What is audit?
Audit can be defined as a systematic review of
aspects of practice that results in a change in that practice. Johnson defined
medical audit as ‘a means of quality control for medical practice by which
the profession shall regulate its activities with the intention of improving
overall patient care’. ‘A First Class
Service’ (Department of Health, 1998) states ‘Clinical audit involves
systematically looking at the procedures used for diagnosis, care and treatment,
examining how associated resources are used and investigating the effect care
has on the outcome and quality of life for the patient. Audit is a valuable tool
to improve the quality of professional care and, ultimately, patient choice’.
Much
of what is called audit is actually only fact gathering. The facts are essential
to undertaking the audit, but unless the effects of the activity on patients are
also included (i.e. outcome data) the facts alone cannot influence surgical
practice.
Traditionally
audit has been divided into medical and clinical audit. The term medical audit
refers to an audit undertaken by doctors and consists of a review of clinical
events; e.g. does one surgical procedure result in a better outcome compared
with another? Clinical audit is usually taken as a review of all potential
medical events surrounding the treatment of a patient. This will include
nursing, physiotherapy, social aspects, etc. The boundaries between the two
forms of audit are blurred and indeed ‘medical’ audit is merely a subset of
clinical audit focusing only on the medical aspects. The majority of audits will
consider aspects which are both medical and clinical.
The
separation of the provision (and rationing) of resource from clinical audit is
artificial. All medical activity costs money so an understanding of the
management of the resources has to be included in the audit process. When
healthcare resources are rationed, the limitation on funding is likely to have a
direct effect on structure and process, and hence on outcome. ‘Total’ audit
should include any activity which occurs in the delivery of healthcare to an
individual patient or a group of patients.
It
is, at least, a useful intellectual exercise to consider the financial implications of introducing a new technique. For example, arthroscopic
stabilisation of the shoulder is a relatively new technique to appear in
orthopaedic practice in the UK. If it is to be adopted by a hospital trust the
following questions might need to be answered.
•
Is there a surgeon who can perform the techniques?
•
What training is required?
•
What equipment is required? Is new equipment needed?
•
What will the consumables cost and are they readily available?
•
What are the operating theatre and ‘hotel’ requirements for the
patients?
•
What is the failure rate of the techniques, i.e. will there be a large
number of patients who will need revision surgery or will be unsatisfied with
the outcome?
•
What is the rehabilitation time and when will the patients be able to
return to work?
•
And of course, how does this new technique compare with the usual
accepted techniques when the same questions are asked?
Each
and every surgical procedure could and probably should be examined in this way.
In the example given above, data from prospective clinical trials comparing the
new technique with the old are required to demonstrate a statistically
significant improvement if the method is to be justified purely on the grounds
of clinical benefit. For an individual surgeon, audit data showing that the
results obtained by that surgeon are comparable to the results of the clinical
trials are needed. The cost to the hospital, and the cost to the patient (in
time off work, etc.) will also need to be calculated. Using data like
these there are several ways of justifying the
introduction of a new technique as follows.
•
The new technique is clinically better than the old — better outcomes
(including patient satisfaction), decreased failure and decreased morbidity
•
The technique is cheaper to patient, hospital or both.
•
Patients can be treated more quickly using the new method, which
produces the same results as the old method.