Clinical audit: Minimising chances of errors
With a sense of uncertainty and tension permeating every corner of an emergency department in a hospital, it is essential to have a scrutinising eye that will ensure proper administration. A look at the importance of clinical audit in the emergency department of a hospital.
The medical world is changing everyday with introduction of new technology and new case studies. Healthcare is flourishing at a higher pace than the other sectors and to continue this upward graph, clinical audits should become an integral part of healthcare system. Discussing the importance of audit in hospitals, Dr Swapnil Kharnare, Senior Manager – Administration, Hinduja Hospital, avers, “An audit ensures improvement of the quality of services provided by the hospital, which in turn usually results in long term financial benefits to the organisation along with improvement in patient care that guarantees increased patient satisfaction and footfall. Decrease in medical errors and adverse events also help in creating a brand image for the hospital and build the credibility of the organisation.” Therefore, the process of audit ensures consistency in delivery of clinical and non-clinical services; it also addresses the habit of continual improvement.
The need to audit
National Institute for Clinical Excellence (NICE) (UK) in its publication ‘Principles for best practice in clinical audit’ defined clinical audit as ‘A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in healthcare delivery.’ In other words, clinical audit is a structured process, which ensures that we are carrying out best practice by reviewing what we are doing, compared with what we should be doing. Any departure from ‘best practice’ can then be examined in order to understand the causes and act upon for improvement in clinical effectiveness. According to Dr Kharnare, clinical audit has become part of the Indian healthcare system in the recent past and is implemented in a full-fledged way mainly after the establishment of National Accreditation Board for Hospitals and Healthcare Providers (NABH) in 2005 and the advent of Joint Commission International (JCI) accreditation. In both these cases it is a continuous quality improvement tool rather than one-time exercise.
Types of audit
The different ways of carrying out clinical audit may be classified as follows:
Standards-based audit (criteria-based audit): This is the recommended process. Current practice is compared against defined criteria, standards or best practices, through the ‘audit cycle.’
Peer review audit: With the benefit of hindsight, the quality of services provided is assessed by a team, reviewing case notes and seeking ways to improve clinical care. This is especially applicable in ‘interesting’ or ‘unusual’ cases.
Significant event audit: Adverse occurrences, critical incidents, unexpected outcomes, and problematic cases causing concern are reviewed systematically and solutions implemented.
Surveys: Targets for opinions or suggestions may include patients or special focus groups. Information gathered is then analysed and change implemented as appropriate.
Talking in this regard, Dr Kharnare highlights, “ In other words, the stages of its process can be summarised as: What should be happening? What is happening? What changes are needed? As the process continues and repeats itself, each cycle aspires to a higher level of quality.” Discussing the importance of clinical audit, Dr (Prof) D P Saraswat, CEO, Action Group of Hospitals, remarks, “Clinical audit ascertains whether the person admitted was investigated properly. We have our own systems that help in attending the patients on the basis of priority. Accordingly, specialist opinion is sorted and treatment is given.” Dr (Prof) Saraswat adds that there are also systems that help in determining the speed and accuracy of starting the treatment. He highlights, “Clinical audit helps in checking the competence of the doctors.”
Need for clinical audit in emergency department
Emergency Medicine (EM) is an important and fundamental component of any healthcare system. The Emergency Department (ED) is the face of any hospital, which works around the clock through the year. The department is manned by trained medical & paramedical staff & it serves all the immediate emergency medical interventions. Elaborating on this, Dr Kharnare comments, “Emergency leaders are increasingly faced with challenges that go beyond the scope of traditional clinical medicine and department staffing. A thorough understanding of quality improvement principles and benchmarking is now necessary for ED leaders to be successful in providing patient centred care, improving customer satisfaction and evaluating service initiatives. Correctly treating emergent complaints is no longer the only focus, and emergency physicians are now being asked to also provide safe, timely, efficient and cost effective care. In order to determine whether ED process innovations are effective, standardised markers for efficiency and quality will be required.”
Hurdles on the way
Audit may be seen as a threat of criticism. Elaborating in this regard, Dr Kharnare explains, “Audit may be regarded as an unpleasant, time-consuming distraction from our busy daily practice. However, with a clear aim, good clinical management system, transparency and supportive culture, it will be effective in improving staff performance and patient care. As a quality improvement tool, audit is one way to demonstrate our accountability to those outside the profession that real efforts are being made by dedicated healthcare professionals to deliver high-quality patient care.” Discussing about the challenges Dr (Prof) Saraswat says, “In an ED sometimes the patients are in unconscious state and are unable to respond to the various questions that are asked. They cannot tell what happened at the moment of emergency. Further, identification is also a big challenge. Then there are cases of head injury, etc. Thus, it is essential to pay special attention.”
Countries such as the US, Australia or Canada had their standards for audit set years ago and these standards are acknowledged world over. Dr Kharnare points out, “JCI was established in 1917 in the US and since then has been acknowledged universally in different countries. Other systems like Australian Council on Healthcare Standards (ACHS) and Canadian Council on Health Services Accreditation (CCHSA) have been long established and implemented throughout the world. However, it was only after the establishment of NABH in 2005 that India has woken up to the concept of clinical audit.” He adds that clinical audits in ED thus have become very critical as the chances of errors here is high due to the sheer volume of patients and unpredictable case mix. Thus, it is important to ensure the standard protocols are followed and a check mechanism through clinical audits is established. These can help continuous quality improvement and provide safe environment for patient care.