Question 22

College answer

Syllabus topic/section:

2.3.1 Intensive care administration: Safety and quality: Clinical Audit

Discussion: 

This question sought a discussion which requires some depth to the answers, including addressing the key principles and where appropriate, the advantages and disadvantages. Attention to structure is rewarded in a question such as this. Starting with a list of the steps involved provides the headings from which a discussion can flow but is not in itself enough to achieve high marks. Candidates that scored higher marks provided detail about the individual steps to explain the key principles.

Candidates who scored less well on this question wrote about how to implement a change management or quality improvement intervention rather than how to conduct a clinical audit. Whilst there is some overlap between them it meant candidates missed some of the key steps involved if they didn’t address the question.

The marking rubric is included to aid the candidate’s future study.
 

Below standard	At standard	Above standard
Unable to list basic steps An audit conducted with this sort of structure would lack validity or fail for lack of support.	The basic elements to perform a clinical audit are included with a logical progression of steps Omitted elements would not derail an audit project that is otherwise guided by an experienced supervisor	As at standard with: Steps listed with a detailed description, including the first and last steps (topic identification and re- audit).
Steps listed in name only, not discussed, explained, or explained incorrectly. 0-4.5 marks	For the steps listed some sensible discussion of each step is required for a pass. 5-6.5 marks	For each step, the outlined points are detailed, and specific strategies or methods are listed. These could include insight into organisational dynamics (eg. need for support from hospital admin), the question of ethics approval, effects of audit significance for practice change on sample calculation, strategies to improve the validity of the data collection instrument, etc. 7-10 marks

Discussion

Whereas each other time the examiners had "audit, but it's a rapid response service" or "audit, but its blood products", this time the SAQ was not dressed up in any scenario, and asked for an abstract administrative approach.

Preparation of a quality assurance project:

• Identify critical areas of interest and collect data about meaningful outcomes.
• Prioritise potential projects
• Prepare a plan for the identified projects, with a task list, budget considerations, a timeline, and clearly defined leadership with central reporting
• Clearly define the measured variables
• Assess the logistics of collecting this data
• Create a data collection system, eg. a regularly maintained database of adverse events

Engage stakeholders

• Involve key interdisciplinary decisionmakers early in the process
• Eg. patients, families, quality experts, and management/executive
• Create a leadership group and appoint champions from among locally respected clinical leaders and experts

Identify standards

• Select benchmarks from guidelines or policies
• Establish clear criteria targeting a specific area of interest to narrow the audit

Collection of quality data

• Assess the current quality of care using the established data collection methods
• Morbidity and mortality data collection
• Incident monitoring
• Patient and family satisfaction surveys
• Staff satisfaction surveys
• Feedback from external non-ICU services and prehospital staff

Assessment of quality data

• Morbidity and mortality audit - regularly
• Incident review meetings - regularly
• Encourage the attendance and contribution from all staff
• Sample must be sufficient for the population, e.g for small populations (n <30) 100% of the population may need to be sampled - can be calculated using models such as Donabedian’s

Generation of recommendations

• Evidence-centered literature search for solutions to identified problems
• Consultation with relevant specialists and with local medical staff
• Evaluation of evidence-based recommendations for improvement, and their cost-benefit analsysis
• Assessment of the tolerability of their implementations, the logistics of this and changes to funding.
• The presentation of recommendations at department meetings to encourage discussion

Monitoring and audit

• Ongoing data collection
• Regular review of outcome trends and assessment of effective and ineffective QA strategies

Structure of the QA program

• Education of all staff to be involved in incident reporting
• Specific staff groups responsible for data colelction
• Specific staff allocated the task of ensuring high data quality
• A leader for the project, who reports to the head of department
• Data entry and database maintenance staff