Clinical Audit – Definition, Characteristics, And Importance In Healthcare

Clinical Audit Characteristics

Describe about the Disease Control and Prevention (CDC)?

Clinical audit is the evaluation process of practices that helps in ensuring that patients are receiving accurate treatment and proper services. This is done by measuring the services and the care provided against each research based standards thus identifying scope of improvement in the existing practice in order to deliver best services (Borbasi, 2010).

Research is a systematic process of investigation in order to either increase the current knowledge or to discover new facts. Research is divided into two categories namely basic research and applied research. The aim of the basic research is to increase the scientific knowledge whereas the aim of the applied research is to utilize the basic research for problem solving and to develop new processes and techniques (https://www.rph.wa.gov.au/~/media/Files/Hospitals/RPH/PDFs/The_Difference_between_Clinical_Audit_and_Research%20NHS.ashx.

1.1c

Clinical audit characteristics: Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper	Research characteristics:
It aims at evaluating the parameters of practice to be considered as best	It aims at establishing the best possible practice
It is very specific to a particular patient group	The design and results can be replicated
Initiated by service provider group	Initiated by the researchers
It is practice driven	It is theory driven

1.1d

Project 1:

Project 1 is an example of clinical audit. Here the disease and problem related to its diagnosis has already been defined. The healthcare staffs design a project plan between the primary and secondary care for the patient based upon the experiences of the patient. In research patient is a subject upon whom study is carried out and there is no involvement of the subjects in any the decision making procedure. Secondly the project 1 shows that the project designed aimed at assessing different aspects of the standards maintained from diagnosis to treatment and finally the entire management. This is a part of clinical audit where the actions and research are analyzed to find if they are appropriate or not and what is the scope to make improvements in delivering the services. Clinical audit is carried out for a specific group of patients likewise here a particular sample of patients is identified and assessed. Findings from the analysis of the questionnaires, local guidelines, the status of secondary care, improvements to be made in the treatment and support system are some of the outcomes of the clinical audit carried out.

Project 2:

The project 2 is also a clinical audit. The various steps of clinical audit are planning, measurement of the performance, implementation of the changes and sustaining the improvements. In the present project, the issue considered is administration of drug, which is a crucial aspect of nursing care. This is because error in drug administration will lead to fatal consequences. There is a chain of events in administration of drug that involves different healthcare staff members. To carry out clinical audit first a specific methodology was designed which was reviewed by a designated committee. The project aimed at ensuring the accurate drug administration in a safe way, improving the clinical practice and to provide evidences to support further planning and managerial changes. Close analysis of all the planning leads to few outcomes such as a proper analysis of pre and post registration and to design a policy in order to manage and support the nurses involved in any kind of drug incidents.

1.2

The clinical governance is mechanism used to ensure high standards of clinical care are being maintained across all the NHS (McSherry, 2011). Clinical audit is one of the six elements of clinical governance the other five are education, management of risk, clinical effectiveness, research and openness. Initially clinical audit was not considered as a part of clinical governance used for measuring the quality of the clinical care given rather it was a separate process for clinically managing the activities. However it was realized that the clinical audit has several primary functions for the clinicians as it helps in shaping and managing the programs to achieve the strategic objectives of an organization. The board of clinical governance is responsible to take care of the extent of effectiveness of the functions and to carry out scrutiny of the arrangements for risk management. Clinical audit is the top priority of the board as it gives scope to increase the assurance and functions by proposing different programs to increase the trust factor between the healthcare staffs and the patients. Hence it can be said that the clinical audit is an integral part of the clinical governance in order to design a quality framework (McPherson, 2011).

Examples of Clinical Audit

2.1

The clinical audit obligations for a healthcare organization are as follows:

To fill the gap between the actual care and evidence based practices in order to address the shortcomings in the safety of the patients.

Healthcare staffs required to participate in the systems for quality assurance and improvement and so has to increase the opportunities of the patients to heal faster.

Disciplined and ethical conduct of the healthcare staffs is required. This is because often it happens that patients do not get safe and effective care or benefit of one patient is in the expense of another patient. Hence a focused and discipline staffs will increase the effectiveness of the services provided without wasting much of the healthcare resources.

Healthcare organizations also do have ethical obligations regarding medical practice and should ensure that medical staffs are bound by their professional ethics and oaths.

All the healthcare staffs at their own level should constructively respond to the audit outcomes and performance reviews so as to undertake any kind of training further as and when necessary (Nouraei, 2009).

2.2

The potential advantages of clinical auditing are as follows:

It offer ways to assess and improve the patient care services

It helps the healthcare staffs to identify the risk factors within the services provided

Regular audit helps in creating a culture of improvement in the quality in the clinical setup.

For the participants it is informative process.

It helps the healthcare staffs to keep themselves updated with evidence based practices.

It helps in achieving job satisfaction

Altogether it can improve the effectiveness and quality of the healthcare (Gupta, 2009).

The involvement of healthcare staffs in carrying out clinical auditing is important as it enhances their analytical skills, helps them to gain knowledge through collaborations with colleagues. Healthcare staffs tend to learn many clinical to technical aspects of their job and to work in a dynamic group. Theoretically gaining knowledge often doesn’t help healthcare staffs to take crucial decisions hence evidence based practical gain of knowledge helps in identifying real issue and to take important crucial decisions (Som, 2009).

Clinical audit improves the patient care by routinely checking whether patients are getting right treatment and in a right way or not. When and as required the clinical staffs are able to take measures to improve the care and services provided to the patient. Understanding and defining the standards of patient care is very important outcome of clinical auditing. This is done when clinical staffs goes thoroughly into the records of the patient and directly collects information from them. Precise data analysis helps in gathering accurate information regarding health status of the patient  which in turn helps in deciding whether the quality of care provided to the patient is acceptable or not. Depending upon the results of the quality of care being provided, further actions are taken. For example if quality of care is not found good enough then possible reasons are searched and actions are taken to improve the quality (Luxford, 2011).

3.1

Criteria and standards are the two terminologies in clinical audit that are often misunderstood. Criteria can be defined as the item for care or an aspect to perform practice for. A criterion is written as individual statement and represents the best practice that should take place in day to day operations. Whereas standards are refer in percentages. Example of criterion with respect to pharmacists is that the drugs supplied to patients should not be outdated and that of standard is that the drug should be 100% in date. 

3.2 Person having diabetes should get his eye and feet checked in every 6 months and not annually. This is because a person suffering from diabetes is vulnerable to several foot problems. High diabetes tends to damage nerves and reduces the blood flow to the feet. Similarly eye check up is required in every six months as the small blood vessels in retina gets affected due to high diabetes. Damage of retinal vessels is known as retinopathy. It damages the vision and when left untreated can causes permanently blindness (Centers for Disease Control and Prevention (CDC), & Centers for Disease Control and Prevention (CDC), 2011).

The front sheet of the patient’s record should consist of name of the patient, NHS number, age. However apart from this it should also consist of last diagnosis, the disease and the code of operation and the signature of the doctor attending. This is important because the next attending doctor will instantly get an idea of the present situation of patient and accordingly can plan for next diagnosis or treatment (Baorto, 2009).

Flu is a common disease yet it can cause fatal consequences if not treated at right time. Mostly flu is accompanied by mild illness that which requires light medication and they can recover in less than a week time. However there are certain conditions under which the complications of flu may increase and patient will be required to hospitalize. People generally aging above 65 years need special care for flu. Administration of antiviral drugs and proper care is required as the complication of flu increases with age. The immune system of older people becomes weak compared to young and healthy adults. The seasonal diseases easily affect the weak immune system of the older people and since the immune defense system is weak, older people are not being able to revive easily from the flu symptoms often leading to death (Mereckiene, 2010).

3.3

PATIENT POPULATION	AUDIT DATA COLLECTION SAMPLE
50	44
300	169
1000	278
10000	370

.3.4a

The below documentation audit is developed to analyze the type of diagnosis and care is provided to patients admitted in ICU. This is important because patient in ICU requires high quality and safe nursing care. Hence nursing documentation audit is integral part of delivering good care to the patients.

Name of the patient:

Age:

Personal details of the patient

Name of the Unit referred to

Ongoing medications:

The nursing care plan

The nursing diagnosis

Nursing outcomes

Nursing interventions

Progress report

Discharge note

 

No	Criterion	Standard	Source
1	Should be clear and accurate	100%	Trust policy
2	In English	100%	Trust policy
3	Time of entry	100%	Trust policy
4	Date of entry	100%	Trust policy
5	Written in dark ink and should be reproducible	100%	Trust policy
6	Written in objective way	100%	Trust policy
7	Relevant with the patient	100%	Nursing documentation in nursing records
8	Include only personal information of the patient	100%	The personal details of the patient in the patient’s record.
9	Accurate statements of clinical interaction	100%	Evaluation notes in the nursing record.
10	Distinguish between what was observed and performed.	100%	Nursing care plan in the nursing record

3.4b

Data Collection Form:

Name of the patient

Age:

Sex:

Past medical history of the patient

Result of any physical examination conducted before

Any kind of alcohol or drug abuse

Allergies

Findings of physical examination

Current illness

Types of diagnosis carried out

Recommendation made

 

References:

Baorto, D., Li, L., & Cimino, J. J. (2009). Practical experience with the maintenance and auditing of a large medical ontology. Journal of biomedical informatics, 42(3), 494-503.

Borbasi, S., Jackson, D., & Lockwood, C. (2010). Undertaking a clinical audit.Using evidence to guide nursing practice, 2, 113-132.

Centers for Disease Control and Prevention (CDC), & Centers for Disease Control and Prevention (CDC). (2011). National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 201.

Gupta, V. (2009). Benefits versus risks: a prospective audit. World journal of surgery, 33(7), 1432-1438.

Luxford, K., Safran, D. G., & Delbanco, T. (2011). Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. International Journal for Quality in Health Care, 23(5), 510-515.

McPherson, R. A., & Pincus, M. R. (2011). Henry’s clinical diagnosis and management by laboratory methods. Elsevier Health Sciences.

McSherry, R., & Pearce, P. (2011). Clinical governance: a guide to implementation for healthcare professionals. John Wiley & Sons.

Mereckiene, J., Cotter, S., D’Ancona, F., Giambi, C., Nicoll, A., Levy-Bruhl, D., … & O’Flanagan, D. (2010). Differences in national influenza vaccination policies across the European Union, Norway and Iceland 2008-2009. Euro surveillance: bulletin européen sur les maladies transmissibles= European communicable disease bulletin.

Nouraei, S. A. R., O’Hanlon, S., Butler, C. R., Hadovsky, A., Donald, E., Benjamin, E., & Sandhu, G. S. (2009). A multidisciplinary audit of clinical coding accuracy in otolaryngology: financial, managerial and clinical governance considerations under paymentâ€Âbyâ€Âresults. Clinical Otolaryngology,34(1), 43-51.

Onwuegbuzie, A. J., & Leech, N. L. (2004). Enhancing the interpretation of “significant” findings: The role of mixed methods research. The Qualitative Report, 9(4), 770-792.

The Difference Between Audit & Research, https://www.rph.wa.gov.au/~/media/Files/Hospitals/RPH/PDFs/The_Difference_between_Clinical_Audit_and_Research%20NHS.ashx, retrieved on 05.04.2015

Saleem, J. J., Russ, A. L., Justice, C. F., Hagg, H., Ebright, P. R., Woodbridge, P. A., & Doebbeling, B. N. (2009). Exploring the persistence of paper with the electronic health record. International journal of medical informatics, 78(9), 618-628.

Som, C. V. (2009). “Quantity” versus “quality” dilemma of health staff in NHS UK: Does clinical governance provide a solution?. Clinical Governance: An International Journal, 14(4), 301-314.

Vadiveloo, T., Donnan, P. T., Cochrane, L., & Leese, G. P. (2011). The Thyroid Epidemiology, Audit, and Research Study (TEARS): morbidity in patients with endogenous subclinical hyperthyroidism. The Journal of Clinical Endocrinology & Metabolism, 96(5), 1344-1351.