Clinical Audit, Research or Service Evaluation? Flashcards
What is the definition of a Clinical Audit ?
Clinical Audit - A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation off change
- Self examination
“Are we doing it right according to clinical standards? If not, how can we improve?”
What is the definition of Research ?
Research - The attempt to derive generalisable new knowledge by addressing clearly defined questions with systematic and rigorous methods
- Dabble in other areas with other researchers
“What should we be doing?”
What is Service Evaluation ?
Service Evaluation - A review process undertaken solely to define or judge current service with the intention of benefiting those who use it
- Used to inform local practice
- May result in service redesign
“How well does a service achieve its intended aims (patient experience and outcomes)?
What are the differences between the Purpose of a Research, Audit and Service Evaluation ?
Purpose:
- Research: Generalise new knowledge
- Audit: Inform delivery of best care
- Service Evaluation: Define or judge current care
What are the differences between the Question of a Research, Audit and Service Evaluation ?
Question:
- Research: Test hypothesis (quant), explore themes (qual)
- Audit: Does it reach a pre-determined standard ?
- Service Evaluation: What standard does this service achieve
What are the differences between the Objective of a Research, Audit and Service Evaluation ?
Objective:
- Research: Specific research objectives
- Audit: To measure service against accepted/defined standard
- Service Evaluation: To measure current service without reference or a standard
What are the differences between the Interventions of a Research, Audit and Service Evaluation ?
Interventions
- Research: Novel use or application
- Audit: Already in use
- Service Evaluation: Already in use
What are the differences between the Data additional to usual care of a Research, Audit and Service Evaluation ?
Data additional to usual care:
- Research: Yes, including invasive tests
- Audit: Can include questionnaire/interview
- Service Evaluation: Can include questionnaire/interview
What are the differences between the Allocation to intervention of a Research, Audit and Service Evaluation ?
Purpose;
- Research: Yes, usually
- Audit: No
- Service Evaluation: No
What are the differences between the Randomisation of a Research, Audit and Service Evaluation ?
Purpose;
- Research: Maybe
- Audit: No
- Service Evaluation: No
What are the general differences between Research, Audit and Service Evaluation ?
See image
What kind of questions would you ask in Service Evaluation Questions ?
- Does the service achieve its objectives?; How?; What are the costs ?
- Does the service (still) meet patients needs?
- Is the service equitable ?
Components: Structure, process, outcome
Examples;
- What are the patient experiences of attending a community pulmonary rehabilitation service ?
- What are the waiting times for patients attending A&E department in the hospital ?
What kind of questions would you ask in Audit Questions?
Does this service reach a predetermined standard ?
- What proportion of patients presenting to A&E are seen within 4 hours ? Standard is >95%
- What proportion of patients referred for urgent investigation of colorectal cancer are seen within 2 weeks? Standard = 100%
- What proportion of patients with diabetes have an annual review by their GP or practice nurse? Standard = 100%
What kind of questions would you ask in Research Questions?
How do patient outcomes compare between this service (or treatment) and an alternative ?
- Quantitive research (hypothesis test)
Example: What is the impact of a nurse-led dermatology clinic in primary care on the quality of life of children with eczema ?
Parts to a (quantitative) research question = PICO (Patient or Population, Intervention, Comparison, Outcome)
Example: What are the concerns of women being recalled for a repeat cervical smear ?
- Qualitative research (no stats)
What was the significant of the RECOVERY trial?
NHS Research - University of Oxford
Research during COVID that looked at multiple overlapping trials of potential treatments in 187 Hospitals, 44,500 hospitalised pts.
It showed;
- Dexamethasone 6mq/day reduced mortality by 1/3 in
pts needing respiratory support & by 1/5 in pts
needing O2
- Hydroxychloroquine and convalescent plasma - no clear
clinical benefit
Use of it estimated to have saved >22,000 lives in Uk & > 1 million worldwide !!!
Managed to get treatments published in only 9 days, incredible!
Ingredients to this quick and informative research;
- A national health service,
- Proficient research group, efficient organisation (Oxford best researchers)
- Dedicated medical teams,
- Many volunteers
Affected patient outcomes during covid tremendously
What should you look for when critically appraising papers?
BIAS!
Bias is the unequal distribution or error
Where does audit come from?
Where does audit come from?
Department of Health, 1989, ‘Working for Patients’
Part of the clinical governance agenda;
- Personal responsibility (expectation that staff will do audit)
- Organisational culture / Clinical audit strategy
- Reduce variation between providers (post-code lottery)
Your role as a newly qualified doctor;
- more than a tick box exercise !
- audits can improve practice / quality / pt experience
- improved professional satisfaction
- audits can be published !!
(e.g. the BMJs Quality Improvement Reports)
What is Healthcare Quality Improvement Partnership (HQIP)?
Healthcare Quality Improvement Partnership (HQIP)
- The National Clinical Audit Programme - (England & Wales)
Topics:
- COPD
- Diabetes
- Heart Failure
- Stroke
- Dementia,
- Bowel Cancer
- Care at the End of Life
- + Many more
How can Research and Audits overlap ?
- Research finding can identify areas for audit
- Audit can be the final stage of a research project
- Audit can help with dissemination of research findings
- Audit can identify gaps in research evidence
e.g Measuring Carbon Monoxide in the
breath of all pregnant women at booking
- October 2011: introduced in NHS Fife
April 2012: audit of implementation of recommendations
- 4 weeks, proportion of women offered CO breath test
- Hospital A: 25/25 (100%)
- Hospital B: 19/35 (54%)
- Why the difference?
Scotland-wide research study of opinions of midwives on the new policy
What are the main methods/processes involved in Audits?
Prospective - ongoing data collection (beware the
“Hawthorne effect” - E.g when someone watching you, you do bloods more carefully)
Steps:
1). Identify a topic / problem
2). Identify local resources (? local audit dept)
3). Choose the standard, create the audit proforma
4). Define the sample
5). Collect data (? do a pilot)
6). Compare data with the standard
7). Develop and implement change
8). Re-audit
What is the criteria for choosing a topic?
Criteria for choosing a topic;
- Is the topic of high cost, high volume, or risk to staff or users?
- Is there evidence of a serious quality problem, for example patient complaints or high complication rates?
- Is evidence available to inform standards, for example systematic reviews or national clinical guidelines?
- Is the problem amenable to change?
- Is the topic a priority; for the organisation?; for a national policy initiative?
- Is there potential for involvement in a national audit project?
What is the criteria for choose a standard ?
Criteria for choosing a standard;
Agree the standard (minimal, ideal or optimal);
- Minimal: lowest acceptable level of performance
- Ideal: the care possible under ideal conditions (e.g. 100% survival ???) - elusive!
- Optimal: realistic under normal conditions of practice (somewhere between minimal and ideal)
Is it evidence based and related to aspects of care?
Sources of evidence:
- National guidelines (e.g. NICE, SIGN)
- Cochrane database of systematic reviews
- MEDLINE, PubMed, EMBASE (check with NHS library)
‘Evidence-Based Practice’ versus Practice-Based Evidence’
How should you select the sample?
Selecting the sample;
- Inclusion criteria
- Exclusion criteria (e.g. comorbidities)
- Size of sample: power calculations
- Estimated percentage (P)
- Standard error (SE) of percentage [ P (100 - P) / n ] where ‘n’ sample size
- SE is a measure of the error of your estimate
- Small ‘n’ large error, Large ‘n’ -+ smaller error
- SE used to derive a 95% confidence interval (95%CI)
- 95%CI is an interval in which we are 95% confident that
the TRUE percentage lies
