AUDIT CLINICO

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AUDIT CLINICO

1. Definizione 2. Struttura

3. Pianificazione e conduzione 4. Report

5. Barriere e fattori facilitanti Audit Clinico

“Audit is the systematic and critical analysis of the quality of medical care including the procedures

used for diagnosis, treatment and care, the associate use of resources and the resulting outcome and quality of life for the patient”

Secretaries of State for Health, England, Wales Northern Ireland and Scotland,1989

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“Audit is the process of reviewing the delivery of health care to identify deficiencies so that they may be remedied”

Crombie IK, et al. 1993

“Clinical audit is the process by which the doctors, nurses and other health professionals regularly and

systematically review, and where necessary change, their clinical practice”

Primary Health Care Clinical Audit Working Group, 1995

From “Medical” to “Clinical” Audit

Clinical Governance Tools & Skills

• Evidence-based Practice

• Information & Data Management

• Practice Guidelines • Care Pathways

• Health Technology Assessment

• Clinical Audit

• Clinical Risk Management

• CME, professional training and accreditation

• Staff management E v id e n c e -b a s e d H e a lt h C a re

• Consumer Involvement

Modificata da:

Cartabellotta A, et al Sanità & Management Novembre 2002

• Research & Development

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Audit di sistema*

Audit puntuale**

Audit clinico

Contenuti professionali

Revisione tra pari

Sistematicità

NO

SI’

NO NO

SI’

* Accreditamento, certificazione

**Discussione di casi clinici, significative event audit (SEA)

1. Definizione 2. Struttura

3. Pianificazione e conduzione 4. Report

5. Barriere e fattori facilitanti Audit Clinico

• Clinical audit can be described as a cyclical or spiral systematic process, with the ultimate aim of improving care.

• The spiral suggests that as the process continues, each cycle aspires to a higher level of quality.

2. Struttura dell’audit clinico

Benjamin A. BMJ 2008

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1. Identify topic

3. Measure practice against standard

4. Identify areas which need to

be changed 5. Implement change

in practice 6. Re-audit to ensure

change has been effective

2. Set standard

1. Definizione 2. Struttura

3. Pianificazione e conduzione 4. Report

5. Barriere e fattori facilitanti

Audit Clinico

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1. Identify topic 2. Set standard

3. Measure practice against standard 4. Identify areas which need to be changed 5. Implement change in practice

6. Re-audit to ensure change has been effective

3. Pianificazione e conduzione

- High frequence - High risk - High variability - High cost - High anxiety

Department of Health, 1994

1. Identify topic

Presentazioni cliniche - Dispepsia Diagnostic pathways - Dolore toracico anteriore

Test diagnostici - Gastroscopia Technology assessment - Coronarografia

Malattie, sindromi - Ulcera peptica Care pathways - Infarto del miocardio

Trattamenti - Linezolid Technology assessment

- NIV

Prevenzione primaria - Prev. infezioni post-chirurgia Preventive care - Screening

1. Identify topic

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Presentazioni cliniche - Dispepsia Diagnostic pathways - Dolore toracico anteriore

Test diagnostici - Gastroscopia Technology assessment - Coronarografia

Malattie, sindromi - Ulcera peptica Care pathways - Infarto del miocardio

Trattamenti - Linezolid Technology assessment

- NIV

Prevenzione primaria - Prev. infezioni post-chirurgia Preventive care - Screening

1. Identify topic

Livello Macro: Azienda

- Riferimento organizzativo: Collegio di Direzione - Numero limitato di progetti di GC: 2-3 per anno,

spesso su committment regionale Livello Meso: Dipartimento, Distretto

- Riferimento organizzativo: Comitato di Dipartimento, Comitato di Distretto

- Coinvolgere tutti i dipartimenti in almeno un progetto (mono o interdipartimentale), ma evitare che un singolo dipartimento sia coinvolto in oltre 2-3 progetti/anno

1. Identify topic

CHI

• Collegio di Direzione/GC (priorità aziendali)

• Comitato di Dipartimento (priorità dipartimentali)

COME

• Processo di consenso formale (metodo Delphi modificato) QUANDO

• Prima della definizione del budget

1. Identify topic

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1. Identify topic 2. Set standard

3. Measure practice against standard 4. Identify areas which need to be changed 5. Implement change in practice

6. Re-audit to ensure change has been effective

3. Pianificazione e conduzione

• Gli standard (di processo e di esito) possono essere derivati da:

- Evidenze scientifiche à Linee guida à Percorsi assistenziali

- Normative - Benchmarking

- Processo di consenso locale

2. Set standard

Criteri di definizione Appropriatezza Professionale

Revisioni sistematiche Trials randomizzati Studi osservazionali

2. Processi di consenso formale (RAND) Evidence-based

Guidelines

Care Pathways 1. Evidenze scientifiche

3. Normative nazionali (note AIFA) o regionali

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Criteri di definizione Appropriatezza Organizzativa

2. Benchmarking

3. Evidenze scientifiche (health service research) 1. Normative nazionali (LEA) e regionali (requisiti

accreditamento, direttive specifiche)

• Per massimizzare la probabilità

dell’implementazione, uno standard dovrebbe avere le seguenti caratteristiche:

- Evidence-based

- Condiviso tra tutti i professionisti - Adattato al contesto locale

2. Set standard

• Gli indicatori di processo, ed eventualmente di esito, vengono definiti utilizzando un formato standard:

- Tipo indicatore - Categoria indicatore - Denominazione indicatore - Numeratore/Denominatore - Fonte dei dati

- Target

- Eccellenza (max) - Accettabile (min)

2. Set standard

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Fase 1 Definizione Priorità

Fase 2 Costituzione G.L.A.M.

Fase 3 F.A.I.A.U.

Fase 4 D.I.E Framework GIMBE

1. Finding Ricerca delle LG

2. Appraising Valutazione critica delle LG (e scelta della LG di riferimento)

3. Integrating Integrazione della LG

4. Adapting Adattamento locale e costruzione dei PA

5. Updating Aggiornamento

FASE 3: F.A.I.A.U.

FASE 4: D.I.E.

1. Disseminating Disseminazione del PA

2. Implementing Implementazione del PA

3. Evaluating Valutazione dell’impatto del PA

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1. Identify topic 2. Set standard

3. Measure practice against standard 4. Identify areas which need to be changed 5. Implement change in practice

6. Re-audit to ensure change has been effective

3. Pianificazione e conduzione

Dove cercare i dati?

• Documentazione sanitaria (cartelle cliniche, relazioni, etc)

• Archivi/database aziendali, regionali o nazionali (eventualmente integrati)

• Database clinico ad hoc

3. Measure practice against standard

Come organizzare il data entry?

1. CC tradizionale • Scheda cartacea • Scheda elettronica • DB 2. CC tradizionale • • Scheda elettronica • DB

3. CC elettronica • • • • • DB

CC= Cartella Clinica DB= Database

3. Measure practice against standard

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3. Measure practice against standard

Come selezionare un campione rappresentativo e casuale?

1. Definire l’unità temporale di riferimento e il denominatore 2. Calcolare il campione rappresentativo

3. Scegliere le cartelle cliniche

• Campione consecutivo (errore random?)

• Randomizzazione semplice

• Randomizzazione stratificata (stagionalità)

3. Measure practice against standard

WARNING!

• Un audit dipartimentale (o di U.O.) richiede un campionamento ad hoc

3. Measure practice against standard

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1. Identify topic 2. Set standard

3. Measure practice against standard 4. Identify areas which need to be changed 5. Implement change in practice

6. Re-audit to ensure change has been effective

3. Pianificazione e conduzione

• In questa fase vengono identificate, rispetto agli standard definiti, le inappropriatezze, sia in difetto, sia in eccesso

4. Identify areas which need to be changed

La visione “strabica” dell’inappropriatezza

Inappropriatezza in eccesso

Risparmio

Tagli

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Inappropriatezza

Dallo “strabismo” alla visione bidimensionale

Appropriato Inappropriato

Erogato Non erogato

OK

OK NO NO

€

Inappropriatezza in eccesso

Risparmio Tagli

Inappropriatezza

Dallo “strabismo” alla visione bidimensionale

Inappropriatezza in difetto

Spesa Incremento utilizzo

Inappropriatezza in difetto

• 30-45% of patients are not receiving care according to scientific evidence

Inappropriatezza in eccesso

• 20-25% of the care provided is not needed or could potentially cause harm

Stime dell’inappropriatezza

Schuster et al. Milbank Q, 1998 Grol R. Med Care, 2001

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Merlani P, Garnerin P, Diby M, Ferring M, Ricou B.

Linking guideline to regular feedback to increase appropriate requests for clinical tests: blood gas

analysis in intensive care.

BMJ 2001;323:620-4

Merlani P, et al. BMJ 2001

The problem

• In our surgical intensive care unit, 46 000 arterial blood gas analyses were performed each year.

• A one week prospective study showed that over half of these tests could not be justified clinically.

• In addition, 96% of requests were left to the discretion of the nursing staff,while clinical signs such as respiratory rate or altered pattern of breathing were seldom taken into account in deciding whether the test was necessary.

• Values of percutaneous oxygen saturation from pulse oximetry were rarely used, even though they match arterial measurements.

Merlani P, et al. BMJ 2001

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Wolff AM, Taylor SA, McCabe JF.

Using checklists and reminders in clinical pathways to improve hospital

inpatient care

Med J Aust 2004;181:428-31

Wolff AM et al.

Med J Aust, 2002

Wolff AM et al.

Med J Aust, 2002

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1. Identify topic 2. Set standard

3. Measure practice against standard 4. Identify areas which need to be changed 5. Implement change in practice

6. Re-audit to ensure change has been effective

3. Pianificazione e conduzione

• In questa fase vengono attuate le strategie di implementazione con l’obiettivo di modificare i

comportamenti professionali e migliorare l’appropriatezza

5. Implement change in practice

Cabana MD, Rand CS, Powe NR, et al.

Why don't physicians follow clinical practice guidelines?

A framework for improvement

JAMA 1999;282:1458-65

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Perché i clinici non seguono le linee guida?

1. Internal Barriers

• Lack of Awareness

• Lack of Familiarity

• Lack of Agreement

• Lack of Self-efficacy

• Lack of Outcome Expectancy

• Inertia of Previous Practice

2. External Barriers

• Guideline-Related Barriers

• Patient-Related Barriers

• Environmental-Related Barriers

Cabana MD, et al. JAMA 1999

Conoscenze

Attitudini

Comportamenti

Interventions to promote behavioural change among health professionals

Consistently effective

Bero L, et al. BMJ 1998 SIGN 50. April, 2002 Grol, et al. Lancet 2003

• Educational outreach visits (drugs)

• Reminders

• Interactive educational workshops

• Multifaced interventions

Variable effectiveness

Little or no effect No conclusive evidence

• Audit and feedback

• Local opinion leaders

• Local consensus processes

• Patient mediated interventions

• Educational materials

• Traditional lectures

• Financial incentives

• Policy, regulation

1. Identify topic 2. Set standard

3. Measure practice against standard 4. Identify areas which need to be changed 5. Implement change in practice

6. Re-audit to ensure change has been effective

3. Pianificazione e conduzione

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• In questa fase viene ripetuto l’audit per verificare il miglioramento dell’appropriatezza

6. Re-audit to ensure change has been effective

1. Definizione 2. Struttura

3. Pianificazione e conduzione 4. Report

5. Barriere e fattori facilitanti Audit Clinico

How to write…

an audit report

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1. Definizione 2. Struttura

3. Pianificazione e conduzione 4. Report

5. Barriere e fattori facilitanti Audit Clinico

G Johnston, IK Crombie, HTO Davies, et al.

Reviewing audit

Barriers and facilitating factors for effective clinical audit

Qual Health Care 2000;9:23-36

To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process.

Johnston J, et al. Quality Health Care 2000

Objective

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A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of “audit”, “audit of audits”, and “evaluation of audits” and a handsearch of the indexes of relevant journals for key papers.

Design

• 93 publications were reviewed

• These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care.

• The studies reviewed incorporated the experiences of a wide variety of clinicians

Results (1)

The literature review identified 4 main themes 1. Importance of clinicians’ perceptions of the benefits of audit 2. Importance of clinicians’ perceptions of the disadvantages

of audit

3. Barriers which block its success

4. Facilitating factors which promote its success

Results (2)

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• Professional benefits

• Patient care and service delivery

1. Benefits of Audit

• Increased workload

• Restriction of clinical freedom

• Professional threat

2. Disadvantages of Audit

3. Barriers to successful audit

• Lack of resources

• Lack of expertise in project design and analysis

• Lack of an overall plan for audit

• Relationship problems

• Organizational impediments

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4. Facilitating factors to successful audit

• Quantifying success

• Factors which promote success

1. Clinical audit should assess structure, process, or outcomes of care

2. The audit should be part of a structured programme and should have a local lead

3. Audit should ideally be multidisciplinary 4. Patients should ideally be part of the audit

5. Choose audit topics based on high risk, high volume, or high cost problems or on national clinical guidelines

Summary of elements of effective clinical audit

6. Derive standards from good quality guidelines

7. Use action plans to overcome the local barriers to change, and identify those responsible for service improvement 8. Repeat the audit to find out whether improvements in care

have been implemented as a result of clinical audit 9. Develop specific mechanisms and systems to monitor and

sustain service improvements once the audit cycle has been completed

Summary of elements of effective clinical audit

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