6.1 Where to start in clinical audit
Like most things in life, clinical audit is best learnt through practical experience. It is better to gain this experience with small, simple projects that are narrowly focused rather than attempting to do everything all at once.
Choosing an area to audit
The overarching aim of clinical audit is to improve the quality of care, therefore try to choose an audit topic that offers realistic potential to lead to measurable improvements for patients, clients or the practice team.
Start with something that:
- occurs relatively frequently, or is of significance when it does occur
- has a clearly defined outcome or is clearly measurable
- is a priority or a topical issue for you or your practice
- you care about (or believe that some stakeholders care about)
- is in an area in which change is possible, should findings of the audit identify that some improvement is required
Good areas for a first audit are:
- re-audit of a clinical audit topic previously carried out by colleagues/peers
- suspected nosocomial infections
- compliance with a protocol or guideline
- peri-operative deaths
- postoperative complications for common elective surgeries (e.g. neutering ).
Types of clinical audit
This is a clinical audit which seeks to improve services through comparing current practice against a standard that has already been set by examining:
- whether or not what ought to be happening is happening
- whether current practice meets required standards
- whether current practice follows published guidelines
- whether clinical practice is applying the knowledge that has been gained through research
- whether current evidence is being applied in a given situation.
Significant event audit (Mosedale, 2017) is defined as:
an 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)
Responding appropriately to findings from incidents, errors and near misses is an essential element of quality improvement.
What can be audited?
Any aspect of the structure, process or outcome of health care can be evaluated in a clinical audit (NICE, 2002).
- related to the organisation or provision of services
- staff and resources that enable healthcare
- environment in which care is delivered
- documentation of policies/procedures/protocols
Practical examples of structure audits
Structure audits evaluate environmental factors within which health care is delivered, and can provide an indirect assessment of a patient’s care. An example of a structure audit is auditing whether the right equipment and team members are available when planning a new procedure in the practice (for instance, a laparoscopic spay). A structure audit for an ambulatory practice could be auditing which equipment is carried in different vets' cars.
- related to procedures and practices implemented by staff in the prescription, delivery and evaluation of care
- diagnostic investigations, treatments, procedures
- may be specific to the clinical process or to service/administrative processes
Practical examples of process audits
Process measures may include communication, assessment, education, investigations, prescribing, surgical or medical interventions, evaluation, and documentation (NICE, 2002). Process audits provide a more direct measure of the quality of care, and examples include: appropriate prescribing of fluoroquinolones (Dunn and Dunn, 2012), evaluating the number of equine laminitis cases that undergo laboratory testing for an underlying endocrine disorder, or assessing practice processes for patient discharge following hospitalisation.
- related to any outcome following delivery of care (i.e. not solely limited to patient outcomes)
- physical or behavioural response to an intervention
- measurable change in health or survival status
- outcome measures can be:
- desirable e.g. improvement in the patient’s condition or quality of life
- undesirable e.g. adverse effects of a treatment
- measuring the views of those who use services (e.g. level of knowledge or satisfaction) enables assessment of the care delivered from the client’s perspective e.g. client satisfaction
Practical examples of outcome audits
Outcomes are not a direct measure of the care provided, and not all patients who experience substandard care will have a poor outcome; however outcome audits are the most frequently performed type of audit in veterinary medicine (Rose et al., 2016a). Examples of outcome audits include evaluation of postoperative complications following tibial tuberosity advancement surgery (Proot and Corr, 2013), evaluation of canine quality of life following medical treatment of osteoarthritis, reduction in adrenocorticotropic hormone (ACTH) in horses diagnosed with pituitary pars intermedia dysfunction (PPID) following treatment with pergolide, or evaluating client satisfaction with the practice’s new weight management clinic for obese dogs.
Small animal dental imaging
Tom has just recently performed a Knowledge Summary for his practice, which demonstrated that high definition computed radiography in dogs and cats has superior diagnostic capability for periodontal disease compared to visual examination.
On the basis of this evidence, and because of the potential to improve animal welfare by reducing additional visits or prolonged morbidity associated with undiagnosed disease, the partners have just invested in dental radiography. In accordance with available dental care guidelines (Bellows et al., 2019), Tom’s practice recommended survey intraoral radiographs for all dogs and cats presented for dental treatment, with subsequent extraction of any diseased teeth identified.
Tom now wants to establish and demonstrate to the partners (practice owners) that this has been a good investment and that it has improved animal welfare. A practice meeting is held to discuss how best to assess their new radiography system. The partners are keen to discover the cost-effectiveness of their equipment purchase, but everyone agrees that client feedback would be a useful measure of clinical benefit. Therefore, Tom plans an outcome clinical audit, evaluating owner-reported improvement in health-related quality of life following dental treatment.
This is an example of an outcome audit, using client feedback to evaluate the quality of care following practice investment in new equipment for dental radiography.
Tom selected his audit topic as it was an important area for his practice, and of considerable interest to him personally.