The National Agenda for Clinical Audit

1. THE NATIONAL AGENDA
FOR CLINICAL AUDIT
Kenneth Mealy, MD, FRCSI
Clinical Director
NOCA

3. Media interpretation of the
Mid-Staffordshire Report:

4. Why clinical audit?
• To improve the quality of service provided to patients
and hence patient care
• It is a unique mechanism for ongoing quality
improvement
• Obliged to audit by the Medical Practitioners Act
• Results of audits are a valuable sources of information
for clinicians, healthcare managers, patients and the
general public.

5. Clinical Audit
• Educational
• Benchmark outcomes Clinical
against national activity
standards Change Audit
practice
• Allow individual
clinicians reflect on Assess against Measure
practice standards outcomes
– Change based on ‘no
blame culture’ and
‘shared learning’

6. Influential publications in Ireland:

7. Madden Report found………….
• Clinical audit is advanced in many organisations
• But not linked to service improvements, planning or
resource allocation
Lourdes Hospital Report (2006)
- concluded that robust and effective peer review and audit
was the only process which could have identified the
failings in clinical practice and governance in that hospital

8. National Standards for Safer Better
Healthcare (HIQA 2012)

9. Features of a hospital which meets the
National Standards include the following:

10. • The Royal College of Surgeons in Ireland (RCSI) and the
Health Service Executive (HSE), under a jointly
developed service level agreement have undertaken the
establishment, administration and management of
NOCA through the NOCA Governance Board.
• NOCA established in 2012
• The primary purpose is to establish sustainable clinical
audit programmes in agreed specialties at national level
• Through this framework, feedback will be provided to
both clinicians and hospitals in order to ensure that
individual and organisational learning occurs.

11. Improving clinical outcomes through peer review and education
• By enabling continuous education through the issue of feedback from its
findings.
• By working with all stakeholders from both state funded and independent
providers
• By encouraging the identification and reporting of incidents to improve
clinical outcomes and the care of future patients
• By ensuring lessons from national clinical audit streams are applied either
through the actions of individual participating clinicians or through the
identification of more general systems improvements to the care of patients.
Addressing the findings of Madden Report and anticipating the
requirements of HIQA inspections

15. Irish Audit of Surgical Mortality
• Based on the methodologies used by the Scottish Audit of Surgical
Mortality (SASM) and the Australia and New Zealand Audit of
Surgical Mortality (ANZASM).
• Similarly to these established national audits the main aim of IASM
will be to reduce surgical mortality in Ireland, through systematic,
independent peer review.
• A professional competence scheme associated with RCSI and CAI
• Governance Committee of IASM overseeing audit

16. Irish Audit of Surgical Mortality
Objectives of an audit of surgical mortality
 Reduction of mortality associated with surgery
 Increasing patient safety, confidence and overall experience
 Promoting and encouraging reflective practice
 Identifying systems failures in Irish hospitals and putting changes in
place

17. Irish Audit of Surgical Mortality
Scope of IASM:
•IASM will provide confidential, independent, peer review of all reported
deaths which occur following an episode of surgical care.
•Reporting will be encouraged and shared learning will be the focus
The experiences of SASM and ANZASM indicate that IASM is likely
to result in changes to clinical practice, at both individual and
institutional level.

18. Irish Audit of Surgical Mortality
A reportable death:
Any patient death that occurs in hospital, where the patient
is under the care of a surgeon
Including:
• All deaths following surgery
• Deaths where patient was under a surgeon but no surgery took
place
• Surgical deaths, any where in the hospital, regardless of their
inclusion in other audits

19. Irish Audit of Surgical Mortality
IASM Workload…………….
IASM Workload…………….
• Mean of 11,500 public hospital deaths annually (2005-2010
inclusive, HIPE data)
Year 2005 2006 2007 2008 2009 2010
Deaths
in
hospital 11524 11681 11933 11753 11582 10970
• Breakdown of surgical deaths in hospital more difficult to ascertain
• Medical deaths to Surgical deaths ratio 2:1………we can predict
3,858 surgical deaths
• Population based calculations using the experience of
SASM….4,000 surgical deaths

20. IASM – governance process
First line assessment No areas for
Sign off
concern
Areas for concern
Areas for concern Sign off
Second line assessment addressed
-Consultant feedback
-Clinical Director feedback
Review process -Local M&M meeting
IASM and NOCA
Repeat second line assessment Governance
Boards

21. IASM -Reporting
Annual reports
– Individual consultant
– Institution
– Specialty
– National

22. Irish Audit of Surgical Mortality
Confidentiality and data protection:
•IASM, and its Governance Committee and the Governance Board of NOCA
will endeavour to ensure that all records are retained in the strictest of
confidence.
•Freedom of Information requests will be considered on a case by case basis. If
possible requests will be denied, but refusals may be challenged under current
legislation.
•Additionally under current legislation an order of discovery may be granted by
the Courts in a civil action for audit data held by NOCA. Currently the data held
by NOCA cannot be claimed to be privileged and therefore maybe accessible
through an order of discovery.
•NOCA is actively working with the HSE to ensure that the upcoming Health
Information Bill will offer full protection to clinical audit data in Ireland.

23. Irish National Orthopaedic Register
 To provide a national system for monitoring joint arthroplasty
 To increase patient safety, confidence and overall experience
 To optimise inpatient care, waiting lists inpatient and out patient
attendances
 To reduce surgical revision rates / reduce the cost of service
 To monitor and grade Implant performance
 To enable early detection and review of outliers
 efficient and accurate recall process if required
 To proactively include Consultant Orthopaedic Surgeons in the clinical audit
process in both public and private practice

24. National ICU Audit
• Measure –
– activity data, case mix and patient outcomes
– quality outcomes benchmarked against
international standards
• Audit of potential organ donors and organ
donation
• Use audit to drive improvements in ICU
performance

25. • Health Service • Clinician
– Quality assurance – Reflective practice
• Benchmarking to national – Improved performance
and international best-
practice
Improved patient outcome