Simple Audit Research Articles

The use of audit as a means of improving the quality of a health promotion intervention

Currently more than 16,000 children in Manchester receive plain milk or milk with added fluoride (dental milk) at school. The health benefits of drinking plain or dental milk can be maximised by ensuring high levels of uptake by maintaining good quality in the supply process. In response to Clinical Governance requirements to measure and improve quality and in response to adverse comments from consumers of school milk in Manchester, a simple audit of milk quality was carried out in June 2003 and repeated in 2004. The aim was to investigate quality issues and take action to make improvements where possible, to maximise the number of children drinking milk in school. Four audit standards were set relating to the accuracy of deliveries, milk freshness, quality of packaging, and milk temperature. The audit tools were a questionnaire designed to be completed by school pupils and an electronic milk thermometer. Fourteen schools took part in the initial audit, each completing a questionnaire on five different days. The results revealed that incorrect deliveries were received on 19 of the 70 days, all milk was fresh enough to consume (was within specified use-by date) and leaking cartons were received on 13 of the 70 days. The mean temperature of milk on delivery was 14.5 °C (sd 3.43) and at consumption 10.9°C (sd 3.96). The results from the second cycle of the audit show some areas of improvement. The audit process proved to be an excellent exercise in collaborative working and facilitated efforts to improve this health promotion intervention.

Non-pharmacological management of breathlessness: a collaborative nurse--physiotherapist approach.

Breathlessness is a common and challenging symptom in palliative care. A simple audit of 470 patients under the St Christopher's Hospice Homecare team found that 43% complained of breathlessness. Research has indicated that non-pharmacological management can be of benefit to terminally ill patients with breathlessness. Knowing that both nurses and physiotherapists each have core skills to offer these patients, the authors aimed to integrate and consolidate their approach to enhance best practice. The supportive care and advice of the clinical nurse specialist was combined with physiotherapy sessions. The aim of this collaborative approach was to reduce patient anxiety, maximize respiratory function and provide information to help patients understand, adapt and regain some control of their breathing. A leaflet containing simple written information for patients was developed and found to be useful. It was found that supportive professional relationships strengthened links between the multiprofessional team. Positive feedback has been received from patients and health-care professionals about the sessions and breathlessness leaflet. By establishing this combined approach the authors have contributed to significant practice development at St Christopher's Hospice.

Pressure care in the paediatric intensive care unit

Nursing staff in paediatric intensive care units (PICUs) regularly face a complex combination of nursing problems when admitting critically ill children. The assessment of skin integrity might not always be a priority during the initial period following admission. This article outlines some of the difficulties facing nurses involved in the care of critically ill children and reviews the literature on pressure ulcer assessment, highlighting the lack of a universal tool for risk assessment in this area. It also shows how a simple audit changed practice and reduced the incidence of pressure ulcer development in the PICU of the Royal Belfast Hospital for Sick Children over a two-year period.

The automatic production of space

This paper is concerned with the changing nature of space. More and more of the spaces of everyday life come loaded up with software, lines of code that are installing a new kind of automatically reproduced background and whose nature is only now starting to become clear. This paper is an attempt to map out this background. The paper begins by considering the nature of software. Subsequently, a simple audit is undertaken of where software is chiefly to be found in the spaces of everyday life. The next part of the paper notes the way in which more and more of this software is written to mimic corporeal intelligence, so as to produce a better and more unobtrusive fit with habitation. The paper then sets out three different geographies of software and the way in which they are implicated in the reproduction of everyday life before concluding with a consideration of the degree to which we might consider the rise of software as an epochal event or something much more modest.

2.4.3 Verification “Auditability” can be “Free”

AbstractWhen simple audit support standards are applied to developing project requirements verification documentation in the current new product development environment, several benefits accrue. Data then made available from the verification documentation supports technical test reviews and an effective project status metric, as well as rigorously proving that verification is complete for specified requirements. Essential to verify requirements for systems affecting human safety, audit support standards enabled rigor could be useful during planning and testing to assure quality under ISO 9001 parameters claimed as met by many companies. When methods described in this paper virtually automate the resulting auditability, it essentially becomes “free“.

Optometrist prescribing of therapeutic agents: findings of the AESOP survey

Throughout the USA and in some parts of Australia and Canada, licensed optometrists may prescribe therapeutic agents for certain eye conditions. However, this role is not currently available to European optometrists. The extension of prescribing rights to new professional groups was the subject of a UK government-commissioned review, which cited optometrists as potential candidates. A recent literature review found limited evidence to assess the appropriateness of eye care delivered by different health care providers. To inform the UK decision, we therefore conducted a national postal survey to explore how optometric practice might change with the introduction of therapeutic prescribing. The Anonymous Enquiry of the Scope for Optometrist Prescribing (AESOP), was sent to a random 10% sample of registered optometrists. Over 80% of respondents indicated that optometrists should be able to train as therapeutic prescribers. Most respondents were willing to undergo training, periodic re-accreditation and continuing education, as well to participate in simple professional audit of their prescribing. Respondents anticipated that referrals to general practitioners (GPs) would be reduced by nearly 40% and to ophthalmologists via a GP by nearly 20%. Optometrist participation could increase patient access to therapeutic ocular care by between 29% and 50%. Authorising UK optometrists to prescribe therapeutically for eye diseases would appear to make good use of their existing skills and improve patient access to eye care, while relieving pressures upon other healthcare providers. Tentative economic analysis suggests that the introduction of independent optometrist prescribing may be cost neutral. However, adequate comparative research on the performance of optometrists as prescribers is needed and the issue of reimbursement will require careful consideration.

ICT for adults with learning disabilities: an organisation‐wide audit

Microcomputers have recognised value for people with learning disability (mental retardation) and their use has been a feature of many service settings since the 1980s. Recent technological advances, such as the modern and powerful personal computers with multimedia capability and the Internet, have, however, not yet been widely adopted in day and residential services. The implications of these developments for service planning and management are not fully understood. A survey of microcomputer use for adults with learning disability within The Home Farm Trust, a UK national organisation for people with learning disability was carried out in the light of a planned organisation‐wide initiative to introduce modern information and communications technology (ICT) to service users. Results show that there had been a limited provision of computers within the organisation and that staffing and support for the introduction of new ICT were not fully in place. The findings are discussed in the light of research on the organisational requirements for effective ICT use. These requirements were built into the planning of a major initiative to equip the organisation with new ICT for its service users. Future research should lead to simple audit procedures to aid organisations develop effective ICT use.

Tracing of information links empirically (TILE) in small and medium sized enterprises (SMEs)

Information systems (ISs) are at the heart of any responsive organisation. However current tools and techniques of evaluation and design of ISs are not well suited to the needs of small and medium sized companies, and the achievement of their strategic, commercial and operational goals, and perhaps not even to those of larger organisations. The failure rate in the use of many computer‐based systems is very high especially in manufacturing organisations. This suggests that a new and simpler technique is required to lay down the foundation for an IS at an early stage in the development of a company. This system must be capable of being applied by non‐specialist managers but nevertheless be one that incorporates all of the elements of information, in circumstances which may be a mix of technology‐based and manual systems. This paper proposes the design of a simple audit tool that may be used in any area of a company’s organisation to aid in the evaluation, planning and design of holistic ISs in SMEs.

A repeated criterion-based audit of radiographic usage by a paediatric dentistry unit.

To report a simple clinical audit which was conducted within a single hospital paediatric dental unit and to demonstrate the potential value of such small-scale projects. A criterion-based audit of radiographic practice which was repeated after 3 years in order to evaluate changes. Six 1 hour meetings of an audit group consisting of the staff and postgraduate students of the Unit. Various aspects of radiographic usage were quantitatively assessed using a sample of patient records and a pre-planned check list to assess the extent to which agreed good-practice criteria were being met. The initial audit identified areas for improvement which were addressed before repeating the exercise 3 years later. Clinical note-keeping to accompany radiographic examinations was found to be the least satisfactory area of practice. When the exercise was repeated, encouraging improvements were demonstrated. The audit was worthwhile because it appeared to produce improvements in standards of patient care.

NEW LONG‐STAY PATIENTS ON ACUTE PSYCHIATRIC UNITS: DOES AUDIT CHANGE PRACTICE?

SUMMARYPatients who have prolonged stays on acute psychiatric wards are a feature of many modern community psychiatric services. The present study aimed to determine if the care delivered to these patients could be improved by reflecting back to practitioners easily auditable components of the patients' care. The subjects comprised patients resident on the acute psychiatric units in Sheffield for more than six months. These patients were surveyed in April 1995 and again in February 1996. After the first survey, clinicians received a presentation and feedback regarding aspects of their patients' care. The results demonstrated there had been little change in the percentage of acute bed capacity occupied by patients with inpatient stays in excess of six months, despite improvement in many of the audit standards. The main reason for prolonged inpatient treatment was continued mental state or behavioural disturbance. The mean length of stay of patients in this category actually increased. The results suggest that a simple audit exercise can improve the quality of care delivered to this group of patients, but that they will continue to occupy a substantial proportion of acute bed capacity in the absence of suitable alternative treatment settings.

Focusing on risk: a simple audit study can have a major impact on clinical practice

Recent developments in medical treatments have resulted in the increased use of infusion devices for the administration of highly potent drugs. Drug administration is one of the highest risk areas of clinical practice and infusion devices are associated with a substantial number of adverse drug events. Locally, there was a perception that adverse drug events involving infusion devices appeared to be increasing, and there was anecdotal evidence to suggest that the available number of devices was inadequate to meet the increasing demand. A two‐part, observational audit, carried out in an acute district general hospital, was used to identify weak areas in the systems associated with the use of infusion devices and to implement actions to rectify the weaknesses and consequently reduce the risk to patients and staff.

Analysis of necropsy request behaviour of clinicians.

To develop a necropsy related audit system to record accurate information in relation to necropsy requests, necropsy rates and coronial referrals. A simple audit form was used to record detailed necropsy related data via an integrated questionnaire design and data entry system based on available optical image scanning technology. The system recorded the numbers and locations of deaths, referrals to the coroner, clinical necropsy requests, hospital and medicolegal necropsies, the grade of clinician involved in these processes, and the identity of the consultant in charge of the case. The overall, hospital and medicolegal necropsy rates were calculated by individual consultant, specialty and for the whole hospital. Necropsy request rates and coronial referral rates were also calculated and these data were related to the grade of clinician. All data were available on a monthly or an accumulative basis. Of 1398 deaths, 534 (38%) were discussed with the local coroner's office and 167 of these were accepted for further investigation. House officers and senior house officers referred over 80% of all cases, whereas consultants referred only 2%. There were no significant differences in case acceptance rates by grade of clinician. Clinicians made 307 hospital necropsy requests (overall hospital necropsy request rate 22%). House officers made 65% of all necropsy requests. Consultant necropsy requests represented 13% of all requests. There were no significant differences in necropsy request success rates by grade of clinician. The referral of cases to coroners and clinical necropsy requests are still being inappropriately delegated to the most junior clinicians. This study illustrates the type of useful information which can be produced for individual clinicians, specialty audit groups and pathology departments using a simple necropsy related audit system.

Auditing palliative care in one general practice over eight years.

To document the delivery and outcome of palliative care in one practice. All appropriate deaths were documented over the period of the study. One general practice of four doctors caring for 8000 patients in the North-West of England. All patients dying of malignant disease which had included a palliative phase of at least one week. Place of death; continuity of care; general practitioners' assessment of symptom relief; follow-up of bereaved relatives. 118 deaths from terminal malignant disease were recorded over eight years in my practice. 75% were being cared for by us (GPs) at the time of death. More detailed information was recorded on 64 of these patients showing generally "satisfactory" care. A simple audit can help maintain high standards of palliative care. General practitioners are encouraged to maintain registers of the care received by terminally-ill patients as an aid to quality assurance in this area.

Simple physical, chemical, and biological safety assessments as part of a routine institutional radiation safety survey program.

To assist in providing comprehensive surveillance for potential health and safety hazards, simple assessments of physical, chemical, and biological safety concerns were incorporated into traditional radiation safety facility surveys for a biomedical research and clinical care facility for a 1-y period. Customized training was provided to radiation safety staff members concerning each of the hazard areas identified and a brief checklist was developed. During the 1-y period 802 laboratory and clinic surveys were performed, and of the 372 safety issues noted by the staff, approximately 55% were identified as not related to traditional health physics surveillance activities. The utilization of these simple safety audit tools as part of a routine radiation safety surveillance program can serve as a cost effective way to assist in maintaining a teaching, research, and clinical environment that is free from a variety of recognized hazards.

Improving information given to patients before endoscopy: a regional audit.

To improve the information given to patients before endoscopy an audit was performed in 16 of 18 endoscopy units in Northern region. Details of current endoscopy information leaflets provided by the 16 respondents were discussed by nurses and consultants from the participating units, and a standard, including 12 separate items, was agreed. Each unit was provided with a comparison of its current leaflet with the standard, which highlighted areas for potential improvement. Six months later the participating units were again asked to provide details of the information; 13 replied, 11 of which had produced new leaflets and two which were in the process of doing so. In the initial survey only 35% (range 8-67%) of the items in the standard were included in the leaflets. Particular omissions were an indication of risks of procedures (three units), notification of follow up procedures (two), details for obtaining the results of the endoscopy (five), advice for people with diabetes (two) and providing a contact number for the endoscopy unit (four). In the repeat audit all 11 units had made changes to their leaflets and, overall, 80% of the items were included. Through this simple audit the range of information given to patients attending for endoscopy in the region has improved.

Simple surgical audit: an aid to undergraduate curriculum development

This study investigates the usefulness of a simple surgical audit in designing the undergraduate surgical curriculum in the newly established medical school of the United Arab Emirates. The audit system was designed for use by people previously unaccustomed to this activity. The pattern of disease is found to be biased towards a young male expatriate population. It has been possible to predict the likelihood of a particular disease being available for teaching purposes and has drawn attention to the relative absence of some conditions which are commonly found elsewhere. Allowances need to be made for this and teaching strategies other than those which require direct patient contact should be considered. This method of curriculum design may find use in other places where health care patterns are changing.

Quality assurance in obstetric ultrasound.

Ultrasound examination is a routine element of antenatal care, and an accurate and reliable ultrasound service is essential for confident patient management. Qualitative findings, e.g. fetal normality and placental site, may be confirmed at delivery, but this form of audit is not suitable for fetal measurements owing to the variation in gestation at delivery and the complexity of neonatal assessment. Our aim was to develop a simple audit method applied a short time after the ultrasound scan. The method was based on assessment of measured images against measurement criteria which are clearly defined in the literature, results for each criterion being recorded in a spreadsheet. Two main forms of report were generated, the first showing overall achievement of satisfactory measurements for each sonographer, the second providing graphical information to show which criteria required greater attention by individual sonographers. Over several phases of audit problems of quality recognition and technical skill were isolated, graphical reports were used to guide tuition and the levels of performance were improved. The method itself and the results satisfy managers at all levels that standards are in place and are being maintained.

ECT – current practical administration

In the current climate of interest in audit (Standing Medical Advisory Committee, 1990) and a desire at our hospital to embark on criterion based projects, we set out to undertake a simple audit project surveying the practice of ECT. The aim was to audit the treatment facilities, the treatment procedure and the supervision and training. It was hoped that the full cycle of audit – setting goals, measuring activity, and then effecting change – would be achieved (Shaw & Costain, 1989)

Audit of diabetes in general practice.

To complete a first audit cycle of diabetes care in a general practice and to develop a simple method for continuing the audit cycle. Retrospective examination of the medical records of all diabetic patients in a general practice in 1990. A group general practice in a Bristol health centre with roughly 13,200 patients, which since 1983 had had a protocol for care of its diabetic patients. 223 known diabetic patients in the practice. MAIN AUDITED MEASURES: Comparison against previously agreed standards of process and outcome of diabetes care in the practice, including number of patients whose care had been reviewed in accordance with the practice protocol, serum fructosamine and blood glucose concentrations in patients aged under 70, and number of newly diagnosed patients given explicit education and referred for diatetic advice. Defined standards were not met for several criteria--for example, percentages of patients aged below 70 (n = 149) with serum fructosamine concentrations less than 3.5 mmol/l (62% v 90% defined value) and less than 2.8 mmol/l (35% v 70%) and last recorded blood glucose concentrations less than 10 mmol/l in insulin dependent patients (n = 48) (23% v 90%) and less than 8 mmol/l in non-insulin dependent patients (n = 101) (17% v 90%). Of newly identified diabetic patients (n = 32), 59% and 28% respectively were referred to dietitians and given educational material compared with the 100% standard. The practice has a high prevalence of diabetes (1.7%) but has the resources for their care. The format and implementation of the agreed systematic process of care for diabetic patients needs improvement. A simple audit suitable for most general practices might record two measures of the process of care--a disease register of all diabetic patients in a practice and an attendance register to determine whether they have regular check ups--and one measure of the outcome of care, such as serum fructosamine concentration (or local equivalent). A practice could establish its own standards for these measures and monitor its performance against them.

Obstetric audit using routinely collected computerised data.

To examine the use of routinely collected computerised data in clinical audit. Retrospective review of all analyses of obstetric practice based on a computerised data system from January 1983 to June 1988. Maternity department of the regional referral hospital in Oxford. Congruence with the principles of clinical audit; that is, comparing clinical practice with previously agreed standards and changing practice to meet these standards if necessary. Over the five and a half years of the study the data formed the basis of 130 special inquiries into different aspects of obstetric practice. Most inquiries seemed to be aimed only at describing current activities and identifying trends. Genuine clinical audit was rare. Simple audits--for example, concerning induction for pregnancy after term--could be supported by the computerised data, but for detailed and wide ranging audits--for example, reducing antenatal clinic visits for low risk multiparas--the data had to be supplemented from other sources. Routinely collected computerised data enable ongoing clinical audit, but it becomes a reality only when clinicians agree on standards of practice and have a flexible attitude towards change. Even then, genuine clinical audits of obstetric practice demand more detailed and comprehensive data than are generally available on such systems.