AUDIT CLINICO. Audit Clinico. 1. Definizione 2. Struttura 3. Pianificazione e conduzione 4. Report 5. Barriere e fattori facilitanti

AUDIT CLINICO Audit Clinico 1. Definizione 2. Struttura 3. Pianificazione e conduzione 4. Report 5. Barriere e fattori facilitanti 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 From Medical to Clinical Audit Clinical audit is the process by which the doctors, nurses and other health professionals regularly and systematically review, and where necessary change, their clinical practice Primary Health Care Clinical Audit Working Group, 1995 Evidence-based Health Care 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 Research & Development Staff management Consumer Involvement Modificata da: Cartabellotta A, et al Sanità & Management Novembre 2002

Contenuti professionali Revisione tra pari Sistematicità Audit di sistema* NO NO SI Audit puntuale** SI SI NO Audit clinico SI SI SI * Accreditamento, certificazione **Discussione di casi clinici, significative event audit (SEA) Audit Clinico 1. Definizione 2. Struttura 3. Pianificazione e conduzione 4. Report 5. Barriere e fattori facilitanti 2. Struttura dell 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. Benjamin A. BMJ 2008

Benjamin A. BMJ 2008 1. Identify topic 6. Re-audit to ensure change has been effective 2. Set standard 5. Implement change in practice 3. Measure practice against standard 4. Identify areas which need to be changed Audit Clinico 1. Definizione 2. Struttura 3. Pianificazione e conduzione 4. Report 5. Barriere e fattori facilitanti

3. Pianificazione e conduzione 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 1. Identify topic - High frequence - High risk - High variability - High cost - High anxiety Department of Health, 1994 1. Identify topic Prevenzione primaria - Prev. infezioni post-chirurgia - Screening Presentazioni cliniche - Dispepsia - Dolore toracico anteriore Preventive care Diagnostic pathways Malattie, sindromi - Ulcera peptica Care pathways - Infarto del miocardio Test diagnostici - Gastroscopia Technology assessment - Coronarografia Trattamenti - Linezolid Technology assessment - NIV

1. Identify topic Prevenzione primaria - Prev. infezioni post-chirurgia - Screening Presentazioni cliniche - Dispepsia - Dolore toracico anteriore Preventive care Diagnostic pathways Malattie, sindromi - Ulcera peptica Care pathways - Infarto del miocardio Test diagnostici - Gastroscopia Technology assessment - Coronarografia Trattamenti - Linezolid Technology assessment - NIV 1. Identify topic Livello Macro: Azienda - Riferimento organizzativo: Collegio di Direzione - Numero limitato di progetti di GC: 2-3 per anno, spesso su committment regionale Livello Meso: Dipartimento, Distretto - Riferimento organizzativo: Comitato di Dipartimento, Comitato di Distretto - Coinvolgere tutti i dipartimenti in almeno un progetto (mono o interdipartimentale), ma evitare che un singolo dipartimento sia coinvolto in oltre 2-3 progetti/anno 1. Identify topic CHI Collegio di Direzione/GC (priorità aziendali) Comitato di Dipartimento (priorità dipartimentali) QUANDO Prima della definizione del budget COME Processo di consenso formale (metodo Delphi modificato)

3. Pianificazione e conduzione 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 2. Set standard Gli standard (di processo e di esito) possono essere derivati da: - Evidenze scientifiche Linee guida Percorsi assistenziali - Normative - Benchmarking - Processo di consenso locale Criteri di definizione Appropriatezza Professionale 1. Evidenze scientifiche Revisioni sistematiche Trials randomizzati Studi osservazionali Evidence-based Guidelines Care Pathways 2. Processi di consenso formale (RAND) 3. Normative nazionali (note AIFA) o regionali

Criteri di definizione Appropriatezza Organizzativa 1. Normative nazionali (LEA) e regionali (requisiti accreditamento, direttive specifiche) 2. Benchmarking 3. Evidenze scientifiche (health service research) 2. Set standard Per massimizzare la probabilità dell implementazione, uno standard dovrebbe avere le seguenti caratteristiche: - Evidence-based - Condiviso tra tutti i professionisti - Adattato al contesto locale 2. Set standard Gli indicatori di processo, ed eventualmente di esito, vengono definiti utilizzando un formato standard: - Tipo indicatore - Categoria indicatore - Denominazione indicatore - Numeratore/Denominatore - Fonte dei dati - Target - Eccellenza (max) - Accettabile (min)

Framework GIMBE Fase 1 Definizione Priorità Fase 2 Costituzione G.L.A.M. Fase 3 F.A.I.A.U. Fase 4 D.I.E FASE 3: F.A.I.A.U. 1. Finding Ricerca delle LG 2. Appraising Valutazione critica delle LG (e scelta della LG di riferimento) 3. Integrating Integrazione della LG 4. Adapting Adattamento locale e costruzione dei PA 5. Updating Aggiornamento FASE 4: D.I.E. 1. Disseminating Disseminazione del PA 2. Implementing Implementazione del PA 3. Evaluating Valutazione dell impatto del PA

3. Pianificazione e conduzione 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. Measure practice against standard Dove cercare i dati? Documentazione sanitaria (cartelle cliniche, relazioni, etc) 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 Benjamin A. BMJ 2008 3. Measure practice against standard 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. Pianificazione e conduzione 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 4. Identify areas which need to be changed In questa fase vengono identificate, rispetto agli standard definiti, le inappropriatezze, sia in difetto, sia in eccesso La visione strabica dell inappropriatezza Inappropriatezza in eccesso Tagli Risparmio

Inappropriatezza Dallo strabismo alla visione bidimensionale Appropriato Inappropriato Erogato OK NO Non erogato NO OK Inappropriatezza Dallo strabismo alla visione bidimensionale Inappropriatezza in eccesso Inappropriatezza in difetto Tagli Incremento utilizzo Risparmio Spesa Stime dell inappropriatezza 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 Schuster et al. Milbank Q, 1998 Grol 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 The problem In our surgical intensive care unit, 46 000 arterial blood 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. Merlani P, et al. BMJ 2001 Copyright - GIMBE Merlani P, et al. BMJ 2001

Wolff AM, Taylor SA, McCabe JF. Using checklists and reminders in clinical pathways to improve hospital inpatient care Med J Aust 2004;181:428-31 Copyright - GIMBE Wolff AM et al. Med J Aust, 2002 Wolff AM et al. Med J Aust, 2002

3. Pianificazione e conduzione 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 5. Implement change in practice In questa fase vengono attuate le strategie di implementazione con l obiettivo di modificare i comportamenti professionali e migliorare l appropriatezza Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement JAMA 1999;282:1458-65

Perché i clinici non seguono le linee guida? 1. Internal Barriers Lack of Awareness Lack of Familiarity Lack of Agreement Lack of Self-efficacy Lack of Outcome Expectancy Inertia of Previous Practice Conoscenze Attitudini 2. External Barriers Guideline-Related Barriers Patient-Related Barriers Environmental-Related Barriers Comportamenti Cabana MD, et al. JAMA 1999 Interventions to promote behavioural change among health professionals Consistently effective Variable effectiveness Little or no effect Educational outreach visits (drugs) Reminders Interactive educational workshops Multifaced interventions Audit and feedback Local opinion leaders Local consensus processes Patient mediated interventions Educational materials Traditional lectures No conclusive evidence Financial incentives Policy, regulation Bero L, et al. BMJ 1998 SIGN 50. April, 2002 Grol, et al. Lancet 2003 3. Pianificazione e conduzione 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 Copyright - GIMBE

6. Re-audit to ensure change has been effective In questa fase viene ripetuto l audit per verificare il miglioramento dell appropriatezza Audit Clinico 1. Definizione 2. Struttura 3. Pianificazione e conduzione 4. Report 5. Barriere e fattori facilitanti How to write an audit report

Audit Clinico 1. Definizione 2. Struttura 3. Pianificazione e conduzione 4. Report 5. Barriere e fattori facilitanti G Johnston, IK Crombie, HTO Davies, et al. Reviewing audit Barriers and facilitating factors for effective clinical audit Qual Health Care 2000;9:23-36 Objective To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process. Johnston J, et al. Quality Health Care 2000

Design A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of audit, audit of audits, and evaluation of audits and a handsearch of the indexes of relevant journals for key papers. Johnston J, et al. Quality Health Care 2000 Results (1) 93 publications were reviewed These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians Johnston J, et al. Quality Health Care 2000 Results (2) The literature review identified 4 main themes 1. Importance of clinicians perceptions of the benefits of audit 2. Importance of clinicians perceptions of the disadvantages of audit 3. Barriers which block its success 4. Facilitating factors which promote its success Johnston J, et al. Quality Health Care 2000

1. Benefits of Audit Professional benefits Patient care and service delivery Johnston J, et al. Quality Health Care 2000 2. Disadvantages of Audit Increased workload Restriction of clinical freedom Professional threat Johnston J, et al. Quality Health Care 2000 3. Barriers to successful audit Lack of resources Lack of expertise in project design and analysis Lack of an overall plan for audit Relationship problems Organizational impediments Johnston J, et al. Quality Health Care 2000

4. Facilitating factors to successful audit Quantifying success Factors which promote success Johnston J, et al. Quality Health Care 2000 Summary of elements of effective clinical audit 1. Clinical audit should assess structure, process, or outcomes of care 2. The audit should be part of a structured programme and should have a local lead 3. Audit should ideally be multidisciplinary 4. Patients should ideally be part of the audit 5. Choose audit topics based on high risk, high volume, or high cost problems or on national clinical guidelines Benjamin A. BMJ 2008 Summary of elements of effective clinical audit 6. Derive standards from good quality guidelines 7. Use action plans to overcome the local barriers to change, and identify those responsible for service improvement 8. Repeat the audit to find out whether improvements in care have been implemented as a result of clinical audit 9. Develop specific mechanisms and systems to monitor and sustain service improvements once the audit cycle has been completed Benjamin A. BMJ 2008

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