ABSTRACT

The main aim of the project is atomization of the clinical auditing system to atomize all clinical data from manual errands. It is a front end database for the hospital in the image based clinical auditing system. This application can be used to analyze the complete clinical audit process and how this data is used to evaluate the patient information and their health improvement process. This project also focuses on data reliability by maintaining the database solutions. All updating from the auditing will be performed regularly and sporadically analyses the data. This application will provides the frontend database and used to Analyzing The internal audit for organization in any hospital. It will provide a user interface for any user and icon based auditing system. In this dissertation the project will provides the security in each and every level of the database. Only Administrator can have the right to add the clinical data and the number of user in the hospital. For the others the level of hierarchy will maintain with the surety access. Periodically final reports will generates and the reports will export to the excel format as for the operations required.

CHAPTER 1

INTRODUCTION

1.0 What is Clinical Auditing?

Clinical audit is a process that has been defined 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”. (NICE, 2002)

The key component of clinical audit is that performance is reviewed (or audited) to ensure that what should be done is being done, and if not it provides a framework to enable improvements to be made. It had been formally incorporated in the healthcare systems of a number of countries, for instance in 1993 into the United Kingdom’s National Health Service (NHS), and within the NHS there is a clinical audit guidance group in the UK.

One of first ever clinical audits was undertaken by Florence Nightingale during the Crimean War of 1853-1855. On arrival at the medical barracks hospital in Scutari in 1854, Florence was appalled by the unsanitary conditions and high mortality rates among injured or ill soldiers. She and her team of 38 nurses applied strict sanitary routines and standards of hygiene to the hospital and equipment, and with Florence’s gift with mathematics and statistics, kept meticulous records of the mortality rates among the hospital patients. Following this change the mortality rates fell from 40% to 2%, and were instrumental in overcoming the resistance of the British doctors and officers to Florence’s procedures. Her methodical approach, as well as the emphasis on uniformity and comparability of the results of health care, is recognised as one of the earliest programs of outcomes management.

Another famous figure who advocated clinical audit was Ernest Codman .He became known as the first true medical auditor following his work in 1912 on monitoring surgical outcomes. Codman’s “end result idea” was to follow every patient’s case history after surgery to identify individual surgeon’s errors on specific patients. Although his work is often neglected in the history of health care assessment, Codman’s work anticipated contemporary approaches to quality monitoring and assurance, establishing accountability, and allocating and managing resources efficiently.

Whilst Codman’s ‘clinical’ approach is in contrast with Nightingale’s more ‘epidemiological’ audits, these two methods serve to highlight the different methodologies that can be used in the process of improvement to patient outcome.

The integration into contemporary Healthcare:

Despite the successes of Nightingale in the Crimea and Codman in Massachusetts, clinical audit was slow to catch on. This situation was to remain for the next 130 or so years, with only a minority of healthcare staff embracing the process as a means of evaluating the quality of care delivered to patients.

As concepts of clinical audit have developed, so too have the definitions which sought to encapsulate and explain the idea. These changes generally reflect the movement away from the medico-centric views of the mid-Twentieth Century to the more multidisciplinary approach used in modern healthcare. It also reflects the change in focus from a professionally-centred view of health provision to the view of the patient-centred approach. These changes can be seen from comparison of the following definitions.

In 1989, the White Paper, Working for patients, saw the first move in the UK to standardise clinical audit as part of professional healthcare. The paper defined medical audit (as it was called then) as

“the systematic critical analysis of the quality of medical care including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient.”

Medical audit later evolved into clinical audit and a revised definition was announced by the NHS Executive:

“Clinical audit is the systematic analysis of the quality of healthcare, including the procedures used for diagnosis, treatment and care, the use of resources and the resulting outcome and quality of life for the patient.”

The National Institute for Health and Clinical Excellence (NICE) published the paper Principles for Best Practice in Clinical Audit, which defines 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.”

Types of Audit

Standards-based audit – A cycle which involves defining standards, collecting data to measure current practice against those standards, and implementing any changes deemed necessary.

Adverse occurrence screening and critical incident monitoring – This is often used to peer review cases which have caused concern or from which there was an unexpected outcome. The multidisciplinary team discusses individual anonymous cases to reflect upon the way the team functioned and to learn for the future. In the primary care setting, this is described as a ‘significant event audit’.

Peer review – An assessment of the quality of care provided by a clinical team with a view to improving clinical care. Individual cases are discussed by peers to determine, with the benefit of hindsight, whether the best care was given. This is similar to the method described above, but might include ‘interesting’ or ‘unusual’ cases rather than problematic ones. Unfortunately, recommendations made from these reviews are often not pursued as there is no systematic method to follow.

Patient surveys and focus groups – These are methods used to obtain users’ views about the quality of care they have received. Surveys carried out for their own sake are often meaningless, but when they are undertaken to collect data they can be extremely productive.

1.3 Place of clinical audit in modern Healthcare

Clinical audit comes under the Clinical Governance umbrella and forms part of the system for improving the standard of clinical practice.

Clinical Governance is a system through which NHS organisations are accountable for continuously improving the quality of services, and ensures that there are clean lines of accountability within NHS trusts and that there is a comprehensive programme of quality improvement systems. The six pillars of clinical governance include:

Clinical Effectiveness

Research & Development

Openness

Risk Management

Education & Training

Clinical Audit

Clinical audit was incorporated within Clinical Governance in the 1997 White Paper, “The New NHS, Modern, Dependable”, which brought together disparate service improvement processes and formally established them into a coherent Clinical Governance framework.

1.4 Clinical Audit-The process

Clinical audit can be described as a cycle or a spiral, see figure. Within the cycle there are stages that follow the systematic process of: establishing best practice; measuring against criteria; taking action to improve care; and monitoring to sustain improvement. As the process continues, each cycle aspires to a higher level of quality.

Stage 1: Identify the problem or issue

This stage involves the selection of a topic or issue to be audited, and is likely to involve measuring adherence to healthcare processes that have been shown to produce best outcomes for patients. Selection of an audit topic is influenced by factors including:

Where national standards and guidelines exist; where there is conclusive evidence about effective clinical practice (i.e. evidence).

Areas where problems have been encountered in practice.

What patients & public have recommended that be looked at.

Where there is a clear potential for improving service delivery.

Areas of high volume, high risk or high cost, in which improvements can be made.

Additionally, audit topics may be recommended by national bodies, such as NICE or the Healthcare Commission, in which NHS trusts may agree to participate. The Trent Accreditation Scheme recommends a culture of audit to participating hospitals inside and outside of the UK, and can provide advice on audit topics.

Stage 2: Define criteria & standards

Decisions regarding the overall purpose of the audit, either as what should happen as a result of the audit, or what question you want the audit to answer, should be written as a series of statements or tasks that the audit will focus on. Collectively, these form the audit criteria. These criteria are explicit statements that define what is being measured and represent elements of care that can be measured objectively. The standards define the aspect of care to be measured, and should always be based on the best available evidence.

A criterion is a measurable outcome of care, aspect of practice or capacity. For example, ‘parents / carers are involved in negotiating or planning their child’s care’.

A standard is the threshold of the expected compliance for each criterion (these are usually expressed as a percentage). For the above example an appropriate standard would be: ‘There is evidence of parent / carer in care planning in 90% of cases’.

Stage 3: Data collection

To ensure that the data collected are precise, and that only essential information is collected, certain details of what is to be audited must be established from the outset. These include:

The user group to be included, with any exceptions noted.

The healthcare professionals involved in the users’ care.

The period over which the criteria apply.

Sample sizes for data collection are often a compromise between the statistical validity of the results and pragmatically issues around data collection. Data to be collected may be available in a computerised information system, or in other cases it may be appropriate to collect data manually or electronically using data capture solutions such as Formic, depending on the outcome being measured. In either case, considerations need to be given to what data will be collected, where the data will be found, and who will do the data collection.

Ethical issues must also be considered; the data collected must relate only to the objectives of the audit, and staff and patient confidentiality must be respected – identifiable information must not be used. Any potentially sensitive topics should be discussed with the local Research Ethics Committee.

Stage 4: Compare performance with criteria and standards

This is the analysis stage, whereby the results of the data collection are compared with criteria and standards. The end stage of analysis is concluding how well the standards were met and, if applicable, identifying reasons why the standards weren’t met in all cases. These reasons might be agreed to be acceptable, i.e. could be added to the exception criteria for the standard in future, or will suggest a focus for improvement measures.

In theory, any case where the standard (criteria or exceptions) was not met in 100% of cases suggests a potential for improvement in care. In practice, where standard results were close to 100%, it might be agreed that any further improvement will be difficult to obtain and that other standards, with results further away from 100%, are the priority targets for action. This decision will depend on the topic area – in some ‘life or death’ type cases, it will be important to achieve 100%, in other areas a much lower result might still be considered acceptable.

Stage 5: Implementing change

Once the results of the audit have been published and discussed, an agreement must be reached about the recommendations for change. Using an action plan to record these recommendations is good practice; this should include who has agreed to do what and by when. Each point needs to be well defined, with an individual named as responsible for it, and an agreed timescale for its completion.

Action plan development may involve refinement of the audit tool particularly if measures used are found to be inappropriate or incorrectly assessed. In other instances new process or outcome measures may be needed or involve linkages to other departments or individuals. Too often audit results in criticism of other organisations, departments or individuals without their knowledge or involvement. Joint audit is far more profitable in this situation and should be encouraged by the Clinical Audit lead and manager.

Re-audit: Sustaining Improvements

After an agreed period, the audit should be repeated. The same strategies for identifying the sample, methods and data analysis should be used to ensure comparability with the original audit. The re-audit should demonstrate that the changes have been implemented and that improvements have been made. Further changes may then be required, leading to additional re-audits.

This stage is critical to the successful outcome of an audit process – as it verifies whether the changes implemented have had an effect and to see if further improvements are required to achieve the standards of healthcare delivery identified in stage 2.

Results of good audit should be disseminated both locally via the Strategic Health Authorities and nationally where possible. Professional journals, such as the BMJ and the Nursing Standard publish the findings of good quality audits, especially if the work or the methodology is generalisable.

Fig: The Life cycle of clinical audit process

CHAPTER 2

2.0 Literature review:

Clinical audit process was actually introduced in 1993 by United Kingdom’s National Health Services (NHS). The main purpose of clinical audit is to diagnose the patient and giving treatment in regarding the quality of health care. In simple words Clinical audit can be defined as the quality measures taken to improve the patient care and reviewing the changes better outcome. It is a systematically practice to examine the patient in all aspects. The main important aspect in clinical audit system is to ensure that everything is done as per the predefined procedure and if not introducing measures to happen this.

Both the quantitative and qualitative approaches are considered for the research process. Basic attributes that contribute the clinical audit system are analyzed by the quantitative approach and even the hidden truths of the hospital maintenance can be derived by these quantitative approaches. Behaviour the clinical auditing system and its impact on the typical operations of hospital can be analyzed by the qualitative methods. A separate database is maintained to record all the clinical audit issues and the same data is used to populate at the front end. Research is the process of getting better knowledge on new aspects and clinical audit is all about finding the best practices and providing an interface to implement them and thus we can conclude that all the data required for better implementation of clinical audit is based on the inputs provided at the research level. All the statistical data that was collected can be best evaluated with the help of database design and this design can is best decided by the quantitative methods. Database capacity and its relevant can be decided with the help of these methods. All the research is focused on the patient information and this information is collected from the clinics directly to evaluate the best research methods.

2.1 Issues in the present System:

Problems:

All the data in the clinical auditing process is manual

The data collected from the medical professional is done manually.

The evaluation process of data related to the clinical auditing need the lot of effort and time taking process. Sometimes it may take one month or more to evaluate a single file.

The quality of health care is provided by setting and estimating of best practice

Results are not movable to others, it shows specific and local to one individual patient group

It is practice-based and continue process Allocating patients never involve randomly to diverse treatment groups

It never accepts an entire new treatment

2.2 Proposed System:

This application will provides the frontend database and used to Analyzing The internal audit for organization in any hospital. It will provide a user interface for any user and icon based auditing system. In this dissertation the project will provides the security in each and every level of the database. Only Administrator can have the right to add the clinical data and the number of user in the hospital. For the others the level of hierarchy will maintain with the surety access. Periodically final reports will generates and the reports will export to the excel format as for the operations required.

The main steps are taken by clinical audit are as follows:

Normal clinical management will proceed whether patient contact is involved or not but it doesn’t take any difference

Few audits can have efficiency to entail patient input and carry risks like psychological harm and distress

Individuals may accept different treatment or services through general clinical assessment, they are not randomized

Various settings of results were not transferable

Statistical analysis and interviews are best examples for research methodologies

Principles of good practice are source of theoretical constructs and measurement not hypothesis

The quality of practice is improved by Clinical audit and Clinical research results to enhanced knowledge

The Nurse role in clinical audit is to address the clinical governance which is focused on the frame work. The information will be useful for the data collection correctly. While nurses involve the ward staff, they indirectly correspond to the patient care. Since the nurse managers have to avail a several tools to simplify the process systematically and giving effective strategy. The nurse manger takes necessary steps for the audit to encourage and empower the staff for the best resources as this is the first change agent. (Morrell 1999; Harvey 1999).

As they believed in “change agents” and the second change agent was needed to change the staff mode with the result of memo mostly, they are verified by opinion leader who was a second change agent who was convinced with the conversation (Lomas, 1991).

Facilitator, it is a professional ward which is external in the third change agent. It is a part of trusts in clinical governance; this department is to expertise in audit. Co-coordinator, who will guide the standard setting and services comparing with practices. (Stark, 2002)

Innovator is fourth agent, here the ward staff enjoys on sudden change, and they are passion to promote peers. These are offered and utilized by four change agents, nurse led clinical audit are believed. (Morrell 1999; Harvey 1999).

Problems are identified in based clinical audit, to rectify the problem audit needs an allocated time. It is an extra work for the team with the audit cycle working on a few skilled members. To introduce clinical audit and pay to nurses need extra funds to achieve the process but this resource is lacking in ward level (Chambers and Jolly, 2002; Nice, 2002).

It is difficult to validate the ward staff to get audit result by not funding them. Absence of good managers, the particular nurses role in audit will provide an effective training, if audit is incomplete it is difficult to implement and it cannot be worth. (Smith, 2004; Kinn, 1995).