Audit and SEA Made Easy

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Audit and SEA Made Easy GPST Teaching May
2012 Dr Kate Lewin GPST Course Organiser NHS
Education for Scotland
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Definitely not rocket science
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Aims of workshop

• Refresh your knowledge of, or introduce you to,
  audit and SEA
• Define criteria and standards
• Increase confidence in performing Audit/SEA in
  your own practice
• Appreciate the use of audit/SEA in quality
  assurance, also for revalidation, QOF etc.
• Signpost to resources for further guidance

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What is audit?
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What is Audit?
A range of definitions exist

• Audit is about taking note of what we do,
  learning from it and changing if necessary
• Audit is the improvement in the quality of care
  through standard-setting, peer review,
  implementation of change and re-evaluation
• Quite simply, audit is a tool that enables you to
  monitor and then improve the quality of care you
  provide to your patients.
• Systematic critical analysis of the quality of
  health care

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The Audit Cycle
Choose the Topic
Define Criteria Standards or What do you think
you should be doing
Define Criteria Standards or What do you think
you should be doing
Collect the Data i.e. The Information on what
you are doing
Identify the Changes Required Implement Them
!!
Assess Performance against criteria
standards How are we doing in relation to what
we should be doing ?
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The Audit Cycle
Choosing The Topic Eg. Clopidogrel Prescribing
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The Audit Cycle
Define Criteria Standards Criteria - what you
want to measure (yard-stick) eg. Patients
should have clopidogrel prescribed only in
accordance with NHSGGC guidelines (ie. aspirin
contraindicated or postACS/angiography) Standard
- how well you should be doing 80 of patients
should have clopidogrel prescribed in accordance
with NHSGGC guidelines
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The Audit Cycle

• Collect the Data
• Identify patients on clopidogrel
• 2. Pharmacist review of notes identify when
  started, by whom, indication, whether ever on
  aspirin /- PPI
• 3. Determine whether in accordance with
  guidelines

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The Audit Cycle
Assess Performance Compare our results with
the standard previously set e.g. 21 of 116
patients on clopidogrel (18) were prescribed
according to NHSGGC guidelines far below
standard of 80
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The Audit Cycle

• Agree Implement
• Changes Required
• Explore reasons for inappropriate use
• Feedback to colleagues, discuss changes and
  implement them
• Eg. Letters to patients/cardiologists,
  face-to-face medication review, raising awareness
  of prescribers

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The Audit Cycle
Repeat the Audit!!! Data Collection 2 Repeat
data collection once changes have had a chance to
take hold
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The Audit Cycle
Re-assess Performance Compare the results with
the standards previously set and results of data
collection 1 Has the standard now been
met? e.g. Now find that 48 of 90 (53) of
patients on clopidogrel are prescribed within
guidelines ie. Significant improvement but still
below standard
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The Audit Cycle
Identify Further Changes Required Long term
issues Determine if further change is required
to sustain performance, and decide when next to
audit this topic (annually, every 2 years etc.)
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Examples of Criteria Standards
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Criteria
Simple logical statements, used to describe a
measurable item of quality health care ie. What
you want to measure e.g. Patients with asthma
should have their inhaler technique assessed at
least once every 12 months.
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Standard
Describes the ideal level of care to be achieved
for each criterion ie. How well you should be
doing e.g. 80 of patients with asthma should
have their inhaler technique assessed at least
once every 12 months.
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Arriving at Standards

• Dont get overly concerned - standard setting is
  flexible, can be revised upwards or down
• Those involved decide on the level of care they
  find desirable - it is a professional issue.
• Guidance can be derived from the
  literature/textbooks, but ultimately you decide.
• Can be based on your own work and observations,
  varies between practices

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Report format for audit
Report Section Guidance
Reason for Audit Explain why the topic was chosen Potential benefits to patients/staff/practice
Criteria Set Try to limit to 1-3, relevant to topic Short simple logical statements Justify with reference to current evidence
Standards Set Agree a measureable standard for each criterion Set a realistic timescale
Preparation and Planning Who you discussed the audit with, and who assisted you How you collected and analysed the data
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Report format cont.
Report Section Guidance
Data Collection 1 Present using simple descriptive statistics/tables/graphs Do not present irrelevant data Comment on comparison with standard set
Description of Change Describe changes agreed and implemented Attach example as evidence if possible
Data Collection 2 Compare with standard and with data collection 1 If standard not reached speculate as to why
Conclusions What have you learned How do you intend to take forward in future
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Group Exercise 1Criteria StandardsGroup
Exercise 2Implementing Change
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Significant Event Analysis

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What is a significant event?
Any event thought by anyone in the team to be
significant in the care of patients or the
conduct of the practice (Pringle et al,
1995)
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What happened?

• Record all of the facts relating to the
  identified significant event (including any
  relevant dates, times and people or organisations
  involved)
• Data source those directly and indirectly
  involved
• Establish a clear and full picture of what
  happened
• Impact or potential impact

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Why did it happen?

• Establish all of the main and underlying reasons
  why the event actually occurred.
• Eg. A written telephone message about an
  important meeting was not passed to the practice
  manager because it had been lost.
• But. why was it lost?
• Because it was written on a post-it and left on
  top of a report, which was subsequently filed
  away by an unsuspecting member of staff.
• ie. Internal communication practices not up to
  scratch!

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What have you learned?

• Highlight any learning issues you and/or the
  practice experience.
• For example it may be related to a training need
  or a lack of knowledge concerned with
  therapeutics, disease management or
  administrative procedures.
• It could also reflect a learning experience (good
  or not so good) in dealing with patients,
  colleagues, or other organisations
• Ensure that insight into the event has been
  established by the practice team or the
  individuals concerned

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What have you changed?

• Often a change in some aspect of care is required
  to improve the provision of care and/or minimise
  the risk that a similar event will occur.
• If so, a description of the change actually
  implemented should be given rather than a wish
  list of thoughts

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What have you changed? (cont.)

• Sometimes it is not possible to implement change,
  either because the likelihood of the event
  happening again is so rare or because change is
  outwith the control of the individual/practice.
• If this is the case, then reasons should be
  clearly documented.
• Regardless of the type of significant event,
  change should at least be considered, then either
  implemented or justifiably ruled out

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Important points

• Doesnt have to be an bad event
• Could explore example of excellent practice
• Sharing
• Team activity
• Blame-free
• Constructive learning not finger-pointing
• Look beyond the superficial
• For underlying/systematic causes

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Useful links for further information

• Guidance on Audit, RCGP Revalidation Toolkit
  (p28)
• http//www.rcgp.org.uk/PDF/Scot_Complete_Revalidat
  ion_Toolkit_(Read_Only).pdf
• Ideas for Audit, NES
• www.clinicalgovernance.scot.nhs.uk/.../ideasforaud
  itandSEA.rtf
• SEA NPSA Guide 2008
• http//www.npsa.nhs.uk/nrls/improvingpatientsafety
  /primarycare/significant-event-audit/

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Nothing changes if nothing changes
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Group Exercise 3Analysis of SEAs