Audit Training Presentation May 2011 © Tim Coupe

1. Clinical Audit Workshop May 2011

3. Objectives for the session

4. Introductions

5. Healthcare quality

6. Clinical audit

7. Designing and running an audit

8. Exercise

9. Action plans and change

11. Ground Rules First names Phones off (or on silent) please You can ask questions at any time Don’t need to put your hand up

12. Objectives By the end participants should: 1. Understand the principles of clinical audit. 2. Have some basic clinical audit design skills.

13. Introductions In pairs – introduce your partner with Their name and role Where they live/work Why they’re here today One thing they’re very proud of

14. Three dimensions of healthcare quality Structure- resources, physical settings. Process- How knowledge is used (technical), Relationships(the interpersonal). 3. Outcome - the change in service user’s health. (Avedis Donabedian,1966)

15. Why do we look at healthcare quality? To improve how we practice : provide better care To improve how we deliver care: provide a better service

17. Nominate one person to feed back

19. Research, Clinical Audit or Service Evaluation? Research generates new knowledge about an idea/theory Result is abstract: “testing an idea” Clinical audit generates information about clinical practice by measuring it against a standard. Result is practical i.e. “measuring what’s done” Service evaluation generates information about a service by describing it without a standard. Result is practical i.e. “describing what’s done”

20. The Clinical Audit Cycle Select Topic Set Standard/criteria Re-audit Introduce change Collect data Analyse and derive action points

21. Task - The Clinical Audit Race 2 Teams. 15 cards show stages of the audit cycle. Put them in order them on the floor - show the audit cycle Task is over when the first team declares the (right) answer.

23. The Clinical Audit Cycle Select Topic Set Standard/criteria Re-audit Introduce change Collect data Analyse and derive action points

24. Four key things for your project Aim Objectives Audit standard Audit criteria

25. Writing an Aim and Objectives One aim: To ensure procedure X is completed on admission to ward Y Objectives should deliver the aim: Develop a clinical audit of procedure X Use this to measure to what extent X is done on ward Y Write and implement action plan to ensure X is always done Conduct re-audit of X in 2012

26. Measurement of practice against a standard An audit standard is a statement of the level of care/practice expected. All service users have a STORM suicide and self injury assessment within 12 hours of their admission to an adult ward. It should be as unambiguous as possible: “All service users are assessed for potential self harm on admission to a hospital” What kind of assessment, where and when?

27. Each audit standard is measured with criteria 1. What That is the exact process/outcome 2. How much75, 95 or 100% of the time? 3. What not Exceptions and why they are For quantitative audit, criteria will usually be Numerical: Times, Doses, Scores Categories: Yes/No/Don’t know

28. Example criteria All service users have a STORM suicide and self injury assessment within 12 hours of their admission to an adult ward. Audit Criteria: A complete STORM suicide and self injury assessment is done within 12 hours of admission This should occur for 100% of eligible admissions to the adult wards Exceptions – any service user discharged within 12 hours of admission any service user who has was admitted to another ward and has been inpatient for at least 12 hours Data collected could be either categorical (Yes or No) or numerical (hrs to completion)

29. Methods of Data Collection Quantitative Data collection tool/proforma (or a spreadsheet) Numerical data: results, dates, dosages, times. Qualitative Questionnaire, interview, focus groups. Experiences, attitudes, beliefs, meanings, behaviours. Take care about what you’re asking - ethics

30. Designing data collection Keep it simple Paper audits - don’t exceed one sheet (2 sides) if possible Or collect it directly onto a spreadsheet or we will provide a SNAP web survey tool Keep a list of all eligible and all reviewed cases Minimise the amount of personal information you collect Maintain the 6 Caldicott Principles Ask us for help with design

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32. Questionnaires Postal, web or e-mail Short and simple as possible. Clear instructions for respondents. Question types - open/closed, scalar. Least intrusive questions first Layout – clear headings, minimum 10pt font Plain English, avoid clinical/NHS jargon Pilot

33. Interviews Structured, semi structured or unstructured One to one or group Face to face or ‘phone Ethics may be an issue – what are you asking? Need a detailed record of responses Rich data but time/effort intensive Design and execution is skilled task so please ask for advice.

34. Pilot Studies Do a small pilot study of 2- 3 cases before the main project : It will: Test your criteria Show up any practical problems with data collection

35. Sampling An appropriate sample is the number of cases needed to ensure your audit is representative of practice. Random– choosing xnumbers from a list Time Period – all cases from 1 week or 6 months. Cluster – all cases from one team/ward/locality. Rapid Cycle – small numbers (20 - 50), repeated quickly

36. Prospective or retrospective? Prospective(collecting data on practice as it happens) avoids bias from incomplete records but: People may alter their behaviour if their being watched (known as The Hawthorne Effect). Retrospective (collecting data on previous practice) is often quicker and easier but: Open to bias from the quality/completeness of the records.

37. Is my audit design any good? Is it valid? Validity the extent to which the audit measures what it is supposed to. Valid audit measures things accurately. Is it reliable? Reliability means you’d get the same result if the audit was repeated on the same sample. Reliable audit would get the same result.

39. Significant alterations to your team/service

40. Significant staff turnover in your team/service

42. Exercise Scenario: You are concerned patients with bi-polar disorder are not having their physical health checks. You want to ensure they receive physical health checks as detailed in NICE Clinical Guideline Number 38. In your group, write the following An audit aim and objectives to support it. Audit criteria and any exceptions. Methodology – qualitative or quantitative data, data source(s), sampling strategy, pro/retrospective. Feedback in 25 minutes.

43. Thinking about change What year did you get your first mobile phone? Other people Action plans

44. Data analysis and presentation Analysing and presenting findings is the first step of any action/change process. When you do this keep the following in mind: Your results should make sense to the intended audience. Avoid elaborate data analysis – this won’t make your findings any more credible Conclusions and actions should reflect and be proportionate to your findings. Active dissemination/marketing of the results/report/action plan is essential

45. Successfully changing what healthcare professionals do is difficult and requires both skill and commitment. Before writing action plans it’s worth considering what any change in practice actually entails: Carl Lewin (c1947) used the following model for change: This may help you think about how to plan both your project and any action needed from it. Unfreeze Change Re-freeze

46. Healthcare professionals are by definition skilled, knowledgeable and highly autonomous people who work in organisations composed of their peers, other professionals and service users. Responses to any proposed change are personal. Some things that inform how you or I might respond to change are: Awareness and knowledge – Do they know what you’re proposing and why? Motivation – What would motivate people to change? Acceptance and beliefs – Does this fit with their values/beliefs? Skills/Knowledge – Can they actually do what needs to be done? Practicalities – Do they have the resources to change? External Environment – Are there other priorities/competing demands?

47. Adaptation of Innovation E. Rogers c1967

48. Mobile phones – When did you get one? 1991 2011 2000 2005 1995

49. Action Plans Action plans are widely used in the NHS. Some suggestions for writing action point/plans include: Consult as widely as possible before writing your action plan. Consider the other people involved i.e. whose got an interest & what is that interest? Consider the resource implications – can the Trust afford your proposed actions? Scale is significant – bigger changes may be harder to implement Dissemination – your Business Unit, the A & R Committee and who/where else? Review - Are the action points really feasible and implementable?

51. Clinical Audit Resources http://www.rcpsych.ac.uk/pdf/clinauditChap1.pdf http://www.nice.org.uk/usingguidance/implementationtools/auditadvice/audit_advice.jsp http://www.hqip.org.uk/clinical-audit-handbook/ http://www.hqip.org.uk/clinical-audit-resources-3/ http://www.wales.nhs.uk/sites3/Documents/501/Practical_Clinical_Audit_Handbook_v1_1.pdf Statistics resources - random numbers http://www.randomizer.org/form.htm - http://www.graphpad.com/quickcalcs/index.cfm Change and innovation in the NHS http://www.institute.nhs.uk/option,com_quality_and_service_improvement_tools/Itemid,5015.html http://www.sdo.nihr.ac.uk/managingchange.html http://www.tin.nhs.uk/leadership/change-management-workbooks http://www.nice.org.uk/media/D33/8D/Howtochangepractice1.pdf

52. Summation of today Definition of clinical audit. The clinical audit cycle. Four things you need to build an audit Design issues/skills. Written a simple clinical audit. Action plans and change

53. Suggested Personal Development Plan linkages Core Dimension 2: Personal and People Development Levels 1 Contribute to own personal development 2 Develop own skills and knowledge and provide information to others to help their development 3 Develop oneself and contribute to the development of others Core Dimension 4: Service Improvement Levels 1 Make changes in own practice and offer suggestions for improving services 2 Contribute to the improvement of services Core Dimension 5: Quality Levels 1 Maintain the quality of own work 2 Maintain quality in own work and encourage others to do so 3 Contribute to improving quality 4 Develop a culture that improves quality IK2: Information collection and analysis Level 2 Gather, analyse and report a limited range of information IK3: Knowledge and information resources Level 1 Access, appraise and apply knowledge and information G2: Development and Innovation Level 1 Appraise, concepts, models, methods, practices, products and equipment developed by others.

54. Please tell the group one thing that you’ve learnt today Thank you