clinical audit

Re: clinical audit

Lorna McHardy — Sat, 04 Feb 2012 15:30:28 GMT

[quote user="Malcolm Ness"]

Can I use that phrase?

[/quote]

It's not copyright

Re: clinical audit

Malcolm Ness — Sat, 04 Feb 2012 15:10:20 GMT

[quote user="Lorna McHardy"]What's your definition, Malcolm?[/quote]

I haven't found one.

[quote user="Lorna McHardy"]That's my problem. I like the idea, but still can't see a way to do it sensibly.[/quote]

Me too. Can I use that phrase?

Re: clinical audit

Lorna McHardy — Sat, 04 Feb 2012 13:19:25 GMT

[quote user="Malcolm Ness"]

None of the examples of veterinary clinical audit that have been described or discussed, including Dr Viner's example given to RCVS and the examples discussed in Practice Standards, come close to this definition of audit against established bench-marks. One of the reasons is that very few such bench-marks exist. The mantra of "audit is different from clinical research" appears quite consistently yo be a way of excusing/allowing very soft data and softer data analysis.

[/quote]

What's your definition, Malcolm?

[quote user="Malcolm Ness"]

For the avoidance of doubt, I am thoroughly in favour of the concept of auditing clinical performance and outcomes but I am yet to be persuaded that it can be done easily and meaningfully.

[/quote]

That's my problem. I like the idea, but still can't see a way to do it sensibly.

Re: clinical audit

Malcolm Ness — Sat, 04 Feb 2012 12:54:19 GMT

[quote user="Jillian Hall"]With audit somebody else has already done that research, somebody has already established what is best practice, and you are comparing your own performance to that target. And I think it's right to say an audit works best if you are very specific about your goals. That is probably the most important thing I learnt from my clin audit C module[/quote]

I'm afraid that this will only add to the confusion talked about in the OP. None of the examples of veterinary clinical audit that have been described or discussed, including Dr Viner's example given to RCVS and the examples discussed in Practice Standards, come close to this definition of audit against established bench-marks. One of the reasons is that very few such bench-marks exist. The mantra of "audit is different from clinical research" appears quite consistently yo be a way of excusing/allowing very soft data and softer data analysis.

For the avoidance of doubt, I am thoroughly in favour of the concept of auditing clinical performance and outcomes but I am yet to be persuaded that it can be done easily and meaningfully. I am also very well aware of the potential to produce self-justifying egocentric nonsense which can be called clinical audit and thus given a patina of credibility.

Re: clinical audit

Jillian Hall — Fri, 03 Feb 2012 21:44:48 GMT

Data can be prospective but in many situations the fact that the audit is being carried out will affect the audit. Although that doesn't necessarily render the audit pointless, it's just that you will have raised the standard of your first audit cycle. You can still aim for improvements in future cycles. There is a distinct difference between audit and research. With research you are measuring outcomes with the intention of finding out information about what works and what constitutes best practice. With audit somebody else has already done that research, somebody has already established what is best practice, and you are comparing your own performance to that target. And I think it's right to say an audit works best if you are very specific about your goals. That is probably the most important thing I learnt from my clin audit C module. If you pick something like improving care of CRF cats, you don't want to look at every aspect of that care, it will be far too complicated. You would end up making vague sweeping observations about the standard but it would be difficult to implement specific changes and measure improvements. Also important is getting involvement and buy-in from colleagues (the "audit team" if you prefer jargon) before you start. - sorry about the big block of text- when I post from my iPad it doesn't seem to register new paragraphs.

Re: clinical audit

Malcolm Ness — Fri, 03 Feb 2012 19:56:38 GMT

[quote user="Lorna McHardy"] can an audit be prospective? I thought they were retrospective by definition,[/quote]

If clinical audit (whatever it might actually turn out to be) is to have any point then it must be to identify shortcomings and drive improvement. The only way to measure the effect of change is to look again and that bit, at least, is prospective.

Re: clinical audit

Lorna McHardy — Fri, 03 Feb 2012 19:16:45 GMT

[quote user="Malcolm Ness"]

[quote user="Lorna McHardy"]Do your average practice clinical notes count as reliable data?[/quote]

That's where every bit of clinical research has to start. Obviously, prospective stuff is better than retrospective if for no other reason than you can make sure that each clinical record is completed properly as you go.

[/quote]

See, now I'm getting confused again... can an audit be prospective? I thought they were retrospective by definition, and the prospective stuff is research, or a clinical study, or something.

Re: clinical audit

Malcolm Ness — Fri, 03 Feb 2012 19:04:20 GMT

[quote user="Lorna McHardy"]Do your average practice clinical notes count as reliable data?[/quote]

Re: clinical audit

Lorna McHardy — Fri, 03 Feb 2012 16:53:18 GMT

Do your average practice clinical notes count as reliable data?

Re: clinical audit

Malcolm Ness — Fri, 03 Feb 2012 16:49:53 GMT

[quote user="Lorna McHardy"]That actually sounds like quite a good idea <thinking about possibilities> .... I think you'd have to be very precise about what you want to know, what information you want to gather, and what you want to do with it, if it's going to be at all useful.[/quote]

I agree completely and what you have described is good quality clinical research. If your data is reliable and credible then the work is indistinguishable from good quality clinical research that should be published so we can all benefit from it. Conversely, if your data is unreliable then your conclusions are inevitably incredible and your time was wasted.

Re: clinical audit

Lorna McHardy — Fri, 03 Feb 2012 16:37:23 GMT

[quote user="Malcolm Ness"]

Clinical Audit is exactly what you want it to be...................and that is the problem.

[/quote]

I think I'm beginning to understand that... it also explains why my idea of what it is was woolly

So... it's basically an information gathering exercise with the aim of answering any question you consider important regarding clinical outcomes, aims, or procedures in your practice? A formal way of verifying or disproving personal experience?

That actually sounds like quite a good idea <thinking about possibilities> .... I think you'd have to be very precise about what you want to know, what information you want to gather, and what you want to do with it, if it's going to be at all useful.

Re: clinical audit

Malcolm Ness — Fri, 03 Feb 2012 16:03:42 GMT

Clinical Audit is exactly what you want it to be...................and that is the problem.

Re: clinical audit

Rob Davis — Fri, 03 Feb 2012 14:39:18 GMT

Damn, didn't bite, must try harder...

Re: clinical audit

Martin Atkinson — Fri, 03 Feb 2012 14:15:16 GMT

[quote user="Rob Davis"]

[quote user="Martin Atkinson"] if I do something and it works well I do it again if doesn't I will change it[/quote]

Isn't this how homeopaths justify their treatments?

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No they just carry on doing things that don't work but convince their 'victims' that they do.

Re: clinical audit

Rob Davis — Fri, 03 Feb 2012 14:09:51 GMT

[quote user="Martin Atkinson"]Who am I gathering this evidence base for?[/quote]

For yourself, to try to improve your clinical outcomes.

[quote user="Martin Atkinson"] if I do something and it works well I do it again if doesn't I will change it[/quote]

Isn't this how homeopaths justify their treatments?

Re: clinical audit

Mark Holmes — Fri, 03 Feb 2012 13:14:58 GMT

[quote user="Martin Atkinson"]Who am I gathering this evidence base for? If it is to prove to the powers that be that I am worthy of continuing in practice then recorded data will be of use but if its for me then if I do something and it works well I do it again if doesn't I will change it. If a new method or therapy comes along I will try it, if it improves my work I will use it in the future, if it doesn't I won't. Admittedly being single handed rather than standardising something across a big practice makes it easier to make these decisions but it still annoys me that we have to have jargon for a simple procedure that we perform on a daily basis anyway[/quote]

It really irritated me too..... until I did it. As a practice we discuss cases and out comes andyway and it annoyed me that we had to do the same thing but make sure it was minuted to prove it. Anyway the process of review I found really interesting AND I was amazed at how much I would have missed or forgotten had I not done it.

Re: clinical audit

Martin Atkinson — Fri, 03 Feb 2012 13:05:48 GMT

[quote user="Rob Davis"]

[quote user="Martin Atkinson"]I do this all the time without thinking about it why does some anal retentive have to put some stupid management speak jargon title to it?[/quote]

I think we all do it to a certain degree, but data gathered, recorded and analysed is always going to provide a stronger evidence base than memory, impressions and anecdote...

[/quote]

Who am I gathering this evidence base for? If it is to prove to the powers that be that I am worthy of continuing in practice then recorded data will be of use but if its for me then if I do something and it works well I do it again if doesn't I will change it. If a new method or therapy comes along I will try it, if it improves my work I will use it in the future, if it doesn't I won't. Admittedly being single handed rather than standardising something across a big practice makes it easier to make these decisions but it still annoys me that we have to have jargon for a simple procedure that we perform on a daily basis anyway.

Re: clinical audit

Rob Davis — Fri, 03 Feb 2012 12:14:59 GMT

[quote user="Martin Atkinson"]I do this all the time without thinking about it why does some anal retentive have to put some stupid management speak jargon title to it?[/quote]

I think we all do it to a certain degree, but data gathered, recorded and analysed is always going to provide a stronger evidence base than memory, impressions and anecdote...

Re: clinical audit

Mark Holmes — Fri, 03 Feb 2012 11:03:12 GMT

[quote user="Martin Atkinson"]

[quote user="Jillian Hall"]Clinical Audit is a means of measuring performance. You decide on what is 'best practice' for a particular event, ideally based on evidence, and compare your own (or your practice's) performance to that gold standard. The intention is then to look at ways of improving performance, implementing them and repeating the audit cycle in order to assess whether this improvement has been achieved. Continuing regular audit cycles is a way of achieving constant improvements in the level of care.

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I do this all the time without thinking about it why does some anal retentive have to put some stupid management speak jargon title to it?

[/quote]

I did a form of audit recently and it was suprisingly useful. Not in the way listed above so much as taking time to review all the cases over the last 3 months. I limited it to those through the surgery diary so included anything surgical and most medical cases without being full of 2 day diarrhoeas etc. I then took a note of any case which felt noteworthy in a positive or negative sense. It helped to remind me I don't do such a bad job and equally those cases where you think hmmm I'll do it different next time don't get forgotten when next time comes along.

Its amazing how much you forget. I've not seen such and such for ages only to find you had one last month.

Re: clinical audit

Martin Atkinson — Fri, 03 Feb 2012 10:15:03 GMT

[/quote]

I do this all the time without thinking about it why does some anal retentive have to put some stupid management speak jargon title to it?

Re: clinical audit

Jillian Hall — Thu, 02 Feb 2012 22:35:14 GMT

Clinical Audit is a means of measuring performance. You decide on what is 'best practice' for a particular event, ideally based on evidence, and compare your own (or your practice's) performance to that gold standard. The intention is then to look at ways of improving performance, implementing them and repeating the audit cycle in order to assess whether this improvement has been achieved. Continuing regular audit cycles is a way of achieving constant improvements in the level of care. As an example- if you decided that all cats diagnosed with chronic kidney failure should have their blood pressure measured in line with published recommendations, you could search for all cats which have been prescribed renal diets or ace inhibitors, check records to see if they meet your inclusion criteria and check if they have had BP measurement. Then try to make some improvements and repeat the exercise a year later. Without the computer you could do a prospective study and record the data as you go. I did the veterinary general practice certificate so one of my C modules was in clinical audit- I now know more about it than I ever really wanted to know!

Re: clinical audit

Rachael Winder — Thu, 02 Feb 2012 20:25:02 GMT

Not necessarily the computer bit but it helps, but I do think consistency and cooperation from other staff is vital unfortunately ;-)

Re: clinical audit

Lorna McHardy — Thu, 02 Feb 2012 19:33:11 GMT

So you'd need a) a computer system that allows you to retrieve targeted information, and b) vets who are consistent and complete in their writing of notes? Hmmmmm....

Re: clinical audit

Camilla Edwards — Thu, 02 Feb 2012 19:27:24 GMT

I did an audit recently of routine procedures in our practices, looking at whether antibiotics were used at the time of the op. and whether antibiotics were given at either of the post op checks, because we didn't really have a policy at our practice, and we were trying to formulate one relevant to us. I guess it might not actually have been an audit, but research on what happenned in the practice, because I wasn't comparing directly to a gold standard. I just looked at a few recent neuterings to see what stumbling blocks I might come up against (eg people not writing whether antibiotics were given or not), and formulated how I would deal with that so I wasn't making it up as I went along (if they wrote the NSAID dose but not any antibiotic dose I assumed antibiotics weren't given, if there was no NSAID dose then I didn't count it in the study), Then I systematically went through the diary looking at every routine op. I had a target number (plucked out of the air), which I thought might give a useful insight into what was going on. Then I just added the numbers up and compared (didn't do any fancy statistics).

This was my first audit, and I thought it was somewhere to start and to build on - it certainly wasn't perfect, but I learnt a fair bit, and I think the more important thing is to throw yourself into doing it - if you ask too much of yourself the first time then you won't do it again!

Bradley Viner has written some good articles in Vet Times and In Practice I think, that were useful.

HTH