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 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
ce-b
as
ed
Heal t
hC
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
• 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.