Data quality and clinical audit

Clinical audit has an increasingly important role in the quality of care being offered to patients. Only good-quality data can enable valid conclusions to be drawn, which in turn enable changes to be made for the better. More and more patient data are held on NHS computer systems, and increasingly these data are being used to facilitate the audit process. The quality of any such data needs to meet the highest standards. This article briefly defines the audit cycle and goes on to consider a typical data model. The various elements of the data model are defined, the understanding of which should enable individuals to avoid pitfalls in data collection and ensure that the data they collect for clinical audit are of the highest quality.     

Data quality and clinical audit

Clinical audit has an increasingly important role in the quality of care being offered to patients. Only good-quality data can enable valid conclusions to be drawn, which in turn enable changes to be made for the better. More and more patient data are held on NHS computer systems, and increasingly these data are being used to facilitate the audit process. The quality of any such data needs to meet the highest standards. This article briefly defines the audit cycle and goes on to consider a typical data model. The various elements of the data model are defined, the understanding of which should enable individuals to avoid pitfalls in data collection and ensure that the data they collect for clinical audit are of the highest quality.     

Towards effective obstetric anaesthetic audit in the UK

Obstetric audit is multidisciplinary, but maternal mortality data represent the only national obstetric anaesthetic audit currently available in the UK. Maternity and neonatal audit is progressing towards the collection of both numerator and denominator data in order to compare local, regional and national figures. Obstetric anaesthetists as a professional group play a significant role in maternity care and have in the past developed a minimum data set. Such a set now requires revision of items, agreement on definitions and integration with national projects. Since local and regional obstetric anaesthesia data collection systems are available, albeit in various manual or computerized forms, this is an achievable target. A standard maternity and neonatal data set which incorporates obstetric anaesthetic clinical items could offer a qualitative comparison of process variables and outcome, but should be under professional anaesthetic control. In addition, the process may enable professional standards to be defined and tested so that high quality obstetric anaesthetic care can be maintained.     

The CRABEL score--a method for auditing medical records

Medical record keeping has become increasingly important particularly for research, audit and medico-legal purposes. The authors present a protocol, the CRABEL score, that is quick and easy to use for the assessment of the quality of medical record keeping with the purpose of standardizing the audit of medical records and improving their quality.     

Guidelines for surgical audit in Australia and New Zealand

Surgical audit is an important part of the process to measure performance, reduce clinical risk and improve quality of care. Recognizing this, the Royal Australasian College of Surgeons established a Surgical Audit Taskforce as a subcommittee of the Board of Continuing Professional Standards. This study aims to review the recommendations of the Taskforce for data collection and peer review. The minimum data for whole-practice, continuing audit have been defined. The method of data collection, devices and databases are personal choices for the individual surgeon. However, there are many benefits of developing an electronic surgical audit, and these include facilitating comparison and sharing of audit data between units. Surgical audits should not only report on work carried out but also ensure that outcomes include key performance indicators such as major complications, readmissions, reoperations, transfers, incident reports, complaints and mortalities. Effective clinical governance demands that issues raised by audit need to be documented and reported together with recommendations for improvement. Surgeons should be proactive in helping to find and implement solutions to the issues arising from surgical audit.     

Clinical audit,quality improvement and data quality

Clinical audit and quality improvement are essential processes that help to ensure that patients receive safe, effective, and high-quality care. By participating in clinical audit and quality improvement initiatives, anaesthetists can gain a deeper understanding of the care provided to patients and identify areas for improvement. Ensuring good data quality is crucial for these processes, and can be achieved by following a systematic approach to data management, including training on data collection and management techniques, strict data validation procedures and regular data quality checks. Additionally, involving patients, staff, and other stakeholders in the process can help to ensure that changes are well received and implemented effectively. By participating in these processes, we can contribute to the ongoing efforts to improve the quality of care provided by the NHS, and develop the skills and knowledge necessary for continuing professional development.     

Alterstraumazentren von der Idee bis zur Umsetzung

The geriatric trauma working party, a subgroup of the German Society of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU), focuses on the challenges of geriatric fractures, which are steadily increasing due to demographic changes. Inherent comorbidities implicate perioperative complications leading to loss of mobility and endangered independence followed by an increased burden on the social services. An interdisciplinary approach is required. The geriatric trauma working party defined criteria for interdisciplinary treatment and comprehensive care as well as early rehabilitation in interdisciplinary geriatric fracture centers. By passing an independent audit process these centers can achieve certification as a geriatric trauma center DGU (AltersTraumaZentrum DGU). Certified centers can participate in a recently established geriatric fracture registry which includes an internationally consented data set. Audit and registry enable centers to acquire an international benchmark, ensure permanent improvement in quality and allow participation in health services research.     

COMPUTER-BASED SURGICAL AUDIT PROGRAMS: A REVIEW OF THREE CURRENT OPTIONS

Background : In order to find the most useful computerized auditing system for the needs of the QE II Hospital surgical department three surgical auditing software programs were assessed. Methods : The Otago University Surgical Auditing Program, the Australian Surgical Auditing Program, and RACS-Audit were trialled for a period of 1 month each. The software programs were evaluated to find the time requirements for data entry, the level of surgical knowledge needed for effective audit information entry, and the perceived usefulness of the generated reports. Results : It was found that the Otago University program best suited the needs of the department. This system was designed for use in a hospital environment with multiple users. The method of data collection was simple and rapid. Entry of data into the program was logical, well structured and able to be performed by both junior medical staff and clerical staff. Reports generated by this system included information in an appropriate format for the departments' morbidity and mortality meetings. Conclusion : Personal computers are an ideal tool for the undertaking of surgical audit. Software programs are designed for different uses and should be critically assessed to ensure that the method of data entry, the time involved, and the reports generated enable an efficient and effective audit to be carried out.     

Empirical aspects of linking intensive care registry data to hospital discharge data without the use of direct patient identifiers

In the field of intensive care, clinical data registries are commonly used to support clinical audit and develop evidence-based practice. However, they are often restricted to the intensive care unit episode only, limiting their ability to follow long-term patient outcomes and identify patient readmissions. Data linkage can be used to supplement existing data, but a lack of unique patient identifiers may compromise the accuracy of the linkage process. The aim of this study was to assess the quality of linking the Australia/New Zealand critical care registry to a state financial claims database using a method without direct patient identifiers and to identify possible sources of bias from this method. We used a linkage method relying on indirect patient identifiers and compared the accuracy of this method to one that also included the patient medical record number and date of birth. The overall linkage rate using the method with indirect identifiers was 92.3% compared to 94.5% using the method with direct identifiers. Factors most strongly associated with not being a correct link in the first method included patients at one study hospital, admissions in 2002 and 2003 and having a hospital length of stay of 20 days or more. Linking the Australia/New Zealand critical care without direct patient identifiers is a valid linkage method that will enable the measurement of long-term patient survival and readmissions. While some sources of bias have been identified, this method provides sufficient quality linkage that will support broad analyses designed to signal future in-depth research.     

A survey of Australasian obstetric anaesthesia audit.

In order to develop a minimal obstetric anaesthesia dataset based on current Australasian clinical audit best practice, we carried out a postal survey of 69 Australasian anaesthetic departments covering an obstetric service. We asked about data being collected, specifically concerning the high risk obstetric patient, epidural analgesia and postoperative anaesthetic review. Examples of any data collection forms were requested. Of the 66 responses, 35 departments (53%) were not collecting any audit data. Twenty-six of the 31 departments (84%) performing obstetric anaesthesia audit responded to our follow-up telephone survey. Eighteen departments believed that there had been an improvement in patient care as a result of their audit and 13 felt that the benefits outweighed the costs involved. However, only six departments (9%) had performed an audit cycle. The importance of feedback to patients or hospital staff and the incidence of post dural puncture headache (PDPH) were cited by some as priorities for obstetric anaesthesia audit. There was however no consistency as to what data should be collected. Many responses suggested a perceived need to collect clinical data without knowing what to do with it. Our survey has highlighted confusion between three distinct objectives; a dataset for obstetric anaesthesia record keeping, data required for continuing patient management in hospital and, a specific minimal dataset for clinical audit purposes. We conclude that current Australasian obstetric anaesthesia audit strategies are inadequate to develop a minimal dataset for cost-effective clinical audit.     

Developing a system for surgical audit

A system for surgical audit, which has been developed during a 6 year period in an active surgical unit of a teaching hospital, is described. Following a review of the first 3 years of our computerized audit, major modifications to the audit processes and computer program were made. The key lessons for systematic practical surgical audit include the collection of essential data only, establishing audit processes within current department practices, verification of data by consultants, and the provision of incentives for all users. The current system is proving a valuable resource for quality assurance, surgical training and departmental management.     

Assessment and perceptions of intensive care data quality, reporting and use: a survey of ICU directors

It is becoming increasingly common for government bodies, healthcare providers, funders and consumers to seek measures of the quality of critical care. It is important to ensure the quality of intensive care unit (ICU) data is high so these stakeholders can confidently use quality of care measures in decision-making. This paper aims to evaluate the quality of data collected for and submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, and to investigate the perceptions of NSW ICU directors in relation to ICU data quality, reporting and usage. A survey tool was developed based on an existing framework that consisted of procedures for assessing data quality in medical registries. The survey was distributed to the directors of all NSW ICUs that submitted data in the 2007/2008 financial year. Overall, completeness of the data and its quality was perceived to be good. Participants were less likely to engage in activities involving the detection and correction of data errors, feedback of data or use of data for local purposes. A number of barriers and enablers to good quality ICU data as well as strategies to improve data quality were identified. Inadequate staff, training and resources for data collection were widespread concerns. NSW ICU directors believe more work is required to achieve high quality data and appropriate use of the data collected. Strategies targeting increased resources including updated technology and improved staffing and training, as well as low-cost solutions such as audit, feedback and clinician engagement, have been highlighted.     

Requirements for trainee logbooks

All trainees are required to keep a logbook as a record of the procedures they have carried out during their surgical training. However, the current logbook is only a record of work carried out and not of the outcome of the operations. It does not prepare the trainee for either a lifetime practice of surgical audit or for a lifetime of learning from the audit process. The logbook requirements of different training boards vary and consequently, trainees find the keeping of a logbook an inconsistent process with ill-defined learning objectives. The Royal Australasian College of Surgeons should define what needs to be collected, how data should be verified and how experience and learning should be reported, and should approve electronic databases that meet logbook standards. The choice of database software and format can then be left to the trainee. Although there are good examples of electronic logbooks being developed, there is, at present, no perfect logbook available. We recommend that all trainees, from the commencement of basic surgical training, should keep a logbook that contains the minimum and expanded datasets in addition to specific trainee data on supervision and learning. In addition to the current reporting format focused on procedural casemix and supervision level, quality/outcome reports and a record of learning are recommended.     

Centralization of Esophageal Cancer Surgery: Does It Improve Clinical Outcome?

Background  The volume–outcome relationship for complex surgical procedures has been extensively studied. Most studies are based on administrative data and use in-hospital mortality as the sole outcome measure. It is still unknown if concentration of these procedures leads to improvement of clinical outcome. The aim of our study was to audit the process and effect of centralizing oesophageal resections for cancer by using detailed clinical data. Methods  From January 1990 until December 2004, 555 esophagectomies for cancer were performed in 11 hospitals in the region of the Comprehensive Cancer Center West (CCCW); 342 patients were operated on before and 213 patients after the introduction of a centralization project. In this project patients were referred to the hospitals which showed superior outcomes in a regional audit. In this audit patient, tumor, and operative details as well as clinical outcome were compared between hospitals. The outcome of both cohorts, patients operated on before and after the start of the project, were evaluated. Results  Despite the more severe comorbidity of the patient group, outcome improved after centralizing esophageal resections. Along with a reduction in postoperative morbidity and length of stay, mortality fell from 12% to 4% and survival improved significantly (P = 0.001). The hospitals with the highest procedural volume showed the biggest improvement in outcome. Conclusion  Volume is an important determinant of quality of care in esophageal cancer surgery. Referral of patients with esophageal cancer to surgical units with adequate experience and superior outcomes (outcome-based referral) improves quality of care.     

Audit of day case maxillofacial surgery: a pilot assessment

The aim of this study was to design and evaluate an audit structure for day case maxillofacial surgery, which may be applied to other surgical specialities. Retrospective and prospective data collection over a 3-month period revealed that the clinical standards set in advance of the audit procedure were achieved in five of the 11 criteria. In only two instances were the standards not met, only 46% of patients were seen within 3 months of the referral, against the 95% desired standard, and only 50% had surgery within 3 months of being seen, against the 95% standard. Future audit should be prospective but action should be taken as necessary to address the significant failure in achieving the set standards, thus completing the audit cycle.     

Coding for surgical audit

A simple system of codes for operations, diagnoses and complications, developed specifically for computerized surgical audit, is described. This arose following a review of our established surgical audit in which problems in the retrieval of data from the database were identified. Evaluation of current methods of classification of surgical data highlighted the need for a dedicated coding system that was suitable for classifying surgical audit data, enabling rapid retrieval from large databases. After 2 years of use, the coding system has been found to fulfil the criteria of being sufficiently flexible and specific for computerized surgical audit, yet simple enough for medical staff to use.     

CODING FOR SURGICAL AUDIT

A simple system of codes for operations, diagnoses and complications, developed specifically for computerized surgical audit, is described. This arose following a review of our established surgical audit in which problems in the retrieval of data from the database were identified. Evaluation of current methods of classification of surgical data highlighted the need for a dedicated coding system that was suitable for classifying surgical audit data, enabling rapid retrieval from large databases. After 2 years of use, the coding system has been found to fulfil the criteria of being sufficiently flexible and specific for computerized surgical audit, yet simple enough for medical staff to use.     

Evaluating hospital quality for vascular surgery

Increasingly, there is a wealth of data available to aid patients in determining where to seek care for quality vascular disease. At times, these data may be difficult for the public to comprehend. Hospital rating organizations, frequently motivated by profit, are marketing directly to consumers with increasingly granular data. In this report, we examine the most popular ratings for hospitals that perform vascular surgical procedures and describe the methodology of each rating system, as well as the validity of the data underscoring these ratings. Understanding how hospital quality is being evaluated and what outcomes measures are being collated allows vascular surgeons to take appropriate actions to ensure the validity of their own hospital ratings.     

Clinical databases in nephrology: research and clinical practice goals and challenges

In clinical practice we formulate direct questions related to patient management that should be answered on the basis of results of valid studies. Bias problems are dealt with using different approaches in observational studies and in clinical trials. The clinical trial is the standard for assessing the efficacy of treatments while the efficiency of treatments at community level is better captured by observational studies. Electronic medical records have now emerged as a precious, matchless data source for clinical audits. The value of an audit cannot be taken for granted and should be tested in the specific health care setting where it is applied. Electronic medical records and high quality clinical databases offer a great opportunity for performing observational studies and for reducing the cost of clinical trials. Research on audit and feedback functionality is a new, useful and stimulating research area which may be of great interest to nephrologists.