Surgical Audit

 

• INTRODUCTION/DEFINITION.
• HISTORICAL PERSPECTIVE
• CLASSIFICATION/TYPES
• THE AUDIT COMMITTEE
• COMPONENTS OF AUDIT
• PRINCIPLES OF SURGICAL AUDIT
• CONDUCT OF AN AUDIT
• IMPORTANCE/USES OF SURGICAL AUDIT
• LIMITATIONS/RECOMMENDATIONS
• CONCLUSION

INTRODUCTION/DEFINITION

• Audit was derived from the Latin word “Auditus”…..meaning a hearing.

• Surgical audit is a systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources , and resulting outcome and quality of life for the patient when compared to recognized standard.

• David Johnson also defined audit as a means of quality control for medical practice by which the profession shall regulate its activities with the intention of improving overall patient`s care.

• The purpose of an audit is to examine whether what you think is happening is really true, and whether current performance meets existing standard.

• Surgical audit is a critical review of a personal, team or hospital`s clinical work.

• It is not a fault finding process or a punitive process.

• It may be regarded as a cornerstone of professional development.

HISTORICAL PERSPECTIVE

• One of the most notable surgeons to declare his failures, as well as his successes for the benefit of his colleagues, was the great 19thcentury German surgeon of Swedish origin, The odor Billroth (1881).

• Florence Nightingale organized a form of audit in 1857, during the Crimean war.

• Surgical audit was said to have been born when E.A Codman (1896 -1940) proposed that …..”we must formulate a report of results of treatment to access management efficacy”

• H.B Delving (1932 –1998) …..”surgery without audit is like playing cricket without keeping the scores.

CLASSIFICATIONS OF SURGICAL AUDIT

• Essentially two types of audit are encountered;
• National audit
• Local/ Hospital audit

• Audit can equally be divided into;
• Medical audit: -is undertaken by Doctors alone and involves review of clinical events.
• Clinical audit: -a review of all potential medical event surrounding the treatment of a patient. It will include the Nursing services, Physiotherapy, social aspects of the treatment etc.
• Audit can be;

• TOTAL PRACTICE OR WORK LOAD AUDIT –is an audit that covers all the surgical operations performed.

• SELECTED AUDIT FROM SURGICAL PRACTICE –it is an audit that covers all patients who undergo a selected procedure or an audit that covers all procedures conducted within a selected time frame.

• GROUP OR SPECIALTY AUDIT –this is an audit conducted by or under the auspices of a group or specialty society e.g. Australian breast implant registry, SMILE TRAIN etc.

• A FOCUSED AUDIT -It is an audit on the outcome of a particular process initiated by a department. E.g. antibiotic prophylaxis.

THE AUDIT COMMITTEE

• Hospital audit committee draws members from a range of clinical backgrounds such as Doctors ( Consultants, general practitioners, trainee Doctors), Nurses, Pharmacists, Physiotherapists, together with audit staff.

AUDIT COMMITTEE FUNCTIONS

• Coordinate and foster clinical audit for everyone involved in patient care.

• Offer reassurance that audit is valuable to patients and clinicians, and not threatening.

• Determine existing practice of audit.

• Assist clinicians to implement audit methods.

• Monitor the data, results, conclusions, and reporting of audit process.

• When changes are indicated, to ensure they are implemented and the effects monitored.

• Promote educational value of audit.

• Maintain confidentiality.

COMPONENTS OF AUDIT

• Donabedianin 1966 identified three main elements in the delivery of health care;

• STRUCTURE–the physical environment in which health care is provided.

• PROCESS–the activity of providing care.

• OUTPUT –the outcome of that care for both the individual and the community.

FEATURES OF A GOOD SURGICAL AUDIT

1. It should be honest, complete and standard.
2. Confidential
3. It should be about measuring how faryou are from the standard and not where you are.
4. Objectives and goals must be defined as to an agreed standard.
5. Select standards –decide what the standards of good practice are for the selected topic/ practice area. This can be done by using evidence-based research and guidelines.
6. The scope or topic chosen for audit should be clearly defined. Failure to define this may lead to insufficient or inappropriate data being collected.
7. It must be relevant to common clinical problems.
8. It should be educational not punitive.

LIST OF SOME ADVERSE EVENTS REPORTABLE OR MONITORED IN SOME HOSPITALS FOR AUDITING:

• Death in surgical patients.

• Unplanned readmission to ICU from ward.

• Unplanned re-operation.

• Unplanned blood transfusion.

• Complications prolonging anticipated hospital stay for more than seven(7) days.

• Inadvertent perforation of a viscous.

• Serious drug reaction or interaction.

• Medical error.

• Cardiac or respiratory arrest.

• Fall.

• Pressure sores.

• Reportable infection.

• Booked for theater and cancelled in the day of surgery.

DIFFERENCE B/W AUDIT, CLINICAL REVIEW AND RESEARCH

• surgical audit is a comparison against recognized standard of current surgical practice in order to improve the quality of care to patients.

• Data is collected with defined criteria.

• Comparisons are undertaken and recommendations for change made and followed up.

• A clinical review involves detailed presentation of one or more cases often with certain objectives and around a specific theme.

• However, reviewing one or two cases should be seen as one aspect of an audit but not audit in itself.

DIFFERENCE B/W AUDIT, CLINICAL REVIEW AND RESEARCH:

• Audit does not necessarily extend the knowledge base of surgery (no new discoveries), but by critically analyzing surgical practice.
• The primary purpose of an audit is not to promote scientific enquiry and therefore the requirements and constraints of research does not apply.

Before starting an audit, the following questions have to be answered:

• Are the standards measurable, specific and realistic ?
• Will you be able to collect information that can be compared with the standards?
• Are you as clear as possible about what constitutes good practice in your chosen area?
• Can you foresee any reason that you cannot achieve these standards.

CONDUCT OF AUDIT

IDENTIFY A SUBJECT MATTER TO BE ASSESSED. EG.

• Structure

• Resource usage

• Access to treatment

• Post graduate training.

Process.

• Supervision of trainee.
• Maintenance of notes
• Prep assessment.

Outcome.

• Mortality, Morbidity & Quality of life after treatment.

Conduct of an Audit

• SELECT STANDARD -ESTABLISH SUITABLE CRITERIA AGREED LOCALLY AGAINST WHICH TO JUDGE PERFORMANCE.

• COLLECT RELEVANT DATA

• PRESENT AND INTERPRET RESULTS; Compare performance with target standard. Decide about what changes that may lead to improvement e.g. learning new skills, changes in practice, systems etc.

• IMPLEMENT CHANGES AND MORNITOR PROGRESS.

• REPEAT AUDIT CYCLE.

Audit of structure

AUDIT OF STRUCTURE(what’s in place)

• Structure includes the quality and type of resources available.

• It is generally easy to measure.

• It is not a good indicator of quality of care but should be taken into account in the assessment of process and outcome.

PROCESS (what’s done)

• Process defines what is done to the patient.

• It includes consideration of the way an operation was performed, what medications were prescribed, the adequacy of notes, compliance with consensus policies.

• This is the area of patient care that is most open to change by the clinician.

AUDIT OF OUTCOME

Outcome is the result of clinical intervention, and may represent the success or failure of process. For example, outcome can be measured by the following parameters;

1. Mortality
2. Morbidity
3. Duration of admission
4. Unplanned ICU admission
5. Readmission (within 5days)
6. Hospital Admission after day case surgery. etc

It can be considered to be the most relevant indicator of patient care. But it is the most difficult to define and quantify

• It’s the type of audit that Surgeons are most suspicious about.

IMPORTANCE/USES OF SURGICAL AUDIT

1. Educational opportunities –
2. Exposes areas of poor practice.
3. Encourages better practice with good result.
4. Creates awareness and gives room for excellence.
5. Provides avenue for suggestions on how to improve services rendered to patients.
6. Enhances the activities of Doctors, Nurses, and other paramedics( the team approach)
7. Effective clinical audit programme can give reassurance to patients, clinicians and managers that an agreed quality of service is being given within available resources.

LIMITATIONS TO SURGICAL AUDIT

1. All audits takes time and consumes resources.
2. Poor record keeping.
3. Most patients lost to follow-up.
4. Reluctance of Doctors to participate.

RECOMMENDATIONS

• It should be part of national health policy of every country.

• Attending such meetings should be part of continuous professional development.

• Education and health ministry to incorporate it into school curriculum and health care.

CONCLUSION

• Surgical audit is a systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and resulting outcome and quality of life for the patient when compared to recognized standard.

• It is not punitive or fault finding event.

• It can  be tasking, but the benefits of improving the healthcare delivery to the patient make sit essential for good surgical practice.

REFERENCES

• Clinical Surgery in General 4th edition , 2004

• Bailey and Love’s Short practice of Surgery, 25th edition.

• Surgical Audit and Peer review guide, 2014.

• Surgical Audit and Research by Professor Ravi Kant.

Thank You

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