Editorial |
Clinical audit in occupational health services
NHS Greater Glasgow & Clyde, Occupational Health Service, Dykebar Hospital, Paisley
e-mail: eugene.waclawski{at}renver-pct.scot.nhs.uk
Clinical audit is a quality improvement process that aims to improve the quality of patient care. Clinical audit was introduced to the National Health Service (NHS) by the 1989 White Paper ‘Working for Patients’. Previously known as medical audit until a name change in the early 1990s, clinical audit involves reviewing the delivery of health care to ensure that best practice is being carried out [1]. The current accepted definition appears in Principles for Best Practice in Clinical Audit (2002) and was endorsed by the National Institute of Clinical Excellence:
Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the review of change. Aspects of the structure, process and outcome of care are selected and systematically evaluated against explicit criteria. Where indicated changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in health care delivery [2].
Clinical audit involves checking whether best practice is being followed and if there are shortfalls in the delivery of care making improvements. A good clinical audit will identify (or confirm) problems and lead to effective changes resulting in improved patient care [1]. Clinical audit is a requirement of NHS consultant job planning [3], annual appraisal for specialists including those participating in the Society of Occupational Medicine appraisal scheme [4] and the Faculty of Occupational Medicine’s process of continuous professional development [5]. It is required by the General Medical Council as part of Good Medical Practice [6] and will be an essential requirement for medical revalidation.
Working in teams is common in occupational health and clinical audit is not just a medical requirement but a vital team discipline. Occupational health service activity includes a range of services that have potential for clinical audit. These include vocational rehabilitation, management of needlestick and sharps injuries, pre-employment health assessment, immunizations, statutory health surveillance, assessment of employer or self-referrals generically or by specific types of condition and the management of alcohol or drug misuse in staff.
There are specific criteria developed through evidence-based guidelines [7], statutory requirements (such as health surveillance for hand–arm vibration syndrome [8]) and regulatory requirements from the General Medical Council such as consent [9] that can be utilized as explicit criteria for audit.
Local clinical audit is performed in occupational health services with specialty registrars as audit is a requirement of training. National multi-centre audits within the NHS in England are underway via the Occupational Health Clinical Effectiveness Unit of the Royal College of Physicians. It is unclear whether all occupational health services currently undertake clinical audit. In an environment where revalidation of doctors will be required, involvement in local and/or national clinical audit will be seen as essential for all occupational health physicians.
Audit is more than just benchmarking performance against a standard. A full audit cycle requires not only the defining of a standard and measuring performance against the standard. Any deficiencies, in structures or processes or poor outcomes, require an action plan to improve either the structures or processes of care leading to an improvement in outcome. Once the changes have been defined and implemented, a further comparison with the new standard is required to identify improvement occurs and is sustained to complete the audit cycle [10].
Some audit activity can be undertaken locally with learning shared with other services. Where the activity is too small to merit only local audit combining with other services is necessary. For example, services that undertake health surveillance for hand–arm vibration syndrome may have sufficient numbers to audit the structure and processes involved in a surveillance programme for Tiers 1–3. The formal diagnosis (Tier 4) and use of standardized tests (Tier 5) are less common outcomes that may require peer review among doctors diagnosing the condition and interpreting standardized tests from different organizations.
It is important to make best use of resources allocated to audit. As with research projects, this requires some planning of the sample to be studied and the size of group to be studied. A number of options for sampling can be incorporated into an audit protocol including interval sampling, two-stage sampling and rapid-cycle sampling [10]. The latter is a method of using small samples, with many repeated data collections to test change ideas on a small scale, before introducing the change more widely. Rapid-cycle sampling using PDSA cycles (plan, do, study, act) is currently in use in NHS Scotland with the Scottish Patient Safety Programme (http://www.patientsafetyalliance.scot.nhs.uk/programme/) supported by the Institute for Healthcare Improvement (http://www.ihi.org/ihi). These sampling methods can be adopted by occupational health services as alternatives to the traditional method of large data collection exercises that occur over a long period.
The reporting of full audit cycles (traditional, rapid cycling or two stage) should be a priority as these are of more value to practising occupational health professionals than simply reporting of a benchmarking exercise against a standard. Occupational Medicine has, since 1990, published >200 articles reporting on areas such as peer review audit of record keeping [11] and criterion-based audit against NHS and evidence-based standards [12,13,14]. Frequently, publication has identified a gap when compared to a standard but the follow-up to the end of the audit cycle has not been reported. While there is some learning obtained from such publications, completion of a full cycle is more valuable in highlighting effective changes that lead to improvements in care.
While publication remains an important matter, easier access to reports may require alternatives to be considered. It would be of great value if audits were available via the Learning Zone of the Society of Occupational Medicine website to society members, other occupational health specialty groups (such as Association of Local Authority Medical Advisors (ALAMA), Higher Education Occupational Physicians (HEOPS) and Association of NHS Occupational Physicians (ANHOPS)) and other organizations. Such repositories could include the explicit criteria used for audit, the methodology, forms used in specific audits, databases and final reports. In this way, standards of occupational health practice can be improved by referring to audit results that were undertaken in one organization that are then adopted by others in setting standards who then examine the impact on structure, processes and outcomes.
The needs of the single practitioner could also be supported by giving access to results that can inform their practice. Being able to utilize audit results in this way could be documented as part of appraisal and revalidation. Networking with other single-handed practitioners to form audit groups within a region may also be required.
Occupational health services are active in quality management processes such as the European Foundation for Quality Management (EFQM) excellence model [15] or OHSAS 18001: 2007 [16]. Clinical governance is a quality management process for clinical services and clinical audit is a vital element of the quality management of occupational health practice. Clinical audit has developed significantly since its introduction in the early 1990s and its current use should enhance the clinical quality of an occupational health service for the benefit of users (employers and workers) of occupational health services. In addition, participation in clinical audit appears to be an absolute necessity for occupational physicians in the UK in preparation for revalidation.
References
- What is Clinical Audit? Clinical Audit Support Unit. http://www.clinicalauditsupport.com/what_is_clinical_audit.html (27 October 2008, date last accessed).
- National Institute for Clinical Excellence. In: Principles of Best Practice in Clinical Audit. Radcliffe Medical Press Ltd. http://www.nice.org.uk/usingguidance/implementationtools/auditadvice/audit_advice.jsp?domedia=1&mid=79613703–19B9-E0B5-D4F14A0429022FC0 (27 October 2008, date last accessed).
- New Consultant Contract. Scottish Executive Health Department. NHS Circular PCS(DD)2004/2. 2004.
- What is Continuing Professional Development? London: Faculty of Occupational Medicine. http://www.facoccmed.ac.uk/cpd/index.jsp (27 October 2008, date last accessed).
- Quality Assured Appraisal Scheme (2005) London: Society of Occupational Medicine.
- Good Medical Practice. London: General Medical Council. http://www.gmc-uk.org/guidance/good_medical_practice/index.asp (27 October 2008, date last accessed).
- Occupational Asthma: Identification, Management and Prevention: Evidence Based Review and Guidelines (2004) London: British Occupational Health Research Foundation. http://www.bohrf.org.uk/content/asthma.html (27 October 2008, date last accessed).
- Health Surveillance—Guidance for Occupational Health Professionals. http://www.hse.gov.uk/vibration/hav/advicetoemployers/havocchealth.pdf (27 October 2008, date last accessed).
- Consent: Patients and Doctors Making Decisions Together. London: General Medical Council. http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance/index.asp (27 October 2008, date last accessed).
- A Practical Handbook for Clinical Audit. NHS Clinical Governance Support Team. http://www.cgsupport.nhs.uk/downloads/Practical_Clinical_Audit_Handbook_v1_1.pdf (28 October 2008, date last accessed).
- Agius R. Peer review audit in occupational medicine. J Soc Occup Med (1990) 40:87–88.[CrossRef][Web of Science][Medline]
- Steiner M, Murphy E, Roy KM, Dick F. Benchmarking self-reported practice regarding Scottish Executive guidance on hepatitis C-infected health care workers. Occup Med (Lond) (2007) 57:607–609.[CrossRef][Medline]
- Gibson K, Kennedy I. Implementation of the hepatitis C guidelines in UK health care workers. Occup Med (Lond) (2007) 57:599–601.[CrossRef][Medline]
- Walsh L, Menzies D, Chamberlain K, Agius R, Gittins M. Do occupational health assessments match guidelines for low back pain? Occup Med (Lond) (2008) 58:485–489.[CrossRef][Medline]
- EFQM. What is EFQM? Quality Scotland. http://www.qualityscotland.co.uk/efqm.asp (29 October 2008, date last accessed).
- BS OHSAS 18001:2007. Occupational Health and Safety Management Systems. Requirements. BSI. http://www.bsi-global.com/en/Shop/Publication-Detail/?pid=000000000030148086 (29 October 2008, date last accessed).
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