Clinicians and QI staff – creating effective partnerships Improving Effectiveness & Outcomes of Clinical Audit Using Root cause analysis & PLAN-DO-CHECK-ACT Model Venkatesh Kairamkonda Consultant Neonatologist & Audit Lead, University Hospitals of Leicester NHS Trust
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Improving the Effectiveness & Outcomes of Clinical Audit
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Clinicians and QI staff – creating effective partnerships
Improving Effectiveness & Outcomes of Clinical Audit
Using Root cause analysis & PLAN-DO-CHECK-ACT Model
Clinicians and QI staff – creating effective partnerships
Background
• Approximately 12 audits completed per year• Audit standard % achieved in 25% of completed
audits (15/59)• Completed audit loops showed % achieved same or
declining -a worrying trend• Urgent need of New approach
Clinicians and QI staff – creating effective partnerships
Neonatal Audit Pathway
• Audit task groups to carry out action plans from previous audits instead of initiating new audits.
• Each audit should be conducted by a team - SpR, SHO and Nurse. Audits involving multidisciplinary team (Dietician, Pharmacist, Midwife, Baby Care Assistants, ward clerks) are encouraged.
• The team should discuss and agree audit title, aims, standards & proforma with educational supervisors/audit lead/audit facilitator within the first 4 weeks of your post.
• Teams work on root cause of deficiency and implement changes• Audit competition on presentation day (January/August).• Audit action plans reviewed at Neonatal Governance meeting
before forwarding to Clinical Audit Facilitator
Clinicians and QI staff – creating effective partnerships
Problem with traditional Audit cycle?
Make recommendations
for change
Collect data to measure
current practice
Re-audit
Identify Topic Obtain guidelines / set standards
Compare practice
with standards
Implement action plan
The Audit Cycle
Clinicians and QI staff – creating effective partnerships
Root Cause Analysis Model
Random audit 2 to assess improvement
Identify causes of short comings
Increase awareness before re-audit
Select TopicAssess previous audit results
Address root cause of
shortcomings
Implement action plan
Root Cause Analysis
Random audit 1 to assess current performance
Clinicians and QI staff – creating effective partnerships
Identify Topic / Re-audit
• Baseline audit / first audit− A standard or guideline hasn’t
been audited. − frequent topic of concern at
governance, senior team, and ward rounds.
• Re-audit:• Increase awareness of the
results of previous audit after successful implementation of changes.
Clinicians and QI staff – creating effective partnerships
Assess previous audit results
• Identify professionals required to conduct the audit
• Brief team meeting to discuss title, aims, objectives and review previous audit standards, methodology, results
Clinicians and QI staff – creating effective partnerships
Random audit 1 to assess current performance
• Random audit1 to assess current performance
• Comparison to previous audit results
• Identify deficiency in key standards and establish target performance
Clinicians and QI staff – creating effective partnerships
Identify short comings
• Non formal User survey when at work by the team
• Team meeting to discuss their findings and identify common theme/s
• Fish bone model to identify root cause by analysing cause and effect chain backwards
• Relook at standards and current guidelines
Clinicians and QI staff – creating effective partnerships
Address root cause of shortcomings
• Memorable acronym to give simple structure to process.
Clinicians and QI staff – creating effective partnerships
• Lack of necessary forms, leaflets, stickers
• Lack of awareness• Barriers to who should
and when• Lack of guideline
BLEED INITIATIVE
Clinicians and QI staff – creating effective partnerships
NECTAR INITIATIVE
• No thermometers available to monitor and regulate labour ward and postnatal ward room temperatures
• Midwifery staff unaware of thermostatic control
• Existence of 2 guidelines with conflicting standards
• Staffing pressures and lack of computers at LGH
• Baby thermometers failed quality tests
Clinicians and QI staff – creating effective partnerships
OSTRICH INITIATIVE
• Change to the guideline in view of results from SUPPORT trial and BOOST II.
• Revised guideline had target saturations and saturation limits - Recipe for confusion.
• Target limits not easily identified
• Default alarm limits on bedside monitors not programmed to reflect the protocol.
Clinicians and QI staff – creating effective partnerships
Outcomes
• Seeing improvements to patient care as a direct result of clinical audit projects
• Department audit programme overview scores consistently >90%
• UHL Audit speciality of year 2015
Clinicians and QI staff – creating effective partnerships
Summary
• Root-cause analysis system must be integrated within each audit cycle to improve performance of standards without delay
• The process must take advantage of people’s knowledge while preventing their biases.
Clinicians and QI staff – creating effective partnerships
Summary• Audit teams work together
- to draft audit standards based on clinical priorities and governance agenda,
- review previous audit results and recommendations, perform a random baseline audit, understand barriers to achieving target % by random surveys, develop and deliver short teaching sessions while on duty to improve knowledge of standards, work to remove barriers,
- finally perform final audit to recommend changes.