Audit & peer review

Audit is a deliberate critical analysis of the quality of surgical care being provided which is reviewed by peers against explicit pre-defined criteria or recognised standards, with the aim of informing and improving current practice to ensure best outcomes for patients. Comparisons are undertaken and recommendations for change made and followed up

Audit can be regarded as a cornerstone of professional practice, and is a requirement by RACS for surgeons CPD.  Audit provides an opportunity for education and systemic improvement

The aims of audit are:

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

 

1. Determine scope
   1. Clearly define eg. 30 day mortality, LOS, patient satisfaction
   2. Simple
   3. Well defined
   4. Easily measured
   5. Valid relationship to performance
   6. If looking at adverse effects, aim to identify system errors
2. Select standards
   1. As recommended by specialty bodies, or determined from literature, or self-nominated
   2. 85% patients undergoing cystectomy getting neoadjuvant chemo
3. Collect data
   1. May use other staff or other team members for this point
4. Present and interpret results
   1. Should be presented at a clinical meeting designed to discuss clinical outcomes
   2. Peer review is an integral part
   3. Confidential (patients and surgeons)
   4. A unit should review the work of all its surgeons at least once every 6 months
5. Make changes and monitor progress
   1. Implement any changes – make sure all those affected are informed
   2. Re-audit at an appropriate time

 

Why is audit important?

Ensures the quality of care is maintained at an agreed standard

Enables problems to be identified and change to be instituted in a meaningful way, with an avenue for measuring whether change occurs

Allows appropriate allocation of resources and improves efficiency

To inform patients about the standard of care received

Audit is a cornerstone of professional practice and is mandatory for RACS fellows for ongoing CPD

Provides an educational opportunity for surgeons and trainees

 

Potential issues with audit

Location or hospital specific – results and changes implemented may not be transferrable

Usually retrospective chart reviews – notes are not taken with the specific aim of audit so information may be missing

Often identifies problems which may not have easily solutions, or the solutions may be resource intensive

Doctors doing audits may take time away from clinical activities in an already reduced era for training. Alternative may not have time to do important audits

May be a bias to auditing things which are easy to measure/collect data, which may be of lower priority than things which can be difficult to collect data for

If change is recommended, this can cause conflict

Most often done by junior doctors, and therefore they rotate and results and changes are not re-audited

 

Different forms of audit

From RACS

• Total practice audit of caseload and trends
• Personal audit
• Selected procedure audit
• Clinical unit audit
• Group or specialty audit (i.e. PCOR)
• Hospital performance indicator – e.g. LOS, ABx

Other ideas:

• Retrospective audit – analysis of previous cases
• Prospective audit – planned analysis of future cases with prospective data collection
• Audit of operative outcomes – i.e. oncological outcomes, margins, operative time
• Audit of complications (i.e. M&M meetings) – discussion and analysis of complications arising from surgical care
• Planned audit prior to consideration of introducing a new change (i.e. new technology, new guideline, change in practice) – in order to have a baseline prior to change
• Audit after a change in practice, to assess whether outcomes etc have changed

 

Why is peer review important

• Peers and other surgeons can interpret clinical context of outcomes and procedures (i.e. one surgeon with significantly longer OT times or transfusion rates may be not an issue if that surgeon is doing all very complex procedures)
• Peers/surgeons can provide specific feedback based on their experience
• Peer review prevents surgeons from ‘hiding’ outcomes
• Provides a support network for surgeons having issues or complications
• Peers and other surgeons should define what is appropriate standards of care
• Allows all surgeons/peers to learn from others cases and may prevent avoidable complications for other patients in the future
• Important part of training for trainees to understand audit and how complications arise and are managed

 

Important aspects for peer review meeting

• Meetings should be well attended and planned well in advance to allow attendance
• Agendas should be finalised and distributed prior to the meeting
• Record of attendance
• Defined goals of meeting and structured identification of cases to discuss
• Dedicated meeting co-ordinator may help
• Meetings should have a Chairperson or leader to ensure efficiency (role of Chair should rotate, or be independent)
• All discussion should be respectful and productive
• “Ground rules” or understandings of etiquette should be present, with a “no blame” culture (non punitive environment)
• Responsibilities for presenting cases should be clearly defined and clear structure
• Outcomes from the meeting should be recorded and distributed where relevant with a defined time frame to follow up on any changes (and someone nominated as accountable)
• Focus on systems rather than individuals