THE NATIONAL AGENDA FOR CLINICAL AUDIT

Kenneth Mealy, MD, FRCSIClinical Director

NOCA

Media interpretation of the

Mid-Staffordshire Report:

Why clinical audit?

• To improve the quality of service provided to patients and hence patient care

• It is a unique mechanism for ongoing quality improvement

• Obliged to audit by the Medical Practitioners Act

• Results of audits are a valuable sources of information for clinicians, healthcare managers, patients and the general public.

Clinical Audit

• Educational• Benchmark outcomes

against national standards

• Allow individual clinicians reflect on practice– Change based on ‘no

blame culture’ and ‘shared learning’

Clinicalactivity

Measureoutcomes

Assess againststandards

Changepractice

Audit

Influential publications in Ireland:

Madden Report found………….

• Clinical audit is advanced in many organisations• But not linked to service improvements, planning or

resource allocation

Lourdes Hospital Report (2006)

- concluded that robust and effective peer review and audit was the only process which could have identified the failings in clinical practice and governance in that hospital

National Standards for Safer Better Healthcare (HIQA 2012)

Features of a hospital which meets the National Standards include the following:

• The Royal College of Surgeons in Ireland (RCSI) and the Health Service Executive (HSE), under a jointly developed service level agreement have undertaken the establishment, administration and management of NOCA through the NOCA Governance Board.

• NOCA established in 2012• The primary purpose is to establish sustainable clinical

audit programmes in agreed specialties at national level• Through this framework, feedback will be provided to

both clinicians and hospitals in order to ensure that individual and organisational learning occurs.

Improving clinical outcomes through peer review and education

• By enabling continuous education through the issue of feedback from its findings.

• By working with all stakeholders from both state funded and independent providers

• By encouraging the identification and reporting of incidents to improve clinical outcomes and the care of future patients

• By ensuring lessons from national clinical audit streams are applied either through the actions of individual participating clinicians or through the identification of more general systems improvements to the care of patients.

Addressing the findings of Madden Report and anticipating the requirements of HIQA inspections

 

• Based on the methodologies used by the Scottish Audit of Surgical Mortality (SASM) and the Australia and New Zealand Audit of Surgical Mortality (ANZASM).

• Similarly to these established national audits the main aim of IASM will be to reduce surgical mortality in Ireland, through systematic, independent peer review.

• A professional competence scheme associated with RCSI and CAI

• Governance Committee of IASM overseeing audit

Irish Audit of Surgical Mortality

Objectives of an audit of surgical mortality

Reduction of mortality associated with surgery

Increasing patient safety, confidence and overall experience

Promoting and encouraging reflective practice

Identifying systems failures in Irish hospitals and putting changes in place

Irish Audit of Surgical Mortality

Scope of IASM:

•IASM will provide confidential, independent, peer review of all reported deaths which occur following an episode of surgical care.

•Reporting will be encouraged and shared learning will be the focus

The experiences of SASM and ANZASM indicate that IASM is likely to result in changes to clinical practice, at both individual and institutional level.

Irish Audit of Surgical Mortality

A reportable death:

Any patient death that occurs in hospital, where the patient is under the care of a surgeon

Including:•All deaths following surgery•Deaths where patient was under a surgeon but no surgery took place•Surgical deaths, any where in the hospital, regardless of their inclusion in other audits

Irish Audit of Surgical Mortality

IASM Workload…………….

IASM Workload…………….•Mean of 11,500 public hospital deaths annually (2005-2010 inclusive, HIPE data)

•Breakdown of surgical deaths in hospital more difficult to ascertain•Medical deaths to Surgical deaths ratio 2:1………we can predict 3,858 surgical deaths•Population based calculations using the experience of SASM….4,000 surgical deaths

Year 2005 2006 2007 2008 2009 2010Deaths in hospital 11524 11681 11933 11753 11582 10970

Irish Audit of Surgical Mortality

IASM – governance process

First line assessment

Second line assessment

Repeat second line assessment

Sign off

No areas for concern

Areas for concern

Areas for concernaddressed

Sign off

-Consultant feedback-Clinical Director feedback-Local M&M meetingReview process

IASM and NOCAGovernance

Boards

IASM -ReportingAnnual reports

– Individual consultant – Institution – Specialty– National

Confidentiality and data protection:•IASM, and its Governance Committee and the Governance Board of NOCA will endeavour to ensure that all records are retained in the strictest of confidence.

•Freedom of Information requests will be considered on a case by case basis. If possible requests will be denied, but refusals may be challenged under current legislation.

•Additionally under current legislation an order of discovery may be granted by the Courts in a civil action for audit data held by NOCA. Currently the data held by NOCA cannot be claimed to be privileged and therefore maybe accessible through an order of discovery.

•NOCA is actively working with the HSE to ensure that the upcoming Health Information Bill will offer full protection to clinical audit data in Ireland.

Irish Audit of Surgical MortalityIrish Audit of Surgical Mortality

To provide a national system for monitoring joint arthroplasty

To increase patient safety, confidence and overall experience

To optimise inpatient care, waiting lists inpatient and out patient attendances

To reduce surgical revision rates / reduce the cost of service

To monitor and grade Implant performance

To enable early detection and review of outliers efficient and accurate recall process if required

To proactively include Consultant Orthopaedic Surgeons in the clinical audit process in both public and private practice

Irish National Orthopaedic Register

• Measure –– activity data, case mix and patient outcomes– quality outcomes benchmarked against

international standards• Audit of potential organ donors and organ

donation• Use audit to drive improvements in ICU

performance

National ICU Audit

• Health Service– Quality assurance

• Benchmarking to national and international best-practice

• Clinician– Reflective practice– Improved performance

Improved patient outcome