surgical audit

1. Dr T SURESH

2. The Lady with the Lamp

3. Definition
• Clinical audit is a quality improvement process
that seeks to improve patient care and
outcomes through systematic review of care
against explicit criteria and the review of
change.(NICE 2002)
• the word ‘auditing’ has been derived from
Latin word “audire” which means “to hear”.

4. • Clinical Audit is a mandatory element of the
Professional Competence Scheme in some
countries for all Surgeons / Medical
Practitioners according to the Medical
Practitioners Act 2007 on 1st May 2011.

5. Clinical Review

6. Clinical Review
• A detailed presentation of one or more cases
often with certain objectives and around a
specific theme.
• e.g. the clinicopathological case presentation)

7. RESEARCH

8. RESEARCH
• To derive generalisable new knowledge
including studies that aim to generate
hypotheses as well as studies that aim to test
them.
• Eg: clinical trails

9. Service evaluation
• Designed and conducted solely to define or
judge current care.

10. Elements
measure
compare
evaluate

11. Elements
• Measurement - Measuring a specific element
of clinical practice
• Comparison - Comparing results with the
recognized standard
• Evaluation - Reflecting the outcome of audit
and where indicated, changing practice
accordingly.

12. Difference between medical audit and
that of surgery
• In medical audit usually a pharmaceutical
intervention have explicit standards and
outcome that can be measurable.
• Most of the guidelines are evidence based.
• Eg: diabetes sample audit.

14. • In surgical audit, it is difficult to set standards
and to apply.
• So we need to measure the variations in
outcome.
• Eg: mortality rate following radical cystectomy
in a centre of international standing will
definitely differ from that of a remote area.

16. Types
• National audits (e.g. in the UK, the National
Institute for Health and Clinical Excellence –
NICE)
• local/hospital audits.

17. Audit cycle
• Define the audit question.
• Identify the body of evidence and current
standards.
• Design the audit to measure performance
against agreed standards.
• Measure over an agreed interval.
• Analyze results and compare performance
against agreed standards.

18. • Undertake gap analysis : If all standards are
reached, re audit after an agreed interval.
• If there is a need for improvement, identify
possible interventions such as training, and
agree with the involved parties.
• Re audit.

20. Determining scope
Common areas in the scope of an audit include:
• 30 day mortality and significant morbidity;
• length of hospital stay;
• positive and negative outcomes
• operation-specific complications
• use of investigations
• justification of management
• patient satisfaction.

21. Select standards

22. Select standards
• use evidence-based research and guidelines
where ever possible(cochrane collaboration);
• adapt existing local guidelines for local
relevance;
• use an accessible library for evidence about
effective practice and develop new guidelines;
• look to the specialty group to define
standards.

23. Collect data

24. Collect data
• the information necessary to answer the audit
question.
• collect prospectively or retrospectively.
• follow up data collected.
• Data can be collected from a register, medical
records data, review of referrals, or from
previous appointment schedules.

25. Peer review

26. Peer review
• The evaluation of work by one or more people
of similar competence to the producers of the
work (peers).
• It constitutes a form of self-regulation by
qualified members of a profession within the
relevant field.

27. morbidity and mortality meetings

28. Eg: morbidity and mortality meetings
• Peers are other surgeons with comparable
training and experience.
• It can often also be helpful to include other nonsurgical members of the team in the review group
e.g. surgical trainee or senior nursing staff.
• This should be conducted in an atmosphere of
confidentiality, of trust and teamwork, and be
seen as an evolving process.

29. Grand rounds

30. • Grand rounds as the name suggests are hardly
confidential peer review - but cases should be
presented as an educational exercise.
• They are good opportunities to learn from one
or more cases but do not replace formal
surgical audit meetings.

31. Make Changes and Monitor Progress
• Implementation involves not just making
changes but ensuring that everyone affected
is educated/ informed as to what changes are
being made and why.
• It can be at any level from staff to surgeons
and instrumentation.
• Then follow up the change achieved and then
re audit for better results.

32. What Resources are Required
Manual systems
• paper-based systems with notebooks or card
indexes, often with the help of sticky labels.
• As manual data recording and entry can be
tedious and prone to error, it is recommended
that advantage be taken where possible, of
automated or semiautomated entry, such as
bar codes, scanners

34. Computer systems
• It is recommended where ever practicable,
particularly for individuals in private practice.
• in addition to surgical audit data can be used
for multiple purposes such as billing, reporting
or clinical records
• reduce duplication and facilitate data
collection, verification and analysis.

36. Logbooks
• Logbooks used by surgical trainees provide an
opportunity to start a data collection system
as part of an ongoing process towards surgical
audit.

37. Privacy

38. Privacy
• Confidentiality in audit process is essential,
both from the point of view of the rights of
the individual patient and of the surgeon.
• It is also important to reassure participating
surgeons and other team members that peer
review discussions constitute confidential
professional peer review rather than a ‘witch
hunt’.

39. What Opportunities Arise from
Surgical Audit
Educational opportunities
• modify attitudes and approaches to clinical
problems
• enhancing critical approaches and giving a
rational basis to local changes in clinical
practice;
• indicates deficiencies in knowledge and skills,
and to develop educational activities to
address these;

40. Systemic improvement opportunities
• Clear problems and deficiencies identified in
‘systems’ should lead hospital authorities to re
address the issues.
• Similarly individuals and teams can always
improve.

41. • Surgical audit and peer review are essential
components of continuing professional
development.

42. Bibliography
• Bailey and love 26th edition.
• A Guide by the ROYAL AUSTRALASIAN COLLEGE OF
SURGEONS- surgical audit and peer review (2008)
• Professional competence scheme- guidelines for
surgical audit- RCSI ( NOVEMBER 2012)