Surgical Audit

Overview of the principles of Surgical Audits

1. Surgical Audit Akinbode O.O. LUTH

2. Outline Introduction Historical Perspective Aims of Surgical audit Commonly audited Parameters Principles of Clinical Auditing Types of audit Conduct of surgical audit Value of audit Disadvantages and limitations of audits Conclusion

3. Introduction The systematic, critical analysis of the quality of surgical care that is reviewed by peers against explicit criteria or recognized standards, and then used to further inform and improve surgical practice with the goal of improving the quality of care of the patients.

4. Introduction It is a process by which groups of professionals agree upon the required levels of excellence in practice, monitor whether they are being achieved and then resolve deficits found It covers all aspects of surgical care including procedures used for diagnosis and treatment; the use of resources and the resulting outcomes and quality of life for patients The purpose is to bring about improvements in clinical practice and patient outcome

5. Historical Perspective Has existed since antiquity References to similar concepts seen in the Edwin Smith papyrus (2000 BCE) and the Code of Hammurabi (1700 BCE) Modern surgical auditing began with Groves (England) in 1908 and Ernest Armory Codman (Boston) in 1912 who independently reported systems of reporting outcomes of surgical care. In 1912-American College of Surgeons reported the need to standardize hospitals and they set five minimum standards

6. Aims To identify ways of improving and maintaining the quality of care for patients To assist in the continuing education of surgeons To help make the most of resources available for the provision of surgical services.

7. Advantages of Audit Identifies bad practice Reduces unnecessary investigations, medications and treatment Decreased length of admission Allows continuous refinement of treatment modalities Allows objective assessment of quality of care Improves efficiency and guides resource allocation Improved education, training and feedback Healthy competition

8. Types of Audit Retrospective or Concurrent Individual, Unit, Hospital, State, Regional, National

9. Audit vs. Research Audit To inform delivery of the best care Measures against a predetermined standard Usually involves analysis of existing data or simple questionnaires No allocation of patients No randomization Research To produce generalizable new knowledge Tests a hypothesis Usually involves collection of new data e.g.. additional Investigations Patients may be allocated to test and control groups May involve randomization

10. Audit vs. Research Audit Only used to assess modalities currently in use Research May be used to assess new or experimental modalities

11. Principles Objectivity Honesty Accurate and standard forms Complete medical records All that happened to the patient Result of investigations Post Op Notes Follow up Autopsy findings Records should be filed in an accessible manner

12. Principles Confidentiality, patient privacy Relevance to common clinical problems. Clear standards set by peer assessment Education not punishment Audit should lead to appropriate action

13. Audit Parameters Time utilization Cost effectiveness Mortality/morbidity assessment Quality of diagnostic services Monitoring of performance Assessment of newer technologies Surgical outcome Knowledge of patient satisfaction Legal implications of surgery

14. Audit Parameters Audit of Structure Audit of Process Audit of Outcome

15. Audit of Structure Concerned with amount and type of resources available No of hospital beds, staff numbers, nurse to patient ratio, theatres suites, wards, equipment Easy to measure Does not necessarily correlate with quality or effectiveness of care

16. Audit of Process Concerned with the amount and type of processes carried out Time utilization, time to surgery (in specific emergencies), operating time, down time More relevant than audit of structure Identifies problems in surgical practice and proffers solutions Can be difficult to quantify

17. Audit of Outcome Most relevant indicator of quality of care Intra and post op mortality, success rate, morbidity, wound infection rate, specific complication rates, re-operation rate, duration of hospital stay, re-admission rate, cost of care, long term survival, quality of life Can be difficult to measure or quantify Requires adequate and long-term follow up Not always favoured by surgeons Doesn’t always tell the whole story

18. The Audit Cycle

19. Determining Scope Should be clearly defined Time bound Easy to measure Relevant to performance and outcome

20. Selection of Standards Clear cut standard for what is considered acceptable clinical practice Should be evidence based Relevant to local trends Relevant to specialty and types of patients seen Should define adverse events Should define sentinel events

21. Data Collection Determine source of information Identify relevant information Assess accuracy of data Assess need to modify data Determine minimum acceptable quantity of data

22. Interpretation of Results Results should be presented regularly (e.g. monthly, biannually ) Results are evaluated by peers (e.g.. other surgeons or other centres) Results should be compared to those of similar centres/surgeons All sentinel events must be reviewed Quality issues should be identified Peer review is a learning process not for punishment or bragging

23. Appropriate Action Recommendations and changes should be made based on audit findings Staff should be educated on reasons behind each change Follow up Audit cycle should be repeated to assess effects of changes

24. Disadvantages of Audit Takes considerable time and effort Highlights bad practice and “bad doctors” Exposes doctors to punitive action Doesn’t always tell the full story Pointless if no ability to make changes Promotes reliance on protocols and guidelines above clinical judgment

25. Computers in Clinical Practice The availability of computers has significantly changed the process of surgical audit Advantages: Easy storage and analysis of large amounts of data Disadvantages: Translating and entering data to usable formats, staff training, electricity Future trends: Electronic medical records

26. Local Experience Very little audit at individual and hospital level Morbidity and Mortality meetings Little training or emphasis on audit Poor and inconsistent data gathering Punitive mentality

27. Summary Surgical audit is a continuous quality improvement process which systematically reviews surgical care against explicit criteria to guide the implementation of change It is a non- punitive, educational process aimed at improving the outcome of patients Locally relevant criteria should be compared against appropriate local standards to guide resource allocation, surgical practice and decision making

28. Conclusion A good surgeon must never hide his/her faults, but should learn from them in order to better serve his patients and improve his practice

29. Thank You