Why are clinical audits so important?
Clinical audit definition
Clinical audit is the process formally introduced in 1993 into the United Kingdom's National Health Service (NHS), and is defined as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change".
The key component of clinical audit is that performance is reviewed (or audited) to ensure that what should be done is being done, and if not it provides a framework to enable improvements to be made.
The clinical audit process seeks to identify areas for service improvement, develop and carry out action plans to rectify or improve service provision and then to re-audit to ensure that these changes have an effect.
Clinical audit process
Types of clinical audit
The place of clinical audit in modern healthcare
Patient surveys and focus groups - These are methods used to obtain users' views about the quality of care they have received. Surveys carried out for their own sake are often meaningless, but when they are undertaken to collect data they can be extremely productive.
Standards-based audit - A cycle which involves defining standards, collecting data to measure current practice against those standards, and implementing any changes deemed necessary.
Adverse occurrence screening and critical incident monitoring - This is often used to peer review cases which have caused concern or from which there was an unexpected outcome. The multidisciplinary team discusses individual anonymous cases to reflect upon the way the team functioned and to learn for the future. In the primary care setting, this is described as a 'significant event audit'.
Peer review - An assessment of the quality of care provided by a clinical team with a view to improving clinical care. Individual cases are discussed by peers to determine, with the benefit of hindsight, whether the best care was given. This is similar to the method described above, but might include 'interesting' or 'unusual' cases rather than problematic ones. Unfortunately, recommendations made from these reviews are often not pursued as there is no systematic method to follow.
Clinical audit comes under the Clinical Governance umbrella and forms part of the system for improving the standard of clinical practice.
Clinical Governance is a system through which NHS organisations are accountable for continuously improving the quality of services, and ensures that there are clean lines of accountability within NHS Trusts and that there is a comprehensive programme of quality improvement systems. The six pillars of clinical governance include:
Research and Development
Education and Training
Clinical audit was incorporated within Clinical Governance in the 1997 White Paper, "The New NHS, Modern, Dependable", which brought together disparate service improvement processes and formally established them into a coherent Clinical Governance framework.
Clinical audit is an essential and integral part of clinical governance.
"Would you tell me, please, which way I ought to go from here?" asked Alice
"That depends a good deal on where you would like to get to," Said the cat
Lewis Carroll (1865) Alice’s adventure in Wonderland
Research is a systematic and rigorous process of enquiry, which aims to develop and test explanatory concepts and theories .The ultimate aim of research is to contribute to a scientific body of knowledge. The scientific knowledge can then be used to inform patient care, service delivery, staff development /training and further research.
There are ranges of different research methods that are used to investigation health and health services. It is not possible to place research methods in a hierarchy of excellence, as different research methods are appropriate for addressing different research questions.
The researcher is therefore required to choose the most appropriate method and design in order to address a particular research question.
Useful resources to assist researcher in deciding on the most appropriate research design:
John Creswell 2008 Research design: Qualitative, Quantitative and mixed methods approaches 3rd edition Sage Publications
Ann Bowling 2009 Research Methods in health: Investigating health and health services Open University Press
Catherine Dawson 2009 Introduction to research methods 4th edition, How to books ltd.
What is a systematic review?
A systematic review is a systematic literature review focused on a research question that tries to identify, appraise and select and synthesize all high quality research evidence relevant to that research question .A systematic review aims to provide an exhaustive summary of the literature relevant to the research question.
What is a Cochrane Review?
Cochrane Reviews are systematic reviews of research in healthcare and health policy that are published in the Cochrane Database of Systematic Reviews. There are three types of Cochrane Review:
1. Intervention reviews assess the benefits and harms of interventions used in healthcare and health policy.
2. Diagnostic test accuracy reviews assess how well a diagnostic test performs in diagnosing and detecting a particular disease.
3. Methodology reviews address issues relevant to how systematic reviews and clinical trials are conducted and reported.
Cochrane Reviews base their findings on the results of trials, which meet certain quality criteria, since the most reliable studies will provide the best evidence for making decisions about health care. Authors of Cochrane Reviews apply methods which reduce the impact of bias across different parts of the review process, including:
1. Identification of relevant studies from a number of different sources (including unpublished sources);
2. Selection of studies for inclusion and evaluation of their strengths and limitations on the basis of clear, predefined criteria;
3. Systematic collection of data;
4. Appropriate synthesis of data.
Performing a systematic review
The Cochrane handbook outlines eight general steps for systematic reviews.
1. Define the review question and develop a criteria for including studies
2. Search for studies
3. Select studies and collect data
4. Assess risk of bias in included studies
5. Analyze data and undertake meta-analyses
6. Address reporting biases
7. Present results and "summary of findings" tables
8. Interpret results and draw conclusions
Browse the Handbook online at handbook.cochrane.org
Training on how to undertake systematic reviews are available and strongly recommended prior to embarking on your first systematic review.
Evidence based practice
What is evidence -based practice (EBP)?
Many terms are used in relation to evidence-based practice, evidence based nursing, evidence based nursing practice, evidence based medicine and evidence based healthcare.
Evidence based practice originated in medicine in 1992, since that time it has been gaining momentum in other disciplines, like nursing. More information about the development and history of evidence -based practice can be found at www.cebm.net/
Evidence-based practice (EBP) involves complex and conscientious decision-making, which is based not only on the available evidence but also on patient characteristics, situations, and preferences. It recognizes that care is individualized and ever changing and involves uncertainties and probabilities.
Most commonly used definition
Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available clinical evidence from systematic research. (Sackett et al., 1996).
In the good old days when we asked why something was done in a particular way a nurse’s mantra was ‘sister says so’ or ‘we’ve always done it this way’. This is no longer sufficient and there is an expectation that strong evidence must underpin nursing practice.
Nurses need to make sure that the evidence they use is relevant to the practice of nursing. There is a range of evidence that can inform practice, personal experiences and reflections, literature, research, audit, policy, guidelines and clinical expertise all of which has its place within EBP.
The basic principles of evidence-based practice are that practical decisions should be made based on research studies and these studies are selected and interpreted based on the evidence based practice categories of evidence.
Categories of evidence- a rating system for the hierarchy of evidence
Level one – Evidence from systematic reviews or Meta analysis of all relevant randomized control trials (RCT)
Level two – Evidence obtained from well-designed RCT’s
Level three – Evidence obtained from well-designed control without randomization
Level four – Evidence from well-designed case control or cohort studies
Level five – Evidence from systematic reviews of descriptive and qualitative studies
Level six – Evidence from single descriptive or qualitative studies
Level seven – Evidence from expert opinion, authorities and/or reports from expert committees.
Challenges with evidence based practice
Evidence retrieval is one of the most common challenging issues with evidence based practice within a clinical settings learning to frame a question, so that an appropriate literature review can be performed .The following acronym is used to help practitioners remember the key components required and is called the ‘PICO” model.
P = Who is the Patient Population?
I = What is the potential Intervention or area of Interest?
C = Is there a Comparison intervention or Control group?
O = What is the desired Outcome?
Useful resources and references
1. Janet Barker 2009 Evidence Base Practice for Nurses, Sage Publication
2. Users' guide to detecting misleading claims in clinical research reports Victor M Montori, Roman Jaeschke, Holger J Schünemann, Mohit Bhandari, Jan L Brozek, P J Devereaux and Gordon H Guyatt BMJ 2004;329;1093-1096
3. Methods in health services research: Interpreting the evidence: choosing between randomised and non-randomised studies Martin McKee, Annie Britton, Nick Black, Klim McPherson, Colin Sanderson and Chris Bain BMJ 1999;319;312-315
4. Introduction to Evidence Based Medicine Michael Turlik, DPM1 The Foot & Ankle Journal 2 (2): 4
5. Sackett, D.L., Rosenberg, W.M.C., Gray, J.A.M., Haynes, R.B. & Richardson, W.S. (1996). Evidence-based medicine: what it is and what it isn’t. British Medical Journal, 312, 71- 2.
6. Sackett, D. L., Straus, S.E., Richardson, W.S., Rosenberg. W. & Haynes, R.B. (2000). Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingston