guy peacock - southern adelaide local health network - the basic physician trainee clinical audit...

The Basic Physician Trainee

Clinical Audit Program:

Embedding Clinical Audit and Quality

Improvement within the Physicians Psyche

Guy Peacock

Quality & Improvement Manager

Division of Medicine & Critical Care

Southern Adelaide Local Health Network


It is not a matter of willpower, but

rather the facilitation of a readiness

to fully embrace the notion of

change.



> Population demographics

• Primary population: >350,000

• Subsidiary population: >173,000

• Tertiary referral scope: South Australia &

Northern Territory

> Cultural diversity

• Residents born overseas: 68,000 (8%)

• Indigenous residents: 2,700 people (<1%)

> Age profiles

• People >65 years: 52,500 (15%)

• Children and young people: 112,000 (32%)

• Adults of working age: 185,500 (53%)



> Acute Services Structure

• Flinders Medical Centre

Acute Tertiary Referral Centre

• Repatriation General Hospital

Acute General Medical

Aged Care – GEM Unit

Elective Surgical

Mental Health

Rehabilitation

Palliative Care

• Noarlunga Community Hospital

Emergency

Acute General Medical

Elective Surgical – fee for service

Mental Health


Division of Medicine and Critical Care

> Scope: Acute and Ambulatory Care Services,


> Staff: 2,046 (1,647 FTE)

> Capacity: 336 beds

> Admissions: 37,954 (2013/2014)

> Services: Emergency

Critical Care

General Medical

Full Sub-Specialty Medical Services

> Budget: $212,000,000


Basic Physician Trainee Program

> Three year competitive entry program

> Candidates are selected on the basis of:

• Commitment

• Academic and clinical history

• Evidence of sound communication skills and

effective team work.

> Offers training and educational experience through

rotations across the Network

> Ensures specific RACP requirements are met

> Maximises training and preparation for the RACP

Physician Readiness for Expert Practice (PREP)

Program


Basic Physician Trainee

Clinical Audit Program

> February – Clinical Audit Project Information Session:

• One hour lunch time session

• Lunch is provided

• 30 minute presentation

• 30 minute Q&A

> March – Plan Project:

• Establish partnership

• Identify & secure Project Supervisor

• Set criteria & standards for clinical audit




> April – May – Initiate Audit:

• Observe practice & data collection

> June – Review initial data collection:

• Compare actual performance against criteria & standards

• Write up initial findings report

> July – Initiate Change:

• Agree upon changes if indicated and implement




> August – September – Re audit:

• Re-run the initial audit to establish impact of implemented

change

> October – Incorporate results of second audit into report

> 11th October – Submit completed report to Q&I Manager

> 17th October – Presentations commence at Grand Round


The imperative in this process is the

subsequent implementation of change in

order to actively facilitate clinical practice

improvement based upon contextually

appropriate and accurate health

informatics.


Team Engagement:

Winning Hearts & Minds

> The Circle of Safety

> Engendering Trust & Cooperation

• Explaining the why

> The three rights

• Right People

• Right Time

• Right Place


Incentives

> Opportunity to influence clinical practice

> Valuable addition to personal resume

> Publication

> Presentation

> Prize and Certificate for most outstanding project

> Mandatory component of Basic Physician Trainee

Program


The Clinical Practice Improvement Journey

Evidence for a problem

worth solving

Improvement

Intervention

Managing

Change

Evidence of Impact

Future directions


Clinical Audit:

An Action Orientated Framework

> Continuous Process

> Quality Improvement Intervention

> Managing Change

> Determining Evidence of Impact


Embedding Clinical Audit within the

Culture of Health Care

> A continuous process – not simply an accreditation

stop gap

> Must be established as a clear expectation not

simply a preference

> Focus upon audit that is within your scope of

influence

> Target audit that holds meaning for you

> Build efficiency into your audit process


Safe, Effective & Appropriate

> Relentlessly and continuously pursue the

reduction in the risks of injury from care, aiming for

zero harm wherever and whenever possible

> Ensure that every patient, every time, receives the

benefits of care based soundly within the current

evidence of best practice

> Refrain from providing services to those who are

not likely to benefit


Patient Centeredness

> Actively Engaging patients and families in

managing their health and making decisions about

their care

> Honouring each individual patient and family

> Offering voice, control, choice, skills in self-care,

and total transparency

> Readily adapting to individual and family

circumstances, and to differing cultures,

languages, and social backgrounds


Measuring Quality

> Structures

• factors effecting the context of care delivery

> Processes

• All acts of health care delivery both technical and

interpersonal

> Outcomes

• Outcomes are sometimes seen as the most

important indicators of quality because improving

patient health status is the primary goal of

healthcare. However, accurately measuring

outcomes that can be attributed exclusively to

healthcare is very difficult

Avedis Donabedian MD MPH (1919 – 2000)


Right Design

> Is the stated objective of the clinical audit correct?

• Explicit about confirming the standard of current

practice relevant to the evidence of best practice

• Explicit about demonstrating the impact of quality

improvement interventions undertaken to address

the gap between current and best practice

• Clearly establish the intent of the audit in terms of

how it relates to confirming or improving Quality of

care


Right Design

> What features of Quality are to be measured by

the audit?

• Translate the objectives of the audit into specific

aspects of patient care to be measured

• Determine the standards of care that the audit will

focus on

• Ensure data can be accessed for each aspect of

care that will be measured


Right Design

> Has the audit time frame been determined?

• Clearly define the period of time for which the audit

criteria will apply

> Are the correct cases selected for audit?

• Explicit inclusion and exclusion criteria must be

established

> How many cases should be included?

• A minimum of 30 cases or 20% of total cohort,

working with the larger of these two figures


Right Design

> How will data be collected?

• Within the context of the clinical audit

determine the most appropriate method of data

collection:

Who will collect the data

Prospective or Retrospective

Manual or Electronic

Ensure consistency

Target efficiency


Right Design

> Ensure data quality by ensuring alignment

with the following characteristics:

• Accurate

• Available & Accessible

• Complete

• Fit for Purpose

• Relevant

• Reliable

• Timely

• Valid


Quality Improvement Intervention

> Make it specific

• Who is involved

• What do you want to accomplish

• Stipulate location

• Establish time frame

• Identify requirements and constraints

• Specify reasons, purpose or benefit of

intervention


Quality Improvement Intervention

> Ensure it is attainable

• It must be within your scope of influence

> Target what is realistic

• Can it be achieved within current constraints and

permissible time frames?

> Is it tangible to the broader team

• If it is tangible to the team within daily routine there

is greater potential for success

• If something is tangible it will be measurable and

specific


“We can map new processes and systems

and call it change. But if people’s

behaviours have not changed much, all

we have is the illusion of change”

Dr Leandro Herrero

MD MBA FCMI

Consultant, Speaker, Author


Change Management Process

> Engage relevant stakeholders from the outset

> Ensure transparency around the work that is being

undertaken

> Take your colleagues on the journey with you

> Ensure relevant staff receive appropriate

education prior to initiating any change

> Establish a process for effective feedback to

ensure problems are addressed promptly


Evidence of Impact

> Always re-evaluate after initiating change

> Establish how long interventions should be in

place before re-auditing

> Modify audit criteria to ensure impact of any

interventions are captured

> Always duplicate the initial audit methodology to

ensure comparability


Secondary Gains

> Movement away from a medico-centric model

> Promotion of a patient centred model

> Evolution of a multidisciplinary approach

> Promoting transparency

> Evolved sense of teamwork

> Enhanced communication skills

> Setting achievable goals

> Knowledge of change management fundamentals

> Appreciating the value of the journey


Next Steps

> Submission of proposed clinical audits by

prospective supervisors

> Predetermined list of clinical audit supervisors

> Predetermined list of audit topics


“Never doubt that a small group of

thoughtful, committed citizens can change

the world; indeed, it is the only thing that

ever does”

Margaret Mead (1901-1978

Anthropologist

guy peacock - southern adelaide local health network - the basic physician trainee clinical audit...

Business