL AUDIT CYCLE

13. Establishing an area of audit Commonly encountered Amenable to measurement Have room for improvement in performance Important (critical incident review?) 13

14. Build an audit team Consider stakeholders: Which vets? RVN’s Practice manager Front desk staff Clients??

15. THE CLINICAL AUDIT CYCLE

16. Guidelines vs protocols What is the difference between them and when are each appropriate?

17. Clinical guidelines: what are they? They involve an explicit attempt to systematically review the literature on the subject in question for the best available evidence. They represent a consensus in the setting in which they are prepared rather than the opinion of an individual. This may be a panel of experts if they are nationally developed guidelines, or a team of clinical staff if they are guidelines being written or adapted for local use. The information is presented in a summarised form, often as a series of bullet points, so as to be readily accessible in a clinical situation.

18. Clinical guidelines:their value They can assist the application of evidence-based Best Practice to individual patients They help to provide a uniform standard of care They can be used in the education and training of health professionals They can help clients to make informed decisions by improving communications and managing expectations They can incorporate a cost/benefit analysis of the diagnostic and treatment options

19. Clinical guidelines:potential issues They could be imposed by regulators, or by pet insurance companies or employers as cost-cutting exercises and thus restrict access to potentially useful treatments The evidence base may be hard to find They may interfere with the clinical freedom of clinicians Guidelines could be used against the profession in litigation and therefore increase defensive medicine.

20. Guidelines - EBVM Establish guidelines using EBVM: “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. This means integrating individual clinical expertise and the best available external clinical evidence from systematic research” Handbook of EBVM, Cockcroft and Holmes (2003)

21. EBVM hierarchy of evidence At bottom – recommendations from drug sales reps, gossip picked up in the pub whilst sober, and finally gossip picked up in the pub whilst inebriated, info from drug sales reps about their products, and last of all, info from drug sales reps about other companies products! At bottom – recommendations from drug sales reps, gossip picked up in the pub whilst sober, and finally gossip picked up in the pub whilst inebriated, info from drug sales reps about their products, and last of all, info from drug sales reps about other companies products!

22. THE CLINICAL AUDIT CYCLE

23. Selection of criteria Criteria are explicit statements that define what is being measured, and represent elements of care that can be measured objectively (NICE, 2002)

24. Selection of criteria DREAM…… Distinct Relevant Evidence-based Achievable Measurable Examples?Examples?

25. THE CLINICAL AUDIT CYCLE

26. Measure performance Can measure: Processes Outcomes

27. Measure performance Establish standards: “A statement which outlines an objective with guidance for its achievement given in the form of criteria sets which specify required resources, activities, and predicted outcomes. It decides the level of care to be achieved for any particular criterion”. “Targets” is a less ambiguous term 27

28. Clinical audit – avoiding pitfalls Do not confuse audit with practice-based research Pick a topic that occurs commonly Clearly define the criteria Do not over-complicate the audit Allow sufficient protected time Forum - emailForum - email

29. Audit and research –the differences Research A systematic investigation, which aims to generate new knowledge by testing a hypothesis May involve allocating patients randomly to different treatment groups, interviewing or conducting questionnaires. May involve a completely new treatment or service. May involve extra disturbance or work beyond that required for normal clinical management. May involve the application of strict selection criteria to patients before they are entered into the research study. Provides the foundations for national or local agreement about the kind of clinical treatment and care we should be providing – i.e. it helps to answer the question “What is Best Practice?”

30. Audit and research –the differences Clinical Audit Measures processes or outcomes against a set of clinical targets. Never involves experiments. Is all about improving performance Does not involve a completely new treatment. Does not involve disturbance to patients or owners beyond that required for normal clinical management. Answers the question “Are we following agreed Best Practice?”

31. Clinical audit- obstacles 31

32. Clinical audit - summary Ongoing cycle of improvement Pick key areas of audit Build an audit team Create a positive working environment Define your criteria and standards carefully Use the best evidence available Exchange data with colleagues KISS 32 Forum - emailForum - email

33. Thank you for joining me