Introduction to Clinical Audit in Occupational Health

Clinical audit and check list image
Clinical Audit and Checklist

What does clinical audit do?

  • Answers the question ‘Are we following best practice?’
  • Measures against standards (taken from local or national policy)
  • Sets up a review process of practice changing over time
  • Involves a small sample over a short time frame
  • Collects routine data
  • Findings influence activities of local clinicians and teams

The clinical audit ensures that all staff follow best practice and deliver high standards of care, and is also a key component of education and continuing professional development.

Confidentiality

Your audit should do good, not harm. The main ethical consideration of an audit project is that of confidentiality for clients, patients and the organisation. Each data collection tool e.g. questionnaire should not include the names of patients or healthcare professional with a unique ID code used instead. This unique ID can link to a separate list of names/ case record numbers etc that should be stored securely and used only in accordance with all relevant data privacy regulations.

Consent

While express consent is not usually required for auditing, patients should be aware that data from their records may be used for audit in an anonymous way.

Under the General Data Protection Regulations, there is an implication for consent from the patient/client auditing is carried out by a non-healthcare professional.

Appropriate

Use a clinical audit method which is appropriate and rigorous.

‘Clinicians [and managers] have a duty to use the findings from audit to improve clinical care and move towards best practice i.e. audit is an essential tool for continuous quality improvement’ (BMA 1995)

Coordination

Decide who is responsible for the audit and who does it.

‘It is usually the clinicians responsible for the audit that collect that data’ (UBHT 2005).

Select one member of the team to be co-ordinator/lead for that particular audit project with responsibility for the overall management of the project. (CGST 2005). Others can assist with retrieving and recording data.

Purpose

The audit objectives should be set and agreed. Ensure objectives are measurable and achievable and in line with the strategy and objectives for the audit programme and the organisation as a whole. Most find the SMART model outlined here helpful in writing and defining your objectives for audit.

The 5 Smart Objectives Image
SMART objectives

The audit group selects and agrees on the objectives of the audit, with a clear sense of purpose.Feb

Ask yourself:

  1. What do I want to know by undertaking this audit?
  2. What do I want to achieve by undertaking this audit?

Suggested Clinical Audits in Occupational Health

  • Activity information – e.g. number of referrals, reviews, waiting time for an appointment
  • A specific health issue e.g. stress, back pain, short-term absence
  • Analysis of feedback e.g. complaints, satisfaction surveys,
  • Inspections, site visits e.g. workplace visits, surveys eg noise, light
  • Outputs e.g. reports, GP letters, clinical notes
  • Peer review meetings
  • Clinical databases e.g. Database upkeep, security, password
  • Sickness absence

Chose topics but also consider practical points, such as:

  • Is it a real problem?
  • Can it be measured?
  • Are there standards/criteria to measure against?
  • Can a change be made?
  • Is the effort required acceptable?
  • Are there sufficient resources to complete the clinical audit and implement changes?
  • Do we have the necessary expertise and enthusiasm?
  • Will this project lead to measurable improvement for service users/staff?
  • Is this project relevant to the business objectives of the organisation?’ (The Pharmaceutical Journal 2005)

Steps

  1. Develop a project plan with activities set out clearly
  2. Set target dates for completion and assign responsibility for tasks
  3. Agree on criteria to measure against, such as quality guidelines, reviews of the literature or national or local consensus.
  4. Process (what you do), actions and decisions taken by practitioners and users e.g., documentation, interventions.
  5. Outcome (what you expect) measures the physical or behavioural response to an intervention, reported health status and level of knowledge and satisfaction. Remember, poorly defined criteria can be misleading.

There are four requirements for good and valid criteria:

  1. Relevant
  2. Clearly defined
  3. Easily measured
  4. Based on evidence (NICE 2002)

Before you reinvent the wheel, search to see if an audit tool suitable for your audit topic already exists, but don’t collect information that does not relate to the audit just because it is ‘interesting’.

Observation Audits

This form of data collection can be time-consuming, data collected is not always complete and accuracy must be assured e. g. observing vaccinations

Size of Sample

If there were no limitation on resources the whole workforce could be audited; however, if the number of patients in your population is over 100 you will most probably want to look at taking a smaller sample. This gives a ‘snapshot’ of whether standards are being met.

“When choosing a sample two questions need to be answered:

  • How many users (study population) do I need to select?
  • How do I choose a representative sample?” ( NICE 2002)

‘The number needed in the sample will be affected by two factors:

The degree of confidence wanted in the findings and resources available (time, staff, access to data, costs).

The two main types of sampling are:

  1. Random sampling involves the selection at random from a list of the population of the required number of persons for the sample.
  2. Convenience sampling involves choosing the nearest and most convenient persons to act as respondents. The process is continued until the required sample size has been reached

Clinical Audit Records

Proper records should be maintained of the project so that progress against objectives can be monitored and changes to methodology recorded.

Audit Format

  • Ensure that the data collection tool looks good and easy to use
  • Allocate a name (or unique ID code) for each site and collector to make comparisons easier
  • Use standard fonts and a readable size
  • Date each entry you make
  • Do not overcrowd pages, give enough space for recording results and comments
  • Include instructions for collecting the data for posterity

Pilot your Data Collection Tool

Always pilot your data collection tool using a small number of cases to:

  • Highlight any difficulties relating to sequencing
  • Identify missing data items
  • Identify unclear data collection questions or instructions

Quality Control

Check a small sample before issuing – a pilot study first.

Data Analysis

Data analysis should be as simple as possible. Pen, paper and a calculator are often enough for comparisons of frequencies and percentages.

Analysis of Results

There are some tools to assist you in root cause analysis such as:

The fish bone diagram (also known as the Ishikawa diagram or cause and effect diagram)

A problem-solving tool for identifying the cause of a problem with the problem or effect written in the head of the fish. Then, add a common set of major categories of causes into the bones of the fish such as personnel, work methods/procedures, materials and equipment.

Process mapping

Each step of a process is mapped so that problem areas/bottlenecks in the process can be identified and improved.

The five why’s

Asking the question why something has happened five times – each time drilling down further to get to the root cause of the problem. By identifying the root causes, you can then move towards identifying the changes needed to improve.

Report from the Completed Audit

After the collection and analysis of data, an audit report sets out the practice compared with the standard.

The report should identify:

  • Shortcomings, e.g. practice unrecorded, practice not occurring, poor levels of satisfaction.
  • Causes, e.g. poor documentation, inadequate staffing, training and practice issues.
  • Needed improvements, e.g. the introduction of a questionnaire for clients complaining of work-related stress.
  • Relevant, meaningful and useful information that will help to identify and address the issues arising from the audit.
  • Information that explains why some cases do not meet the standard
plan do check act model from HSE image
Plan-do- check- act model from HSE for use after the clinical audit

All audits should have a quality improvement plan with identified priorities so that you can set out the plan and allocate responsibilities.

Some simple quality improvement tools such as the Plan- Do–Check-Act cycle could be used to implement quality improvement.

One method of prioritisation may be to use a risk matrix – in other words, what issue if is not addressed will cause the greatest risk to patients/clients or staff?

HSE Risk Matrix for Priorities
HSE Risk Matrix for Priorities

Sustaining improvement all audits and quality improvement plan should be subject to on-going monitoring and evaluation. You need to evaluate to see if these changes have effectively raised the standards. This is your re-audit. A rapid re-audit is advised to assess the effectiveness of the changes using the same audit tool and protocol.

Occupational Health Audit Check List

Preparation Consent from patients/clients/organisation
  Resources required
  Project Lead and auditors
  Key dates
Selecting Audit Criteria Set out objectives and topic
  Measure against standards, policy or criteria
  Best process to use and size of sample
  Recording outcomes and format
Measuring Performance Audit report  and findings
  Data analysis
  Explanation of poor results, exceptions
Making Improvements Prioritise areas to improve
  Improvement plan and timeframe
  Training and education
Sustaining Improvements Redo Audit
  Ongoing monitoring

For more free templates and policies go to free templates download here

See also SEQOHS website for accrediting your OH services at www.seqohs.org