Clinical audit is a systematic process by which veterinary teams are able to assess and evaluate the effectiveness of procedures they carry out. It can help the whole practice team to look objectively at the care they deliver and can improve outcomes.
Clinical audit at its simplest is a process for the collecting and recording of clinical information with the aim of monitoring the quality of care and identifying action areas for improvement. Clinical audit can help veterinary professionals to understand the care they deliver to their patients and the service they deliver to their clients
It can also be defined as a quality improvement process with the goal of continuously improving the quality of patient care.
Veterinary nurses play a crucial role in preparing for, setting up and running clinical audits. So it is essential that they have a good understanding of the audit process. The RCVS Guide to Professional Conduct states that ‘RVNs must ensure that clinical governance forms part of their professional activities’ (RCVS, 2018a). The RCVS in their guidance to the Code say that clinical governance may include amongst other things, auditing the results of clinical procedures of interest to the practice team and using the results to improve patient care.
The RCVS Practice Standards Scheme asks practices at GP level to have a system in place for monitoring and discussing clinical cases, analysing and continually improving professional practice as a result. At veterinary hospital level it asks that clinical procedures carried out in the practice are audited and any changes implemented as a result (RCVS, 2018b).
Clinical audit is all about looking at what the practice does and trying to improve it. Clinical audits require collection of data in a specific area of the practice. Understanding the performance of the practice is critical, if it is not measured, it is not possible to know what needs to improve. Real data will reveal what already works well and what areas need improvement.
In the author's experience when veterinary professionals talk about clinical audit they are often thinking of outcome audits; these look at the results of a procedure or treatment, for example anaesthetic deaths or complications, or the results of particular surgeries. But clinical audit can be used to assess many other areas, such as structure, process and performance.
In human medicine clinical audit is widely used to assess standards of care. But in their systematic review of clinical audit activity in veterinary small animal practice, Rose et al (2016) revealed a minimal amount of published articles of clinical audit in veterinary medicine and proposed that clinical audit is not widely adopted in veterinary practice.
Clinical audit — before you start
Time spent in preparing for clinical audit is never wasted. Thorough preparation is essential to ensure a successful audit. Some of the common problems in setting up clinical audits identified by Viner (2009) can be:
- Choosing the wrong subject
- Trying to do research not audit
- Making it too complicated
- Not planning the audit well
- Not involving the team from the start
- Not devoting enough time to it
- Not acting on the results when you have them.
Research versus audit
In-practice, research is not the same as clinical audit. Many practices start their audit journey with a subject that is in fact research so can get disillusioned
Research helps to answer the question: ‘What is best practice?’ Whereas clinical audit answers the question: ‘Are we following agreed best practice in our practice?’
Research generates new knowledge whereas clinical audit looks at how we apply that knowledge in our practice. Audit is small scale over a short time period and locally relevant to the practice or group of practices where it takes place. Research is generally large scale and over longer time periods than clinical audit, and often produces results that can be generalised to the whole profession. Audit may not need ethical approval or be statistically significant, research does need both (Table 1).
Table 1. The differences between research and clinical audit
| Research | Clinical audit |
|---|---|
| Attempts to create new knowledge regarding best practice | Creates knowledge of clinical practice and need for improvement |
| To generate or test hypotheses, or to identify or explore these | To answer whether a service reaches a predetermined standard |
| Usually large scale, over a long time period, one-off/discrete summary | Usually small scale, shorter time period, but an ongoing/cyclical process |
| Clearly defined research questions, aims and objectives | Current clinical practice against evidence-based clinical guidelines or standards |
| May involve a completely new treatment, or placebo | Choice remains that of clinician |
| Wylie, 2015 | |
So, in practical terms trying to find out whether drug A or B is safer for anaesthetising rabbits is research. But measuring the anaesthetic death rate of rabbits in the practice is clinical audit.
So the first step is to determine if the aspect of clinical practice you want to investigate is best answered by clinical audit or clinical research. Once that is determined, the most appropriate plan of action can be planned out.
Planning the audit
Deciding on a subject for your audit
The next step is to choose a subject for audit. It needs to be easily understood, easy to measure and relevant to the practice and team.
It should also be realistic bearing in mind what time and resources are available. The plan needs to be achievable in the timescale set. There is no point in choosing something that occurs very infrequently.
If possible there should be evidence to aid in deciding criteria and standards, and it should be an area where there is a possibility that changes will lead to improvement.
Criteria define exactly what is being measured, they should be easily understood and easy to measure. For example: ‘Cats with chronic kidney disease should have their blood pressure measured’, could be the criteria.
The criteria need to be defined more to ascertain whether cats with co-morbidities (hyperthroidism, diabetes etc) are included or excluded and what blood test levels for ’chronic kidney disease’, shoud be included in this audit.
It may be necessary to draw up practice guidelines (RCVS Knowledge, 2018a), and audit to see how the team comply with the guidelines, or it may be better to use consensus guidelines; for example, the ISFM Guidelines on the diagnosis and management of feline CKD (Sparkes et al, 2016).
A standard or target then needs to be set. Standards should be evidence-based where possible. The problem in veterinary medicine, unlike in the human field, is that there are very few external evidence-based standards. This means that it is often necessary, when undertaking clinical audit, to set our own targets.
The target could be set by having looked through the records from the previous months for number of cats that did have their blood pressure measured and simply looking for an improvement on this; or by setting an arbitrary standard, for example 50% of cats with renal failure should have their blood pressure measured.
Deciding what type of audit
There are different types of audit according to what information is required:
- Outcome audits look at the results of a procedure, for example a certain surgical procedure
- Process audits look at whether guidelines or protocols are being followed, for example a protocol for dispensing medicines
- Structure audits look at what facilities and equipment are available, for instance audit of the contents of farm veterinary surgeons' car boots
- Significant event audits look at one event in detail and see what can be learned from it, for example a serious dispensing error. These have been discussed at length in this journal previously (Mosedale, 2018) (Table 2).
Table 2. Choosing the right type of audit
| What do you want to know? | Which type of audit? |
|---|---|
| Want to check have right facilities available? | Structure audit |
| Want to look at how we do something in the practice? | Process audit |
| Want to look at the results we get? | Outcome audit |
| Something had gone wrong (or right)? | Significant event audit |
| Trying to find out the best way to do things? | Research (not audit) |
Planning how to collect data
It is essential to get team members involved from the start in planning the audit. A team meeting to discuss this so that everyone is clear on their role is useful.
It is important to have a leader for the audit, who is enthusiastic about the subject chosen and who will drive the audit forward. Deciding who will be part of the audit team is a very important process (Viner, 2005). Veterinary nurses make great advocates of improving outcomes for their patients and can lead this meeting. It is important however that the audit lead is allocated enough time and resources to successfully run the audit.
The initial meeting is an opportunity to review the recent relevant literature on the chosen topic, which may help with setting a standard or target (Waine, 2018). At the meeting it can be decided who is collecting the data; how they will collect it; whether it will be a retrospective audit looking back through practice records, or whether it is going to be a prospective audit happening from now onwards. Also, how will the audit group communicate with each other, face-to-face in meetings, by mail, WhatsApp group etc?
At this meeting it should also be clearly established to all that this is about improving outcomes and systems, not about criticising the performance of individuals. An open learning culture, where all team members' views are heard and respected, is vital for clinical audit to be successful (Oxtoby et al, 2015).
In planning how to collect the data do not forget to ensure client confidentiality by not including clients' names, addresses or details in any results.
Collecting and analysing the data
Collecting the data does not need to involve sophisticated software or computer programs. Most data are available from clinical records on the practice management software, or from hospital sheets, consent forms, anaesthetic monitoring sheets etc.
Once the data have been collected they can be analysed to see whether the practice met their target. If they did not, what were the barriers to this?
In the earlier example the reasons for cats not getting their blood pressure checked could include not having a clear guideline that this should be done, not having suitable equipment, not having sufficient team members available to carry this out, or not having a quiet area to carry this out.
Making changes
It is really important that the results of the audit are discussed by the practice team and changes made if necessary. If the results of clinical audit are not acted on, so that it is not shown to be improving clinical care, then team members will soon get discouraged from further audits.
The changes that might result from an audit could include team training or CPD, drawing up a protocol or guideline or altering an existing protocol or guideline. It might also identify the need for a further audit in a different area.
Re-audit
Audits should always be revisited after changes have been made to monitor their effect, or if the results of the first audit were good, to ensure this is maintained (Figure 1).
Benchmarking
The results of audits can be used to compare the practice performance against other practices. This may be internal between branches of a practice or practices in a group, or it could be external.
In the NHS it is quite easy to look up individual surgeon data on the MyNHS website www.nhs.uk/Service-Search/performance/search. Patients can, therefore, compare the performance of hospitals or individual surgeons when choosing where to have an elective procedure, e.g. a hip replacement.
RCVS Knowledge now hold the data for vetAUDIT which is an audit of postoperative complications in routine neutering in cats and dogs — it is the results of pooled data from 32 650 routine surgical cases carried out by practices between 2014 and 2018. If practices follow the guidelines for assessing postoperative checks (see example nurse-led outcome audit), these can be benchmarked at www.vetau-dit.co.uk. Practices can then compare their own results against other practices
Examples
Example nurse-led outcome audit
A large, eight veterinary surgeon, 12 registered veterinary nurse (RVN) practice was discussing whether they had seen an increase in postoperative complications, particularly following routine neutering procedures. There were various opinions around the table, so the head nurse suggested they carry out an audit of the results of all routine neutering procedures over the next 3 months, so they would be able to measure if there was a problem.
Postoperative checks were usually carried out by RVNs in this practice, so the RVN team looked at available literature and found the www.vetaudit.co.uk site had a simple system for classifying post-operative complications.
Each case was assigned to a group:
- Group 0 — lost to follow up
- Group 1 — no complications
- Group 2 — abnormal, no treatment necessary
- Group 3 — abnormal, requiring medical treatment
- Group 4 — abnormal, requiring surgical intervention
- Group 5 — fatality of animal.
A meeting was held for all of the nursing and veterinary teams to discuss and decide that this system would be applied to all postoperative check-ups. The meeting gave the chance for all team members to express any issues or concerns about the audit. At this meeting it was made clear to the team that this was not to look for differences in results between individuals, but to look at practice performance overall.
These results were also submitted to RCVS Knowledge Clinical Audit group at www.vetaudit.rcvsk.org/where results for all practices are pooled to show overall complication rates for all results submitted. This benchmarking can be very useful to show practices how they compare with the average and can drive quality improvement (Table 3).
Table 3. Practice results vs. average results on vetAUDIT
| Practice results | Average of all practices | |
|---|---|---|
| GROUP 1 No complications | 72.1% | 75.4% |
| GROUP 2 Abnormal, no treatment necessary | 12.2% | 8.6% |
| GROUP 3 Abnormal, requiring medical treatment | 13.8% | 6.9% |
| GROUP 4 Abnormal, requiring surgical intervention | 0.7% | 1.0% |
| GROUP 5 Fatality of animal | 0 | 0.1% |
On comparing their results it was obvious that Group 2: Abnormal, no treatment necessary and Group 3: Abnormal, requiring medical treatment were higher than the average.
On looking further at the records for those medically treated, most of these cases had required antibiotics. The practice were reassured that their rate of abnormalities requiring surgical intervention and fatalities were below average.
They had another meeting to discuss these results and decided the next step would be to look at the practice's management of infection control and to draw up or modify their infection control protocols. This would be nurse led, but would involve the whole practice team. They also decided to continue to audit all postoperative complications of routine neutering.
The practice are hoping that the changes they have made in their infection control protocols will lead to improvements in the rate of complications and, as they are actually measuring this, they will be able to see quantifiable results.
Example nurse led process audit
The whole practice team were really upset to hear that a swab had been discovered in a dog's abdomen 2 years after a routine spay. A significant event meeting had been held in a constructive way to try to improve systems, not blame individuals.
At the meeting the team discussed what could have been done to avoid this happening again. One suggestion was to modify the existing anaesthetic chart to include a section showing that swabs had been counted in and out.
Adoption of the new anaesthetic chart was implemented throughout the three practices in the group. After 3 months the head nurse carried out a retrospective audit of all routine bitch spays and laparotomies performed. The surgeries were identified from the practice management system by name of procedure and by double checking against the surgical lists. The practice decided to use the following criteria for this first audit:
For all abdominal surgeries in dogs, the anaesthetic chart was checked
- To ensure that it had been scanned onto the patient's record
- To ensure that the identity of veterinary surgeon and nurse involved were filled out
- To ensure that the section of the chart showing swab counts in and out was completed.
The audit results were:
- 82% of anaesthetic charts were scanned on to patient records (14% paper records were found but had not been scanned on, 4% anaesthetic chart not found)
- 75% of anaesthetic charts had recorded the veterinary surgeons and veterinary nurses involved. 21% had no record of team members involved
- Only 47% of cases had used the section of the chart for the swab counts in and out.
The head nurse called a practice meeting where these results were discussed. The importance of filling in the anaesthetic chart fully was explained to the team, as this was a vital part of the animal's records.
The barriers to filling in the section on swabs included poor communication between veterinary surgeons and veterinary nurses, swapping nurses monitoring the anaesthetics mid procedure, time constraints and a lack of clarity on exactly when the swab counts should be performed. It was also mentioned at the meeting that swab packs did not always contain the number of swabs stated on the outer, and surgeons often asked for additional swabs part way through the procedure.
The nurses drew up a clear protocol that swabs should be counted at the start when they were removed from packs, any extras added in during the procedure, just before closure of the abdomen and at the end of the procedure. The chart was modified to show this more clearly.
After a further audit, the head nurse congratulated the nursing team that swab counts were now taking place 89% of the time and all other parameters had also improved. The practice will re-audit on an ongoing basis.
Conclusion
Nurses can be involved in audits at all levels. When carrying out audits in the author's own practice the nursing team were critical to the process and their commitment and enthusiasm kept the audit going
Veterinary nurses are well placed to plan and carry out nursing audits. For example, a process audit of anaesthetic monitoring forms to ensure essential details are always filled in, or of pain scoring sheets to ensure that scoring is taking place at prescribed intervals. Details on admission forms or of the use of surgical checklists can also be audited.
All these process audits could be done over a short period, weeks rather than months, then changes made and a re-audit carried out to monitor the changes. This allows the team to rapidly see the value of the auditing process and real differences made to patient care.
If RVNs can see that use of these audits is not about looking at individuals' performance, but is about improving patient care and outcomes then they can embrace them and use them routinely.
KEY POINTS
- Clinical audit is a process for collecting and recording information in order to monitor the quality of care.
- Clinical audit can be part of an overall quality improvement strategy aimed at improving patient care.
- Registered veterinary nurses should ensure that clinical governance forms part of their professional activities. Clinical audit is an important part of clinical governance.
- Clinical audit is not the same as in-practice research.
- Choosing the right subject to audit is critical to success of the audit.
- Getting the practice team on board is critical to success of the audit.
- Outcome audits look at the results of a procedure.
- Process audits look at whether guidelines or protocols are being followed.
- Veterinary nurses can carry out clinical audits that can lead to changes which can make a real difference to patient care.