Medical error and professionalism:

From Swiss Cheese to Open Disclosure

Dr Rachel Thompson Quality of Medical Practice: Quality and Safety
Phase 2 2012 Acknowledgements: Acknowledgements : A/Prof Tony O Sullivan

Quality
How to define Quality in the health care system system? y ? The extent to which the properties of a service or product produces a desired outcome. outcome.
(Australian Council on Healthcare Standards (accessed 07 06 06) http://www.achs.org.au/ htt // h /) 07.06.06):

Safety
The safety of the health care system has been defined by the National Health Performance Committee: Committee: the avoidance or reduction to acceptable limits of actual or potential harm from health care management or the th environment i t in i which hi h h health lth care is i delivered d li d Australian Council for Safety and Quality in Health Care d fi iti definition: the degree to which the potential risk and unintended results l are avoided id d or minimised i i i d

Dimensions of Quality
Measures of health system performance, including: Measures M of f effectiveness, ff ti appropriateness, i t and d efficiency Responsiveness (Open disclosure) involvement) Accessibility y (Patient ( ) Safety Continuity, capability and sustainability
National Health Performance Committee

Monitoring Quality
Assessing and monitoring Quality is not simple: Service and clinical p performance indicators ( (e.g. g see National Report on Health Sector Performance Indicators 2003) 2003 ) Other indicators based on health care services characteristics that can be compared to benchmarks or clinically defined practices
Li k t t ti ti l information i f ti th safety f t and d quality lit of f health h lth care Links to AIHW statistical on the in Australia Links to other Australian statistical information on the safety and quality of health care

.. But needs reliable reporting systems and a systematic review

Why is quality and safety important?

In Australia, up to 16% of hospital patients suffered an adverse event1
50,000 patients/year suffer permanent disability 18 000 patients/year die 18,000

Iatrogenic injuries:
lt d from f f il f professionalism f i li 35 % resulted a failure of
Lack of care or attention, failure to request a test Acting on insufficient information, lapses etc

1 % due to lack of knowledge

1. Wilson et al 1995, 163; 458-471, Wilson 1999, MJA 170;411, and Wilson & Van Der Weyden 2005, MJA 182(6); 260-1.

Medical error more frightening f i ht i facts f t

1999 - To T err is i human: h building b ildi a safer f h health lth system: system : 44,000 to 98,000 people die in US hospitals each year due to medical error 2 Medication errors (USA) result in 7,000+ deaths alone each y year 2

2 Kohn,

K, Corrigan, J, Donaldson M. (1999). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press

IHI org IHI.org

Based on data collected over several years from multiple p p partner institutions, , IHI estimates that: nearly 15 million instances of medical harm occur in the US each year a rate of over 40,000 per , p day y. 5 million lives Campaign: http://www ihi org/IHI/Programs/Campaign/C http://www.ihi.org/IHI/Programs/Campaign/C ampaign.htm?TabId=1

Definition of adverse event

An A adverse d event t is i an incident i id t i in which hi h unintended harm resulted to a person receiving health care. *

Local events (e.g. North Shore Hospital) reveal that we are all susceptible to being involved
*Wilson, Runciman, Runciman, Gibberd Gibberd. . (1995). Quality in Health Care Study. Medical Journal of Australia, 163(9), 458458 -471.

$$ cost
The financial cost is huge:
USA $37.6 billion each year2 In Australia the total health care budget g was>$50 billion (2004) and adverse events cost us $2 billion = 4% of the health b d t value!* budget l !*

Girl's death triggers NSW health inquiry

SMH Thursday, 24 January, 2008

The NSW government has been forced to call an independent inquiry into the state's public health y after a scathing g assessment from a coroner system investigating the death of a Sydney teenager. Vanessa Anderson, , 16, , died two days y after being g admitted to Royal North Shore Hospital (RNSH) with a skull fracture. She had been hit in the head with a golf ball during a morning tournament at Asquith in Sydney in November 2005. 2005. http://news.sbs.com.au/worldnewsaustralia/girls_dea th triggers nsw health inquiry 538827 th_triggers_nsw_health_inquiry_538827

Nov 22 2007 Royal North Shore Hospital Inquiry as noted by the Joint Select Committee hearing on 28 Nov 2007 http://www.parliament.nsw.gov.au/prod/parlment/hansart.nsf/V3Key/LC20071128049

Warren Anderson

Vanessa did not die from one person's mistake. She died because many people made mistakes at every level in that hospital. She died because the public hospital system was not safe. She died because budgets are prioritised over patient safety. Two years later, has anything changed? We suspect not.
Terms of reference for the NSW public health care system Special Commission of Inquiry: htt // http://www.health.nsw.gov.au/news/2008/20080129_00.html h lth / /2008/20080129 00 ht l code

Launch of windows into safety and quality lit in i h health lth care 2011

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/MediaRelease_2011-10-13_launch_windows_publication

Does unprofessional behaviour in medical school predict future problems in doctors?

Papadakis(1) - 70 doctors who had had significant disciplinary action for unprofessional behaviour - matched to controls 38% of cases vs 19% of controls had breaches in professional behaviour at medical schools However, 62% of cases were not identified at medical school 19% of controls identified with unprofessionalism at med school had no future problems
Suggests we would need a large intervention or a very targeted campaign to make useful improvements with the med students who might g have future problems p
1. Papadakis et al. Academic Medicine 2004;79:244

Risk factors at medical school for subsequent b t professional f i l misconduct i d t

59 doctors identified over 40 years Compared with 236 controls Fi di Findings: Increased risk
Male students Lower socioeconomic status Failure of early pre pre-clinical examinations
1. BMJ 2010: 340: 2040

Factors contributing to unprofessional behaviour in doctors

696 Canadian physicians who had complaints retained eta ed for o investigation est gat o (1) 82 % were due to attitude/communication problems Licensing examination
f th best b t communicator i t quartile til 17 % from the 28 % from the worst communicator quartile

Males, surgeons and GPs had higher rates of complaints

1. Tamblyn et al. Academic Medicine 2004;79:244

Does medical student behaviour predict problems in the future doctor?

Trends are present between medical student behaviour and medical practice BUT Low predictive value Significant costs and resources dedicated already Most unprofessional doctors behaved well as students Most M t students t d t with ith behavioural b h i l problems bl at t university will go on to be good doctors

Professionalism in medical students

Significant amount of discourse on policies, codes and opinion p pieces p Research data on professional behaviour in medical students was lacking(1) What aspects of professionalism should be h and d assessed d(1)? taught

Where do UNSW medical students fit in?

1. Morrison, Medical Education 2008:42;118

What is professionalism?
Professionalism is comprised of a set of values and behaviours that underpin the social contract b between the h public, bli medical di l profession f i and d doctors(1)

M j components of f professionalism f i li i l d Major include empathy, honesty, patience, teamteam-mindedness and intellectual intellect al curiosity c iosit (2)
1. Irvine 2006, 2. Rabinowitz et al. 2004 Med Teach 26;160. , MJA 184;204. ; ;

Definition of Professionalism
1 1. 2. 3. 4. 5. 6. 7 7. 8. Subordinate own interests to interests of patients Demonstrates high ethical and moral standards Behaves according to an accepted social contract Demonstrates h honesty t humanistic values such as integrity and

Shows responsibility and accountability Has a commitment to improve Copes with complexity and uncertainty Demonstrates reflective practice
Swick 2000. Academic Medicine 75;612.

How do medical schools ensure professionalism in their students?

Graduate capability or outcomes Selection S l ti of f students t d t Teaching and assessment of personal and professional development d l t - written assessments - oral or viva assessments - learning logs or reflective diaries - portfolios Fitness to Practice Boards or Committees

Doctors can t be the only problem ...So what is wrong with the system?
Health system prevents honesty and disclosure causing g a vicious cycle y of repeated p errors Blame and shame culture
Human error Individual at fault

Major inquiries fail to deliver satisfaction to victims i ti or change h systems t or prevent t further f th errors

Errors are common

On the wards, wards, in Specialist Clinics, in General Practice, , in the community.. y

Discuss with 2 neighbours: What have you seen or heard? (No names or identifiers)

Examples of common types of errors4

Diagnostic
Error in delay of diagnosis Wrong or outmoded test etc

Treatment
Error in operation or procedure Error in dose of drug etc

Preventative
Failure to provide a prophylactic treatment

Other
Failure in communication

Why do errors occur?

Human mistakes System S failures f l

Active failures = unsafe acts (human)

Latent conditions = resident pathogens (within the system)

Some examples
Active failure:
e.g. g inaccurate measurement of a dose of a drug e.g. ordering the incorrect test e.g. e g amputating the wrong limb (it still happens!)

Latent condition:
e.g. e g Similar labels on different drugs e.g. inadequate policy on how to deal with patients with same name

Reason s Swiss Cheese Model d l

Reason, J. BMJ 2000;320:768-770.5

Holey cheese
Cheese slices = defensive layers within the system, y , e.g. g protecting p g against: g
unsafe acts management deficiencies psychological precursors to slips /mistakes.

Holes = problems in the system: the active failures and latent conditions. conditions.

Accident trajectory
Holes shift and move around

An error occurs only when they all line up Accident trajectory j y or Error

Smelly Swiss cheese

Problems with this model y be the dominant problem p Active errors may Hindsight bias tenuous links seem more important Latent conditions are always present in a system it is the triggers for the active failures that not determine if an error will occur or not. Latent conditions may not be easily amenable better to think about what is changeable changeable and controllable

Swatting mosquitoes
Active failures = mosquitoes can swat them one by one but best to drain the swamps of latent conditions. conditions. (Reason)3

Leape6: A h ill occur Assumes human errors will alter systems to recognise and absorb absorb errors. errors

Draining the swamp

Error management cuts down both active failures and latent conditions Improving healthcare quality by improving patient flow flow, dispensing practice, practice etc Education of patients and healthcare k workers Changing g g the culture from blame and shame to a just just blame blame

Essential actions
Redesigning systems and developing a culture of safety y Clinical practice improvement and EBM etc to improve the appropriateness, appropriateness effectiveness and efficiency l ( ) Patient involvement (citizen s groups etc), issues of equity Clinical governance, accountability, open disclosure, public reporting

Safety and Quality Commission: Commission: http://www.safetyandquality.gov.au/ http://www safetyandquality gov au/
Changes in hospital care systems: Decreased d adverse d events Increased efficiency y Increased openness Increased awareness of patients and workers rights Increased satisfaction with care and work environment

Some other examples of the commission i i s work k / support t

EvidenceEvidence-based adult general observation chart: http://www.safetyandquality.gov.au/internet/safety/publishin g nsf/Content/RaRtCD EBAg.nsf/Content/RaRtCD_EBAg.nsf/Content/RaRtCD_EBA EBA-GOC Patient Identification: http://www.safetyandquality.gov.au/internet/safety/publishin g.nsf/Content/PriorityProgramg.nsf/Content/PriorityProgram -04 Medication Safety: y http://www.safetyandquality.gov.au/internet/safety/publishin g.nsf/Content/PriorityProgramg.nsf/Content/PriorityProgram -06 Clinical Handover: http://www.safetyandquality.gov.au/internet/safety/publishin g.nsf/Content/PriorityProgramg.nsf/Content/PriorityProgram -05

How errors can be reduced d d

Improve overall ll Quality li of f Care
http://www.ihi.org/IHI/Programs/Campaign/

Changes g of p practice ( (e.g. g the new standardised drug g treatment charts) Improve standards of service (e.g. medication reviews)
http://beta guild org au/mmr/content asp?id=53 http://beta.guild.org.au/mmr/content.asp?id=53 http://www.dva.gov.au/health/provider/pharmacy/medrevu.htm #what

Real Real-time audits

http://www.ahrq.gov/research/nov05/1105RA1.htm

Support and educate doctors Educate p patients, , carers and others involved in care
http://www.drugdigest.org/DD/SeniorCorner/SrHome/1,10364,,00.html

Effective Patient Safety

4 Methods - analysis / improvement / response:

Root cause analysis (RCA)

Clinical Practice Improvement (CPI (CPI) ) and Audit

Open Disclosure

Root cause analysis (RCA) = Wh t h What, how and d why h it happened h d

Focusing on prevention Integrated into health system sentinel events and near misses misses Focuses on systems and performance and possible change E Extensive i examination i i to l look kf for underlying d l i contributing ib i factors
State Govt.s: http://www.health.vic.gov.au/clinrisk/sentinel/rca.htm http://www.health.nsw.gov.au/quality/incidentmgt/tools.html Software: http://www.reason4.com/

Basic process of RCA

1. Flow diagram of events and timeline

2.

Identify and examine critical events (following causation rules e.g. cause and effect chart)

3.

Identify root causes (evidence) and categorise these

4.

Identify and select solutions

5.

Develop p recommendations

Clinical Practice Improvement I t

CPI is the new buzz word in Q&S Tackles kl areas of f clinical l l risk k Aims to accelerate improvement p rather than replace system reorganisation etc Can be applied to systems large and small plus adapted to individuals (personal practice p improvement) p ) Based on quality improvement cycle

CPI process
Setting Aims
What are you trying to accomplish?

Establishing Measures
How will you know that a change is an improvement?

Selecting Changes
What changes can we make that will result in improvement?

Testing g changes g
The Plan Plan-DoDo-Study Study-Act (PDSA) Cycle

Institute for Healthcare Improvement

CPI further study and exercise

Visit the Institute for Healthcare Improvement (IHI) for further study

QMP Exercise: Attempt to improve some fundamental skill for the HM3 course using personal improvement practice (e.g. you may wish to improve a particular area of clinical skill (e.g. cardiovascular examination skill, interpreting an ECG, taking a blood (e g pressure measurement etc) or your time management skills (e.g. planning, carrying out and submitting assignments on time) Take this issue / skill for improvement and apply the principles from the IHA site above. Plan and implement this carefully using the PDSA cycle. Try this out over a reasonable length of time as you need to be able to try, observe and review the changes that you plan. Write a brief report and peer review this!

What is Open Disclosure ?

Open, consistent approach to communication with patients after an adverse event Expressing sorrow and regret g a dialogue g Maintaining to p provide:
Facts about the event Info on ongoing care prevent a recurrence of the error Info on steps p taken to p Speculate or blame others Blame l yourself lf Criticise or comment on matters outside your own experience Admit liability

It is not an acceptance of liability. So advised not to:

Why promote Open Disclosure? l

Patients deserve to expect this level of trust from the health care system y

Fosters an environment of learning

Accept fallibility of individuals so that systems can change (Leape)

Ethical basis of Open Disclosure

Disclosure of information to patients and families is vital: Truth Honesty y Respect for patient autonomy P tting the welfare elfa e of the patient first fi st Putting

Health care system based on TRUST Patients able to make fully informed decisions

Error management of this scenario Whi h process to Which t use? ?

Describe the health care process that the patient went through Identify points where the error(s) may have occurred What are the root causes here (evidence)? What could be done to reduce the risk of another error like this occurring? How would you implement changes to prevent this from happening?

QMP Exercise Prevention of errors Q

Take one of the following examples of a health care process that has led to an error (or one of your own) Dissect the h care and d outcomes of f this h process. Remember b to start right at the beginning of the process and analyse every step carefully. You may have to fill in the scenario for the care that occurs before the error takes place. p Analyse this to see what could be changed in the process to prevent errors Examples: Wrong patient s blood taken in busy A&E department by medical student (two patients with similar names) Wrong limb amputated in a deaf patient who was marked up by an intern from a different team

The importance of Safety and Q lit t Quality to you

Practice EBM so that it becomes second nature to you y Follow the guidelines and procedures where you work work ..they they are there to protect you and the patients from errors ll h simple l rules l about b l Follow the Open Disclosure to keep you and your patients safe

What you can do do

Maintain your own high standards Practice EBM and personal and clinical practice improvement Be assertive if y you see malpractice p or errors occurring. Have the courage to:
ask politely what is happening or gently question the practice Read the article cited below in notes!

Learn from your mistakes and the mistakes of others

Websites
Some examples of organisations tackling the issues of medical error and healthcare quality:
Australian Resource Centre for Healthcare Innovations ( (check out the ee-library): y) http://www.archi.net.au/ Clinical Excellence Commission. Browse through and see the quality issues that are being dealt with in NSW: http://www.cec.health.nsw.gov.au/ National Reporting and Learning Service Service. . Similar site for the UK: http://www.nrls.npsa.nhs.uk/ National Institute of Clinical Studies: http://www.nicsl.com.au/ Institute for Healthcare Improvement (the major innovative collaboration for improving quality of healthcare in the USA): http://www.ihi.org/ihi Agency for Healthcare Research and Quality (USA) scroll down for useful information documents: http://www.ahrq.gov/qual/errorsix.htm National Patient Safety Foundation (USA) take a glance at the publications available here: http://www.npsf.org/ Quality and Safety in Healthcare Journal (BMJ Publishing: accessible from campus): http://qhc.bmjjournals.com/ SIN: Sufferers of Iatrogenic Neglect (fascinating) - http://www.sin http://www.sin-medicalmistakes.org/index.html

Medical error references f

1 Wilson, R, Runciman Runciman, , W, Gibberd, Gibberd, R, et al. (1995 ). The Quality in Australian Health Care Study. Med J Aust Aust, , 163, 458458-471. http://www.mja.com.au/public/issues/misc/wilson.pdf And followfollow-up articles: Wilson 1999, MJA 170;411 and Wilson & Van Der Weyden 2005, MJA 182(6); 260260-1. 2 Kohn, K, Corrigan, J, Donaldson M. (1999). To Err is Human: Building a Safer Health System. System Washington, Washington DC: National Academy Press. Press 3 Runciman, Runciman, W and Moller J. (2001). Iatrogenic Injury in Australia. Canberra: Commonwealth Department of Health and Aged Care. 4 Leape, Leape, L, Lawthers, Lawthers, A, Brennen, Brennen, T, Johnson, W. (1993). Preventing medical injury. QRB. Quality Review Bulletin, 19(5), 144144-149. 5 Reason, J. (2000). Human error: models and management. BMJ, 320, 768768770. 770 5 Leape L. (1994). Error in Medicine. JAMA, 272, 18511851-1857. Leape, L and Berwick Human What 6 Leape, Berwick, D D. (2005) (2005). Five years after To Err is Human. have we learned? JAMA, 293, 23842384-2390.

Professionalism references
Irvine. (2006). MJA, 184, 204. Morrison. (2008). Medical Education, 42, 118. Papadakis et al. (2004). Unprofessional Behavior in Medical School is Associated with Subsequent Disciplinary Action by a State Medical Board. Board Academic Medicine, Medicine 79, 79 244. 244 Rabinowitz et al. (2004). Med Teach 26, 160. Swick Swick. . (2000). Academic Medicine 75, 612. y et al. ( ) Academic Medicine, , 79, , 244 Tamblyn (2004). Yates, J and James, D. (2010). Risk Factors at medical school for subsequent professional misconduct: multicentre retrospective case control. BMJ, 340, 2040.

Clinical Practice Guidelines and Audit

Dr Rachel Thompson
QMP convenor rachelt@unsw.edu.au Phase 2 2- Adult Health 1

Remember that clinical audit is

A continuous process of reviewing healthcare quality q y against accepted / EB standards and implementing changes to meet the standard(s) as necessary Repeated to maintain high standards

= A POSITIVE FEEDBACK LOOP

The audit model

Five important stages

1. Identifying a problem or an issue 2. Set criteria / standards of care 3. Observe practice or collect data 4 Compare performance to the set criteria / standards 4. 5. Improvement of services / care to meet the standards if indicated

This last point is key to why we do the audit audit What would you suggest to the practitioners should do to improve their practice?

Key differences between clinical research h & audit dit

Research What should be done New knowledge Hypothesis Experiments Clinical Audit What is being done Tests given knowledge Measures against set standards Normal clinical management

Requires ethical approval

Abides by and ethical framework

May y involve random allocation and / or placebo groups Large scale over a long time Ri Rigorous methodology th d l

Never involves this

A relatively small short study Diff Different t methodology th d l from f research h

Results are generalisable

Results are only relevant locally

Source: United Bristol Healthcare NHS Trust Clinical Audit Central Office. (2005). What is Clinical Audit? Retrieved online on 08.06.06 from: http://www.ubht.nhs.uk/clinicalaudit/docs/HowTo/WhatisCA.pdf

St Vincents Hospital Research Office Low Risk Projects Updated Feb 2010

Ethics
Same considerations as for clinical research Moral l implications l

Abbasi, K and Heath I. (2005). Editorial: Ethics review of research and audit. BMJ, 330, 431431-432 Wade, D. (2005). Ethics, audit, and research: all shades of grey. BMJ, 330, 468468 -471

Clinical Practice Guidelines - Barriers B i t to implementation i l t ti

You are likely to see some real problems as to why y guidelines g aren t fully y adhered to:

What are the underlying causes? How can this be improved on?

The Killer B s
Burden of illness enough to warrant implementing it? Are my patients Beliefs compatible with implementing it? Would the cost involved be a good Bargain? Are there Barriers that are too hard to overcome them? CostCost-effectiveness of implementing guidelines

Is this CPG applicable.. applicable

..to my practice / hospital / community / p patient? How to apply them in practice depends on who you are and where you are Adapting them to your situation may reduce h l their value

code

Guideline adherence
Awareness Familiarity Agreement Self Self-efficacy Outcome expectancy Ability to overcome the inertia of previous practice Absence of external barriers to perform recommendations
Cabana et. al (2000) Implementing practice guidelines for depression: Applying a new framework to an old problem. Gen Hosp Psych, 24, 3535-42.

Awareness Awareness to to Adherence Model Model*

1. PrePre-awareness 2. Awareness 2. 3. Agreement g 4. Adoption 5. Adherence

*Pathman et al. (1996). Awareness to adherence model of the steps to clinical guideline compliance. Med Care,34, 873 873-89.

Tudiver et al s Domains* *
Physician characteristics Patient characteristics h Social factors Practice Factors
*Tudiver, F et al. (1998). Why don t family physicians follow clinical practice guidelines for cancer screening? CMAJ, 159, 797797-8.

Tudiver cont. cont I

Physician characteristics
Perceived effectiveness of guidelines CME level Perceived probability of disease

Tudiver cont. cont II

Patient characteristics
Knowledge and perception of patients pp wishes and social circumstances / support systems Desire to avoid complaints Length and quality of relationship Patients attitudes

Tudiver (cont.) (cont ) III

Social factors
Interpersonal, persuasion, mass media Perceived endorsement and consistency with local practice

Tudiver (cont.) (cont ) IV

Practice Factors (GP)
Type solo / group, payment system Perceived consultation time Access to current info Costs C t i involved l d

Evidence for CPG Compliance l

Varies Could be improved Multifaceted approach linked to CME p in p practice efficiency y Improvements Examples: performance specific Newcastle: computerised system of performance feedback increased GP adherence to several guidelines including BP screening* Using Medical Director to flag patients requiring review or assessment
*Bonevski et al. (1999). Randomised Controlled Trial of a Computer Strategy to Increase General Practitioner Preventive Care. Preventive Med, 29, 478478-486.

Summary
CPGs: Essential part of clinical practice Adherence & keeping up can be a problem Audit: Essential part of clinical practice Problematic - involves introspection and change p g of practice Ethical issues Both are essential to Q&S Q

General advice for the miniminiaudit dit

Background B k d research h for f i intro t What is the CPG? Why is it important? Choice Ch i needs d t to be b supported t d Reference it Introduction impo tant Clinical setting is important Method Selection of cases random (how?) vs. consecutive cases Paper vs vs. Observation

General Advice for the minimini -audit d ( (2) )

Method M th d (cont (cont) t) Mention if you worked with a colleague on the proforma and data collection and remember to submit your own report with your own writing in all sections (Results will be similar but should be written separately too too) ) Referencing Reference the CPG and any evidence you use! APA. If more than one or 2 references vs. footnotes / endnotes and bibliography Formatting PPT slides use your common sense!

Advice - Results
Put all results in this section Illustrate and demonstrate your findings Demographics Age Age-range, mean / median Plot, age age-groups Re datadata-handling Use tables better: summarise, use totals, % if big enough numbers, shading rather than colour etc Summary S table t bl = summary!! !! (see ( examples examples) l ) Plot results to see if distribution shows something then include graphs if shows something Show totals (e.g. n=10)

Graphs gender /age example l

Pa atient Nu umbers 2.5 2 15 1.5 1 0.5 0 50-59 60-69 70-79 80-89 Age Categories

Male Female

Graphs p risk summary y example p

Alcohol Psychological

Risk Fa actors

Smoking High BMI Established Disease Lower SES Biological Risk 0 2 4 6 8 10 12

Patient Numbers
Male Female Total

Tables data summary table

Risk factor Yes No Not recorded N/A Total

Indigenous Smoking BMI >25 Physical Inactivity Lower SES Psychological factors Excess alcohol consumption Biological risk Established disease Total with risk (ex-smokers)

code

Tables risk summary table

Risk category No. of patients No. with appropriate BP measurement t (%) No. with lifestyle counselling lli (%) No. with Absolute CVR assessment t (%) No. with criteria for CVR satisfied ti fi d (%)

Average

Increased

High

Total

code

Discussion of findings
What did findings show? What h could ld h have caused d this? h ? What could y you suggest gg to improve p this practice?

Reflection generally good but lack personal element in some reports

Reviewing audit
Problems: lack l k of f resources lack of expertise p or advice in p project j design g and analysis problems between groups and group members lack of an overall plan for audit organisational impediments
Johnston et al. (2000). Reviewing audit: barriers and facilitating factors for effective clinical audit Qual Saf Health Care, 9, 23-36

Key facilitating factors to audit were also l id identified: tifi d

modern medical records systems effective ff training dedicated staff protected time structured programmes shared dialogue between purchasers and providers

Useful Feedback from previous i audits dit

Background literature: qualitative studies, RCTs, audits i e Good to look beyond if have time i.e. Can t do inferential stats as such as is not a true sample sa p e and a d you are a e not ot testing test g a hypothesis ypot es s but: but:
Ca Can look oo at demographics de og ap cs and a d descriptive desc pt e statistics stat st cs (e.g. (e g number out of total or % completed management etc) etc) Can draw quite strong conclusions and make recommendations Small size of audit: can still be useful. remember that you can audit one case!

A good audit should:

Set, , explicit p E E-B criteria and standards Use objective measurements of practice A conclusion that explicitly identifies the changes necessary to improve the investigated outcomes A high standard of documentation

Adapted from: Shaw, C. Audit Philosophy in: Frostick Frostick, , S., Radford, P. and Wallace, W. (1993). Medical Audit. Rationale and practicalities. Cambridge University Press: Cambridge. P. 2020-1.

Keeping up to date with guidelines

Guidelines change quite frequently so practitioners j p just g get used to them and then they are updated information overload ; hard to keep up

Try to read guideline summaries and recent l when h h f possible bl journals you are there if

Submission
Present to clinical tutor with PPT slides in week 6 Submit via eMed at end of week 6 for your portfolio and feedback from tutor Discuss with clinical tutor if difficulties with the audit / submission etc Email me if not able to resolve: rachelt@unsw.edu.au rachelt @unsw.edu.au