The aim of this assignment is to assess both the positive and negative aspects associated with clinical audit in the ultrasound department and discuss its use in ensuring a high standard of service to clients, patients and clinicians.
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Hine et al (2002) defines clinical audit as “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.” Most literature supports the use of audit as a tool for raising standards in the hospital environment, and views the audit cycle as the structure on which audit projects are based (Godwin et al, 1996; Hine et al, 2002; Sale, 2005; Swage, 2000). Despite its widely accepted use, there are drawbacks linked with performance measurement that must be recognised if potential detrimental effects are to be reduced (Littlejohns et al, 2004).
In order to ensure the correct service needs are being met from a specific audit, the role of each category of people must be clearly defined. Tindall et al (2004) defines the patient, client and clinician as follows:
Patient – A person who is ill or is undergoing treatment for disease.
Client – A recipient of a professional service.
Clinician – A doctor, nurse, dentist or other professional who deals with the observation and treatment of patients
In an ultrasound department the patient is usually the person undergoing the ultrasound scan, the client is the patient and/or the people accompanying them (e.g. friends and relatives) and the clinicians are usually the sonographers and the radiologists. Clinicians closely linked to the ultrasound department are midwives and obstetricians.
The requirements needed to create a high standard of service for patients, clients and clinicians are going to vary depending on which group is being evaluated. An audit by Robson and Wolstenhulme (2010) highlighted areas of weakness in ultrasound room/equipment design, and aimed to reduce work related musculoskeletal disorders among ultrasound practitioners. Improvements of this kind would directly increase the standard of service to the clinician. A visitor (client) to the department may feel hospital service standards were high if the car park facilities were good, and the receptionists were helpful. However, the patient may view the monitoring and raising of pathology detection rates as their primary topic of concern. Consequently audits such as those by Chan et al (2003) and Faught et al (2008) in which the accuracy of ultrasound reports are assessed may be more relevant in maintaining a patient’s perceived standard of service.
Hine et al (2002) identify the five key stages involved in the clinical audit cycle.
Stage One – Preparing for audit
Stage Two – Selecting criteria
Stage Three – Measuring performance
Stage Four – Making improvements
Stage Five – Sustaining improvements
These stages are used as a framework when discussing the implementation and evaluation of audit in section three.
2. The Need for Clinical Audit
Littlejohns et al (2004) explain that patients, voters, policy makers and healthcare workers want to see objective evidence that increased investment in the NHS is improving the level of healthcare in the country. They state that the policy of extending choice to patients means that they are equipped with the correct information to make these choices. The time required by a department for planning, data collection and implementing change strategies are often viewed as initial obstacles to audit (Godwin et al, 1996). Abraham et al (1993) describe how clinicians may be concerned that results will show previous patient care as substandard, and therefore undermine their professional reputation. Littlejohns et al (2004) also warn that the managerial emphasis and financial reward associated with audit may create a reason for institutions to cheat to manipulate the system. Regardless of these drawbacks Hine et al (2002) concur with the majority of the available literature in that clinical audit is at the heart of clinical governance and it is necessary in confirming the quality of clinical services and in highlighting the need for improvement. Sonographers and radiologists spend the majority of their time working independently, creating fewer opportunities to learn from and monitor other clinicians at work. This lone working makes audit in the ultrasound department particularly significant.
3. The Five Stages of Audit
3.1 Preparing for Audit
In preparation for an audit it is useful to maximise the information gained from the patient, and use this as a source of identifying possible areas for improvement in the service (Littlejohns, 2004). The analysis of complaint letters, incident reports, questionnaires, and direct clinician observations may all prove beneficial. Both the patient’s and the client’s/visitor’s view point should be explored. The views of departmental staff are also valuable and could be obtained at staff meetings where radiologists, sonographers and administrative staff may offer their own suggestions.
The audit topic should be given careful consideration to ensure that it benefits the ultrasound department. The audit project must be justified (Godwin et al, 1996). A suitable topic may be one that addresses whether or not clinical practice is safe, and how it can be improved. Faught et al (2008) quantified the variability in the reporting practices of radiologists from different practice environments when evaluating ovarian masses via ultrasound. Considerable variation of the reports was identified leading to 12% of patients having to be rescanned. The study concluded that the use of a standardised synoptic reporting template would improve practice.
A clear definition of the purpose is needed so that the project has a clear focus. The key people conducting the audit will likely stem from the chosen area in which it is being undertaken (Sale, 2005). An audit assessing the level of patient satisfaction with the way they were treated in the ultrasound department may only require the participation of the patients being questioned, and the person performing it. However, if auditing the percentage use of transvaginal scanning compared with transabdominal scanning in the investigation of ectopic pregnancy, it would be necessary to actively involve all radiologists and sonographers performing these investigations. All individuals involved in the audit should be shown how it could potentially affect the department and their personal development and reaccreditation. The funding required for research and implementation of the project must be considered, more funds may also be needed when responding to the findings .In order to be successful it is essential to have the full support of the departmental manager. They must be kept fully informed as their lack of commitment can lead to serious misunderstandings (Sale, 2005).
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3.2 Selecting Criteria
The next step in the audit process is to determine the criteria in which the current practice will be compared against. The criteria must be based on evidence, measureable and related to important aspects of care (Hine et al, 2002) but if there are no specific standards in place Sale (2005) states that standards must be discussed, agreed upon and broken down into measureable elements that can be used in assessing quality. Chan et al (2003) agreed upon the use of an external radiologist as a means of settling discrepancies when comparing the accuracy of pelvic ultrasound scan interpretation between radiographers and radiologists, where as McLennon et al (2009) used criteria described by the Fetal Medicine Foundation when comparing the quality of first trimester images.
3.3 Measuring Performance
Before commencing the audit it should be remembered that hospital imaging software (e.g. PACS), reporting/appointment software (e.g. CRIS), accident reports, complaint reports, along with many more sources can all be utilised to gather information. In a systematic review of the accuracy of ultrasound estimation of foetal weight (EFW), Dudley (2005) made use of databases when searching for studies comparing EFW and birth weight. If however the required audit data is not already available, a suitable data collection instrument should be carefully selected. Robson and Wolstenhulme (2010) found the use of a subjective and objective scoring system when assessing ultrasound equipment for ergonomic optimisation. Methods usually include self complete questionnaires, interviewer administered questions, or proformas on which to record observations (Samuel et al, 1993). The audit study population does not have to be a statistically representative sample and in most cases the number of patients included is not statistically important (Godwin et al, 1996).
During the analysis of the data each individual piece of returned information should be used to quantify the degree to which the standards have been met, and all areas where the service has not conformed to the set criteria should be identified (Sale, 2005). Ethical approval should be sought and obtained where appropriate and the Data Protection Act and NHS guidance must be adhered to at all times (UKAS, 2008).
3.4 Making Improvements
The analysed data should be used in group discussions with departmental staff, in order to identify the necessary improvements that need to be made. Sale (2005) and Swage (2000) recommend developing an action plan that must be communicated effectively with the team. Iles and Sutherland (2001) suggest five stages (below) involved in this improvement management process and that the overall approach helps structure and imposes discipline when changes are performed.
Defining the project’s targets
Monitoring the progress of the project
Completing the project and sustaining the improvements
Firstly the desired change must be identified. Its potential can be justified in terms of cost benefit analysis. This technique involves comparing the costs and benefits associated with the topic, and determining whether they are worth undertaking (Boardman et al, 2004).
Swage (2000) states that it is necessary to identify the existing forces that could facilitate the change and those that are inhibiting it. These forces could be external (e.g. NHS guidelines), specific groups (e.g. Radiologists, managers), or from individual people. It is then possible to select the most significant obstacles and aids to the change process. The possibility of reducing the strength of the force that is preventing change, and enhancing the helping forces should then be explored (Swage, 2000). The change could then be delivered in two phases e.g. short and long term, with regular assessments of project progress compared to the original plan, highlighting any need for corrective action. Staff may be reluctant to change. This stage can potentially cause confusion and unrest in a department if not delivered carefully.
3.5 Sustaining Improvements
In order to ensure that the improvement has been implemented effectively, it is necessary to carefully monitor its progress so that the new standards do not decline. If the new standards are not maintained the overall benefits from the audit process will not be realised and valuable time, money and resources will have been wasted. Pruce and Aggarwal (2000) explain that it is the job of the project team to make sure that the improvement is a success, and that it may be essential to take remedial action as a problem occurs. Dudley (2002) suggested several areas for improvement after a study assessing the use of ultrasound to estimate foetal weight, but acknowledged that further work and regular audit would be required.
Clinical audit within the ultrasound department is of great use in confirming the quality of the service and identifying areas for improvement. The independent work involved in ultrasound makes it difficult for clinicians to monitor and learn from each other in the work place, strengthening the need for a more structured and specific approach of assessing service quality – clinical audit. Although predominantly successful the cost of clinician time and resistance to implement and sustain change are issues that must be considered prior to commencement (Godwin et al, 1996).
As the overall aim is to improve the quality of care that the patient receives, it is imperative to examine the views of patients and staff when selecting the area on which to audit. Once the topic has been decided, clear, measurable criteria must be selected against which the audit data will be compared. Then, through staff discussion recommendations on how to improve the quality of the service can be developed. An action plan should be carefully utilised to implement these changes (Swage, 2000). Checking the improved practice has been implemented effectively is equally important if the benefits from the audit are to be secured. Close monitoring and feedback from staff is required, and the possibility of re-audit should be considered (Pruce and Aggarwal, 2000).
Ultimately, excellent communication within the ultrasound department is the key factor in ensuring that the audit is a success. Beginning with the initial preparation for the audit in which suggestions from patients, clients, radiologists, administrative staff and sonographers are used in deciding what area to focus the audit, right through until the monitoring period in which support of the manager and feedback from staff is vital. These variables combined with the uncertain level of commitment from the staff are factors that have potential to greatly influence the project. Without a high degree of communication and commitment from all staff at all stages of the cycle, an audit can become less effective, and the likelihood of making and sustaining improvements to service can be diminished.
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