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
“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 necessarychange, 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
Evid
en
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as
ed
Heal t
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are
• Consumer InvolvementModificata da:
Cartabellotta A, et alSanità & Management
Novembre 2002
• Research & Development
Audit di sistema*
Audit puntuale**
Audit clinico
Contenuti professionali
Revisionetra pari
Sistematicità
NO
SI’
NO
NO
SI’SI’
SI’SI’
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
Benjamin A. BMJ 2008
1. Identifytopic
3. Measure practiceagainst standard
4. Identify areaswhich need to
be changed
5. Implement changein practice
6. Re-audit to ensurechange has been
effective2. Set standard
1. Definizione
2. Struttura
3. Pianificazione e conduzione
4. Report
5. Barriere e fattori facilitanti
Audit Clinico
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
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
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 definizioneAppropriatezza Professionale
Revisioni sistematicheTrials randomizzatiStudi osservazionali
2. Processi di consenso formale (RAND)
Evidence-basedGuidelines
Care Pathways
1. Evidenze scientifiche
3. Normative nazionali (note AIFA) o regionali
Criteri di definizioneAppropriatezza 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
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
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
3. Measure practice against standard
Benjamin A. BMJ 2008
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
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
InappropriatezzaDallo “strabismo” alla visione bidimensionale
Appropriato
Inappropriato
Erogato Non erogato
OK
OK
NO
NO
€
Inappropriatezza
in eccesso
Risparmio
Tagli
InappropriatezzaDallo “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, 1998Grol R. Med Care, 2001
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 arterialblood 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.
Copyright © - GIMBE
Merlani P, et al. BMJ 2001
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
Copyright © - GIMBE
Wolff AM et al. Med J Aust, 2002
Wolff AM et al. Med J Aust, 2002
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
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 BarriersCabana MD, et al. JAMA 1999
Conoscenze
Attitudini
Comportamenti
Interventions to promote behaviouralchange among health professionals
Consistently effective
Bero L, et al. BMJ 1998SIGN 50. April, 2002Grol, 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
Copyright © - GIMBE
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 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
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
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
Johnston J, et al. Quality Health Care 2000
• 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)
Johnston J, et al. Quality Health Care 2000
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)
Johnston J, et al. Quality Health Care 2000
• Professional benefits
• Patient care and service delivery
1. Benefits of Audit
Johnston J, et al. Quality Health Care 2000
• Increased workload
• Restriction of clinical freedom
• Professional threat
2. Disadvantages of Audit
Johnston J, et al. Quality Health Care 2000
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
Johnston J, et al. Quality Health Care 2000
4. Facilitating factors to successful audit
• Quantifying success
• Factors which promote success
Johnston J, et al. Quality Health Care 2000
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
Benjamin A. BMJ 2008
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
Benjamin A. BMJ 2008
Copyright © - GIMBE
Copyright © - GIMBE