MSOP1010 Clinical Audit Student Handout Nov 2024 PDF

MSOP1010 Clinical Audit Dr Nicola Tyers ([email protected]) Today’s lecture Learning Outcomes By the end of this lecture you will be able to: Explain why we do clinical audit Describe the clinical audit cycle Give examples of pharmacist involvement in clinical...

MSOP1010 Clinical Audit Dr Nicola Tyers ([email protected]) Today’s lecture Learning Outcomes By the end of this lecture you will be able to: Explain why we do clinical audit Describe the clinical audit cycle Give examples of pharmacist involvement in clinical audit Describe how clinical audit was used in the “safe use of NSAIDs in elderly patients” This will be embedded through: 1. Workbook – Task 10 2. An opportunity to put the learning from today’s lecture into practice in the workshop – Ensuring patient safety Clinical Governance What is it? ‘System through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care’ Or more simply… ‘a way of doing the right things right, to the right people at the right time’ Example Overall Accountability Quality & Performance & Audit Safety Delivery Procedures, Quality policy & Finance subgroups targets In action Meetings in public :: Kent and Medway Clinical Commissioning Group (kentandmedwayccg.nhs.uk) Risks… Alerts Actions… Mitigating action Audit What is it? DEFINITION: The on-site verification activity, such as inspection or examination, of a process or quality system, to ensure compliance to requirements. An audit can apply to an entire organisation or might be specific to a function, process, or production step. Some audits have special administrative purposes, such as auditing documents, risk, or performance, or following up on completed corrective actions. ISO 19011:2018 defines an audit as a "systematic, independent and documented process for obtaining audit evidence [records, statements of fact or other information which are relevant and verifiable] and evaluating it objectively to determine the extent to which the audit criteria [a set of policies, procedures or requirements] are fulfilled." Audit....All about improving patient care! Why and how? Can take place in: Tools to improve patient care Community Pharmacy Support change Hospital Pharmacy Help ensure efficient use of resource Aseptic units GP practices etc etc Expect to do undertake an audit in your foundation year Standard Operating Procedures (SOPs) “Designed to provide accurate and detailed instructions on how to perform a defined process or procedure to ensure consistency and standardisation. The purpose is to eliminate variations in processes which need to be completed the same way every time.” Checklists/methods SOP01_How_to_write_a_SOP.pdf (ulh.nhs.uk) Purpose Logical sequence Why? Who? What? Where? When? How? In practice Oversight Inspection Procedures In practice Governance (Quality Assurance) Oversight Audit (Quality Management) Inspection Checklists (Quality Control) Procedures Clinical Audit What is it? ‘…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.’ ‘A process for monitoring standards of clinical care to see if it is being carried out in the best way possible (known as 'best practice’). Clinical audit can be described as a systematic 'cycle'. It involves measuring care against specific criteria, taking action to improve it if necessary, and monitoring the process to sustain improvement. As the process continues, an even higher level of quality is achieved.’ (NICE) Multi-professional vs uni-professional audit Clinical Audit Cycle Decide topic Set standard of care Re-audit expected Audit in a clinical setting Data collection - Implement changes observe practice Data analysis - Make compare practice recommendations with standard Royal Pharmaceutical Society Clinical Audit hub Clinical audit guide (rpharms.com) Decide on a topic Important to choose an area of practice where patient care and outcomes can be improved Must be able to define “best care” Local vs national priorities National Institute of Health and Care Excellence (NICE) Do patients wait at the pharmacy too long? Do MI patients receive aspirin? Clinical Audit Cycle Decide topic Set standard of care Re-audit expected Data collection - Implement changes observe practice Data analysis - Make compare practice recommendations with standard Set standard of care expected REALLY IMPORTANT - bad audits often have poor standards Should be based on best evidence Consist of CRITERIA and STANDARD CRITERIA CRITERIA STANDARD STANDARD Prescriptions are dispensed 80% and ready to be collected by 80% the patient within 20 minutes of receipt of the prescription in the pharmacy Set standard of care expected MUST BE............. Specific Measurable Achievable Realistic (Timescale) As a “guide” 100% Absolutely everyone 80 – 95% Almost everyone 5 – 20% Almost no-one 0% Absolutely no-one Set standard of care expected REALLY IMPORTANT - bad audits often have poor standards Should be based on best evidence Consist of CRITERIA and STANDARD CRITERIA CRITERIA STANDARD STANDARD Prescriptions are dispensed 80% and ready to be collected by 80% the patient within 20 minutes of receipt of the prescription in the pharmacy Is this a GOOD standard for a clinical audit? All patients experiencing a myocardial infarction should take aspirin. A. Yes B. No C. Don’t know Is this a GOOD standard for a clinical audit? A. Yes B. No C. Don’t know CRITERIA STANDARD Patients diagnosed with a myocardial infarction receive oral aspirin 300mg within 4 hours of 95% admission to A&E Is this a GOOD standard for a clinical audit? CRITERIA STANDARD Patients prescribed warfarin receive a yellow book when warfarin is 100% started A. Yes B. No C. Don’t know Is this a GOOD standard for a clinical audit? CRITERIA STANDARD Patients prescribed warfarin by the warfarin clinic have a record, in their clinic notes, that they were given a yellow 80% book at their first clinic appointment A. Yes B. No C. Don’t know Is this a GOOD standard for a clinical audit? CRITERIA STANDARD Patients prescribed warfarin have their yellow book with them each time they 95% attend the warfarin clinic A. Yes B. No C. Don’t know Clinical Audit Cycle Decide topic Set standard of care Re-audit expected Data collection - Implement changes observe practice Data analysis - Make compare practice recommendations with standard Data Collection Data collection Observe practice What data do you need to collect? Is it readily available? Is the data you need routinely collected? OR Do you have to collect the data from clinical / medical records? How will you collect the data that you need (Data collection tool) Clinical and Medical records GP medical records (computerised) Hospital medical records (mainly paper) Community Pharmacy records (computerised record of prescriptions dispensed – other services may be paper or computer records?) ▪ Are these records accessible? ▪ How long will it take to collect the information that you need? ▪ Is the information recorded consistently? Routinely reported data NHS services have to report data on their services e.g. contract monitoring NHS DIGITAL (X) publish certain data sets. For example ▪ Prescribing data (PACT) ▪ Quality of GP services - Quality and Outcome Framework (includes some prescribing indicators) ▪ Community Pharmacy data NHS Organisations will routinely collect their own data NHS Digital - GOV.UK (www.gov.uk) Search Results - NHS Digital Search Results - NHS Digital Prescribing data - PACT Prescribing Analysis and CosTs Produced by Prescription Pricing Division Details of all prescriptions dispensed in England (similar arrangements in Wales, Scotland and Northern Ireland) Drug costs Results - NHS Digital CRITERIA STANDARD Average of 150 influenza vaccines provided per community pharmacy in 100% 2018/2019 What data is available in Community Pharmacy? Dispensing data (PMR, prescriptions) PatieNT records (MURs, Local enhanced services) Information recorded as part of NHS Pharmacy Contract (contract monitoring) Advanced Services e.g. MUR, NMS consultation records Locally enhanced services e.g. smoking cessation patient records Essential services e.g. Standard Operating Procedures, records of staff training and staff levels, Management information e.g. waiting times, owings How would you collect data for this clinical audit? A. From medical records at the warfarin clinic B. From community pharmacy records C. Asking patients attending the warfarin clinic D. Asking patients attending a GP Surgery CRITERIA STANDARD Patients prescribed warfarin by the warfarin clinic have a record, in their clinic notes, that they were given a yellow book at their 80% first clinic appointment How would you collect data for this clinical audit? A. From medical records at the warfarin clinic B. From community pharmacy records C. Asking patients attending the warfarin clinic D. Asking patients attending a GP Surgery CRITERIA STANDARD Patients prescribed warfarin by the warfarin clinic have a record, in their clinic notes, that they were given a yellow book at their 80% first clinic appointment How would you collect data for this clinical audit? A. From medical records at the warfarin clinic B. From community pharmacy records C. Asking patients attending the warfarin clinic D. Asking patients attending a GP Surgery CRITERIA STANDARD Patients prescribed warfarin have their yellow book with them each 95% time they attend the warfarin clinic How would you collect data for this clinical audit? A. A&E medical records B. Community pharmacy records C. Asking patients attending post MI clinic D. GP Medical records E. PACT data CRITERIA STANDARD Patients diagnosed with a myocardial infarction receive oral aspirin 300mg within 95% 4 hours of admission to A&E Clinical Audit Cycle Decide topic Set standard of care Re-audit expected Data collection - Implement changes observe practice Data analysis - Make compare practice recommendations with standard Data analysis Present the data so that it can be compared to the standard. Is the standard met? If the standard is not met are there clues in the data as to why and what needs to change? (further analysis) CRITERIA STANDARD PHARMACY 1 Prescriptions are dispensed and ready to be collected by the patient within 20 minutes 80% 65% of receipt of the prescription in the pharmacy Clinical Audit Cycle Decide topic Set standard of care Re-audit expected Data collection - Implement changes observe practice Data analysis - Make compare practice recommendations with standard Make recommendations What could be done to ensure that the standard is met (and patient care improved?) Implement changes Taking your recommendations forward Recommendations will be dependent on the topic being audited as well as the audit findings (e.g. further analysis). Requires knowledge of the care setting and “best care”. Clinical Audit Cycle Decide topic Set standard of care Re-audit expected Data collection - Implement changes observe practice Need to ensure that improvements have Make recommendations Data analysis - compare practice with standard occurred Examples of audit? https://www.youtube.com/watch?v=_fpQcbQBgwY Decide topic Set standard of care expected “best care” Data collection Data analysis Make recommendations Implement changes Re-audit Decide topic Hospital death rates unacceptably high because of deaths from preventable causes e.g. typhoid, cholera and dysentery Set standard of care expected “best care” Soldiers dying from typhoid, cholera or dysentery ……………………….. 0% (Hospital death rates ……………. 5%) Data collection Death rates – data collected on number (and cause) of deaths Data analysis Hospital death rate over 40% (many deaths believed to be avoidable) Make recommendations ❖ Sanitary Commission – flushed out sewers Implement changes and improved ventilation ❖ Improved laundry facilities ❖ Increased medical supplies and drugs Re-audit Hospital death rate reduced to 2% Clinical Audit Cycle Decide topic Set standard of care Re-audit expected Data collection - Implement changes observe practice Data analysis - Make compare practice recommendations with standard Pharmacist involvement in Clinical Audit Community Pharmacy NHS Contract - Essential Service requirement Topics - include local enhanced services, prescribing audits, multi-disciplinary care Hospital Pharmacy Audit embedded into practice Topic – anything that involves medicines! Primary Care / Public Health Pharmacy Prescribing audits e.g. PACT data, prescribing safety Service audits e.g. Local enhanced services Clinical governance requirements for community pharmacy Pharmacy Contractors must undertake two clinical audits per year: Topic chosen by pharmacy Examples / resources available on PSNC and RPS websites NHS England determined audit 2021/2022 – valproate during pregnancy 2018/2019 – Flu vaccination for people with diabetes https://psnc.org.uk/contract-it/essential-service-clinical-governance/clinical-audit/ https://www.rpharms.com/resources/pharma cy-guides/research-and-evaluation- guide/clinical-audit-hub Pharmacist involvement in Clinical Audit Community Pharmacy NHS Contract - Essential Service requirement Topics - include local enhanced services, prescribing audits, multi-disciplinary care Hospital Pharmacy Audit embedded into practice Topic – anything that involves medicines! Primary Care / Public Health Pharmacy Prescribing audits e.g. PACT data, prescribing safety Service audits e.g. Local enhanced services Clinical audit : PSNC Main site Prescribing audit example Decide a topic “Safe use of NSAIDs in elderly patients” Safety of NSAID prescribing following MHRA warning re: cardiovascular safety, particularly in elderly patients (GI and renal safety also considered but not reported here) Absolute contra-indication – Heart Failure Avoid NSAIDs in elderly patients with cardiovascular disease Where NSAIDs required use ibuprofen or naproxen (safest CV profile) For this audit elderly = 75 years and over  Set standard of care expected CRITERIA STANDARD Percentage of elderly patients prescribed a NSAID with Heart Failure as a recorded diagnosis 0% Percentage of elderly patients prescribed a NSAID with Cardiovascular Disease (Heart Failure, MI, IHD/CHD, hypertension, stroke, 20% TIA) as a recorded diagnosis) Percentage of elderly patients prescribed NSAIDs who are prescribed ibuprofen or naproxen 80%  Data collection (GP computer records) Practice Name A Date of data collection 30th November Number of patients registered with practice (list size) 6,123 No over 75 years 1,345 22% Number of patients over 75 prescribed NSAIDs (BNF 10.1.1) 107 8% NSAID Medical Contions (READ CODE DIAGNOSIS) Patient Heart IHD/CH Hyper- NSAID Dose MI Stroke / TIA Reference Failure D tension A001 Diclofenac 50mg TDS No No No No No A002 Ibuprofen 400mg TDS No No No No No  Data analysis (1) CRITERIA STANDARD A B C D Percentage of elderly patients prescribed a NSAID with Heart 0% 3.7% 1.9% 7.5% 0% Failure as a recorded diagnosis Percentage of elderly patients prescribed a NSAID with Cardiovascular Disease (Heart Failure, MI, 20% 56.1% 50.0% 79.1% 0% IHD/CHD, hypertension, stroke, TIA) as a recorded diagnosis) Percentage of elderly patients prescribed NSAIDs who are 80% 57.9% 48.1% 53.7% 100% prescribed ibuprofen or naproxen Data analysis (2) Data analysis (3) Data analysis (4) Data analysis (5) Data analysis (summary) NSAIDs are being prescribed inappropriately in elderly patients NSAIDs are being prescribed for patients with cardiovascular disease Elderly patients are not being prescribed the safest NSAIDs The audit has identified variation between practices in the CCG Clinical Audit Cycle Decide topic Set standard of care Re-audit expected Data collection - Implement changes observe practice Is there any Make Data analysis - compare practice information recommendations with standard to help me? Make recommendations Practice pharmacist to review ALL elderly patients prescribed NSAIDs (clinics, home visits, telephone consultations) Stop NSAIDs in patients with Heart Failure Review NSAIDs in patients with cardiovascular disease Change patients prescribed diclofenac, celecoxib or etoricoxib to ibuprofen or naproxen where possible Practice pharmacist to educate all prescribers regarding safe use of NSAIDS in elderly patients Implement change Practice pharmacist (prescriber) appointed Reviewed all elderly patients prescribed NSAIDs Recommended changes made Educational initiative implemented – prescribing decision making support developed for practice computer Eclipse Login Page (eclipsesolutions.org)  Re-audit - Data collected 6 months after last patient reviewed CRITERIA STANDARD A B C D Percentage of elderly patients prescribed a NSAID with Heart 0% 0% 1% 0% 0% Failure as a recorded diagnosis Percentage of elderly patients prescribed a NSAID with Cardiovascular Disease (Heart Failure, 20% 9% 12% 2% 0% MI, IHD/CHD, hypertension, stroke, TIA) as a recorded diagnosis) Percentage of elderly patients prescribed NSAIDs who are 80% 87% 91% 90% 100% prescribed ibuprofen or naproxen  Data analysis (1) – comparison CRITERIA STANDARD A B C D Percentage of elderly patients prescribed a NSAID with Heart 0% 3.7% 1.9% 7.5% 0% Failure as a recorded diagnosis Percentage of elderly patients prescribed a NSAID with Cardiovascular Disease (Heart Failure, MI, 20% 56.1% 50.0% 79.1% 0% IHD/CHD, hypertension, stroke, TIA) as a recorded diagnosis) Percentage of elderly patients prescribed NSAIDs who are 80% 57.9% 48.1% 53.7% 100% prescribed ibuprofen or naproxen Clinical Audit Cycle Decide topic Set standard of care Re-audit expected Data collection - Implement changes observe practice Is there any Make Data analysis - compare practice information recommendations with standard to help me? Clinical Audit Cycle – 7 steps to success! 1. Topic 2. Standard (of care expected) 3. Data Collection 4. Data Analysis 5. Recommendations 6. Implement Changes 7. Re-audit Today’s lecture Learning Outcomes By the end of this lecture you will be able to: Explain why we do clinical audit Describe the clinical audit cycle Give examples of pharmacist involvement in clinical audit Describe how clinical audit was used in the “safe use of NSAIDs in elderly patients” This will be embedded through: 1. Workbook – Task 10 2. An opportunity to put the learning from today’s lecture into practice in session 3 – Ensuring patient safety from aseptic dispensing What do we need from clinical audit to support quality improvement? - Dr Kevin Stewart - YouTube Resources Meetings in public :: Kent and Medway Clinical Commissioning Group (kentandmedwayccg.nhs.uk) (now, Integrated Care Board) ISO - ISO 9000 family — Quality management SOP01_How_to_write_a_SOP.pdf (ulh.nhs.uk) Home - NHS Digital Search Results - NHS Digital Search Results - NHS Digital Results - NHS Digital Florence Nightingale: Clinical Audit Pioneer – YouTube https://psnc.org.uk/contract-it/essential-service-clinical-governance/clinical-audit/ Clinical audit guide (rpharms.com) Eclipse Login Page (eclipsesolutions.org) What do we need from clinical audit to support quality improvement? - Dr Kevin Stewart - YouTube