Healthcare: the challenge of departmental improvement

Aside from tackling patient care on an individual patient by patient basis, you might wonder how healthcare teams and departments make efforts to improve the organisation of the healthcare they provide.
We have already acknowledged the gap between evidence based medicine and current practice with a real gap between “what we know and what we practice”. One of the key approaches to tackling this gap can be termed “clinical audit”.

Clinical audit has grown in importance over the last few decades in the medical field. I can remember being introduced to the PDSA cycle as a junior doctor and wondering how it might fit into the medical world, as the business improvement culture it hailed from was different to the rest of medical science I was taught at that time (anatomy, physiology etc). Yet it has caught on and become common parlance within the medical community.

Brief Introduction to Clinical Audit

The common approach to clinical audit may be explained with the help of a cycle, the audit cycle. Within some healthcare systems the PDSA or PDCA cycle is the cornerstone of audit. PDSA meanings Plan, Do, Study, Act or PDCA meaning Plan, Do, Check, Act.

Lets examine these important elements in a little more detail.

What does the PDSA or PDCA stand for?

P is for Plan.. i.e. the clinician decides what they want or need to explore. For instance in the field of Emergency Medicine it may be the  management of asthma care in the Emergency Department (ED).

It may begin with an interest to explore this aspect of care in the department and compare this with the gold standard that may be recommended nationally or internationally.
With an eye on the “gold standard” knowledge base a number of parameters from a number of patient records need to be explored, i.e. in asthma care, perhaps the % of patients who had their Peak Flow Rate (PFR) measured on arrival to the department and/or the time within which they received their first treatment.
An analysis of a selection of patient records is needed, gathering the relevant patient related information in order to be able to compare current practice against the gold standard that the best evidence knowledge bases recommend.

That analysis usually highlights some common problems (e.g. the PFRs are not being routinely done).Then related solutions need to be formulated, such as standardise the process of initial assessment of asthma, perhaps with a proforma which mandates the recording of PFRs. This trial solution forms the basis of  the “Plan”

D is to Do..

The second step in this particular cycle is called Do. That simply means implement the changes recommended in the plan, at a small scale at first…

S -Study (or C for Check) is to then measure the effect of the changes that were developed in the Plan. It is hoped that improvements will have been seen as the cycle unfolds, but disimprovements are equally important to measure and inform further improvements and actions.

Act.. is in theory, the final phase acting on the further actions recommended in the Study phase.

It should be evident that as explained this is not a single cycle of change but at least two. One can also note that the formality of  the PDCA cycle is simply as a variant on the human problem solving cycle….albeit focussed on exploring the clinical issue in question.
One interesting thing to note is this clinical audit/process improvement cycle is one of many improvement activities that are to be cyclical in nature (i.e. you complete a loop and then reloop some time later). Most of the various methodologies behind quality and risk management are also cyclical in nature.  As are other approaches to quality management.
If I haven’t said it before, life is full of cycles..

Needless to say that much of the current activity of clinical audit involves trawling through patient records to see if things have been done well or not. Interestingly many of the key findings of clinical audit commonly highlight the poor information available and poor clinical documentation is very often an issues that is uncovered.
Without available, complete or legible clinical notes, much of the conclusion drawn in a typical audit are thereby limited by these constraints. Furthermore one of the most common conclusions from a clinical audit that I regularly see is to improve clinical documentation. ( e.g. suggest a template/proforma for specific documentation purposes)…

Ultimately the important and growing need for clinical audit as an integral part of medical practice clearly highlights that we need to get much slicker at information management in healthcare.
Indeed the clinical audit process ultimately needs to be made available as a by-product of routine care to enable real-time feedback of clinical care and continuous improvement. As this is challenging but important, currently audit has become a common driver to develop information systems around “secondary use” drivers such as audit, without serving the frontline particularly well, which has limited success.

Indeed as the health industry currently suffers from such a poor connection between information and knowledge management systems, one can imagine the complexity of coordinating multiple audits across organisations from a patient oriented perspective.

There is a related need for greater effort towards interoperability of health information systems, to ensure that benefits to primary users of clinical systems can also facilitate secondary use processes such as clinical audit.


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