Completing the audit cycle: the outcomes of audits in mental health services.

AIMS: To assess how far those UK National Health Service mental health settings that tested, and prior to publication, used the Newcastle Clinical Audit Toolkit for Mental Health (NCAT) completed the audit cycle. DATA SOURCES: Twelve clinical audit project reports, each focused on one of the five modules in the NCAT, from four rounds of activity over a 2-year period; clinical and managerial staff in the settings where audit projects had taken place. DATA EXTRACTION: Interviews with audit project team members about the recommendations of the 12 audit project reports and about contextual issues; all projects had reported at least 2 years previously. RESULTS OF DATA SYNTHESIS: In analysing the audit project outcomes, five categories of inaction were discernible and five further categories were needed to describe varying states of progress. It was necessary to discriminate between actions attributed to the NCAT audit projects and actions attributed mainly to other initiatives. In total, 26.4% of audit recommendations were still under discussion or in progress. A relatively low proportion of recommendations from audit report findings (34.7%) had been implemented, and these were divided almost equally between recommendations attributed to the NCAT projects (38) and those attributed to other initiatives in the organization (37). CONCLUSION: Investigation of the medium-term outcomes of clinical audit projects has provided an insight into what might usefully be termed the process of completing the audit cycle. The time-scales required to reach the point at which action is deemed to have been implemented or not may be as long as 3 years. Conceptualizing the action stage of the cycle as a single discrete event fails to do justice to the complexity of the process, and attributing the implementation of change in clinical settings to single causes such as individual audit projects is problematic.     

Developing audit standards required for outbreaks of communicable diseases-lessons from a mumps outbreak

BACKGROUND: A mumps outbreak occurred in 2004-05 in England and Wales. The outbreak in the Avon area of England led to mass vaccination of 16- to 24-year-olds with the measles, mumps and rubella vaccine (MMR). The response to the outbreak was audited. Literature and web searches for audit standards were undertaken, and experts in the field were contacted. No comprehensive audit standards for outbreaks of communicable diseases were found. This article describes an approach to developing audit standards for outbreaks of communicable diseases. METHODS: Audit standards were developed based on the memorandum of understanding between the National Health Service (NHS) and Health Protection Agency.The audit was undertaken involving 25 staff. RESULTS: The audit standards developed identified many areas for improvement including training, strategic co-ordination, inter-organizational communication, consistency and timeliness of communication. Conducting the audit was problematic because there were not pre-defined audit standards. CONCLUSIONS: Audit standards should be developed, which include issues relating to the structure, process and outcome of responses to outbreaks. The development of audit standards for the management of outbreaks is crucial to evaluate outbreak control and make necessary improvements.     

Approaches to the organization of multi-practice audits in primary health care in the UK.

OBJECTIVE: To investigate the approaches taken by audit groups in primary care in organizing multi-practice audits and to identify the strengths and weaknesses of the methods used. DESIGN: Postal questionnaire survey. SETTING: One hundred and six primary care audit groups in England and Wales. RESULTS: Ninety multi-practice audits had been conducted since 1993, 46 of which were audits of diabetes and 44 of asthma care. A total of 48 completed questionnaires (24 each for asthma and diabetes) were returned (response rate 53%). Audit groups reported inviting 3338 practices to take part, of which 1157 completed the audit. The commonest methods used to encourage practice participation were a personal letter (75%), audit group newsletter (63%) and sending an audit protocol to the practice (63%). Groups used various methods for selecting audit review criteria, however only three (6%) used a systematic review of available literature. Each audit group advocated a number of methods for identifying patients and for data extraction. Forty-one (85.6%) groups reported that practices received feedback of results in an individualized practice feedback report. In 19 (39.6%) audits, the audit group had not undertaken any follow-up. CONCLUSIONS: The findings indicate that multi-practice audit can encourage the participation of large numbers of practices. Audit groups are co-ordinating multi-practice audits and feeding back information to practices on a comparative basis. However, there are weaknesses in the design and conduct of some audits. Groups should pay more attention to the selection of audit criteria, methods of identifying and sampling patients, data collection procedures, and methods for implementing changes in performance. For other countries that are beginning quality improvement activities, the results of this study emphasize the need to give attention to basic methodological principles.     

Getting evidence into practice: what works in developing countries?

PURPOSE: We summarize and comment on the available literature on the effectiveness of interventions designed to change professional behaviour in order to bring evidence into practice in developing countries. DATA SOURCES: We used a strategy adapted from the Effective Practice & Organization Care (EPOC) Cochrane group. STUDY SELECTION: Forty-four studies met pre-defined selection criteria. Controlled and uncontrolled trials of interventions were included. Studies measured either professional compliance with agreed standards or patients' clinical outcomes. Data extraction. Data were extracted using a pre-defined extraction tool and studies were appraised accordingly. RESULTS OF DATA SYNTHESIS: Data were synthesized and categorized according to different types of intervention. Audit and feedback was found to be effective, at least in the short term, when combined with other approaches. Similarly, educational interventions were more effective when designed to address local educational needs and organizational barriers. We found insufficient evidence to assess the effectiveness of educational outreach, local opinion leaders, use of mass media, and reminders. Educational materials alone are unlikely to influence change. However, the majority of studies had weak designs and failed to exclude possible biases. CONCLUSION: Current evidence for the effectiveness of interventions to change health professionals' behaviour in developing countries is either scanty or flawed due to poorly designed research. Given the recent drive to improve quality of care, this should be a priority area for researchers and international agencies supporting health systems development in developing countries. This review provides an insight into some of the methodological issues that interested researchers may face.     

Nutrition audit at a community hospital

Background: The Department of Health (DoH) guidelines on hospital catering recognize the benefits of good nutrition in the reduction of medical complications and length of stay. Audit checklists are available to monitor implementation of these guidelines. Aims: To describe current feeding practice in a community hospital; evaluate qualitative aspects of patients’ mealtimes and to audit the food provided in relation to DoH guidelines and reference nutrient intakes. Methods: Qualitative data were collected at mealtimes by observation and recorded on a standard proforma. Nursing staff completed short questionnaires concerning food availability and support for patient feeding. Menus were compared with DoH guidelines using a standard checklist. Food intake data were collected over a 48-h period for a group of patients (n=8) and comparison made with Reference Nutrient Intakes. Results: Qualitative aspects of mealtimes were satisfactory, mealtimes were relaxed and pleasant. Using the DoH checklist, menus met national guidelines for vitamin C, fibre, iron and folate. However, analysis of dietary intakes showed low intakes of iron, fibre, vitamin D and folate. Conclusion: Some aspects of food provision require attention and this would be facilitated by the setting up of a hospital food committee to set goals and monitor progress.     

浅谈医院内部审计如何适应新财务会计制度

探讨医院内部审计工作。主动学习了解新的财务会计制度修订背景、目的、意义、关键更新;掌握新财务会计制度的新变化,主动调整内部审计工作思路和工作重点;借鉴《医院财务报表审计指引》,规范内部审计操作,为接受会计师事务所审计提供审前服务和风险预警。     

The value of audit and feedback reports in improving nutrition therapy in the intensive care unit: a multicenter observational study

Background: The objective of this study was to determine whether auditing practice and providing feedback in the form of benchmarked site reports is an effective strategy to improve adherence to nutrition guidelines. Methods: The authors conducted a multicenter observational study in Canadian intensive care units (ICUs). In January 2007, an audit of daily nutrition information was collected (type and amount of nutrition received and strategies to improve nutrition delivery). Each ICU was e‐mailed individualized benchmarked performance reports documenting their performance compared with the Canadian Critical Care Nutrition guidelines and in relation to the other ICUs. Nutrition practice was reaudited in May 2008 to evaluate changes in practice. Results: Twenty‐six ICUs in Canada participated, with 473 and 486 patients accrued in 2007 and 2008, respectively. The authors observed a significant increase in enteral nutrition (EN) adequacy (from 45.1% to 51.9% for calories, and from 44.8% to 51.5% for protein) and an increase in the percentage of patients receiving EN without parenteral nutrition (from 71.9% to 81.3%). They also observed trends toward improvements in the percentage of patients who had EN started within 48 hours (from 60.3% to 66.8%). There were no significant differences in the use of motility agents or small bowel feeding in patients who had high gastric residual volumes. Conclusion: Audit and feedback reports are associated with improvement in some nutrition practices in many ICUs; however, the magnitude of these effects is quite modest. More research is needed to determine the optimal methods of using audit and feedback to improve quality of nutrition care.     

MAAGs (Medical Audit Advisory Groups): the Eli Lilly National Clinical Audit Centre

Outlines the framework for promoting audit in general practice, created as one part of the health service reforms. Medical Audit Advisory Groups (MAAGs) were set up in each district with the aim of participation in audit of all general practitioners by April 1992. The activities undertaken have included those recommended by the Department of Health; the most significant of these being the appointment of lay facilitators who are able to assist general practitioners and primary care teams co-operate over efforts to improve the quality of care, and may offer one means of introducing some of the methods of total quality management into general practice. Discusses the problems which remain: audit is not yet sufficiently systematic, interface audit with secondary care is at a very early stage, the ways to involve managers and patients in audit remain to be clarified, and there is little evidence of the consequences of audit in terms of improved care. The Eli Lilly National Clinical Audit Centre has been set up within the Department of General Practice, University of Leicester, in order to address these issues.     

Resourcing innovative teaching of audit--models, methods and MAAGs

Audit is an important part of clinical practice, and has been promoted as a core aspect of undergraduate and postgraduate medical education. Few examples of how audit is taught in the undergraduate curriculum exist. This article presents a model for student teaching using innovative methods, which include an extended role for teaching and learning support from Medical Audit Advisory Group staff. This may be a unique arrangement in the UK. We recommend this approach as using skilled resources effectively and encouraging a positive learning experience for students, which should contribute to their motivation and ability to carry out audit at postgraduate level.     

Auditing the nursing care methodology

This study it describes the development of a process of audit of the Method of Assistance of Nursing in a unit of internment of a University Hospital. Identified the standards, the instrument was elaborated, under the form of indicators, in which had been examined, random, five handbooks with examination of the user "in loco". The data had been to add and classified in a quanti-qualification of the assistance of Nursing. The found results indicate the necessity of revision of the Standards of the Method of Assistance of Nursing and of the immediate retaking of the program of auditor of the assistance of Nursing.     

The Department of Health (England) Action Plan for Improving Services for People with Epilepsy

Issues related to avoidable mortality in people with epilepsy have been highlighted in the National Sentinel Clinical Audit of Epilepsy-Related Death in the UK. This audit concluded that 39% of adult epilepsy-related deaths and 59% of epilepsy-related deaths in children were potentially or probably avoidable. Particular attention was drawn to the important and poorly understood condition of sudden unexplained death in epilepsy. This audit prompted a report by the Chief Medical Officer, which was followed by a document prepared by the Department of Health (England) entitled Improving Services for People with Epilepsy: Department of Health Action Plan in Response to the National Clinical Audit of Epilepsy-Related Deaths. The action plan comprises the following sections: (i) Introduction; (ii) Pathology and Post Mortem Investigations; (iii) Improving Care Management and Treatment of Epilepsy; and (iv) Information Provision. The fact that the Department of Health in England has drawn attention to these important matters is in itself worthwhile. However, the action plan does not give a firm commitment to taking the necessary steps required to rectify the shortcomings in the current services.     

Service evaluation and development: experience of a paediatric disability team

Classical audit frameworks encourage the use of audit cycles, with performance being evaluated against predefined quality targets and modified accordingly. This approach has obvious validity in clinical settings where treatments have very clear endpoints and outcome measures can be prioritized with ease. The situation becomes more complex in disability service settings, where the impact of clinical intervention is often qualitative rather than quantitative, and where management strategies are dependent on working in partnership with families, purchasers and other professional colleagues. There is thus a danger of neglecting aspects of service delivery which are of major importance to one sector of this extensive network. To ensure that service goals and standards comprehensively reflect the specific concerns of all parties, it is proposed that measures of service quality should be defined within the context of a dynamic multi-user framework. Development of such a framework is dependent on collating information on specific needs from parents, referrers, purchasers and other involved professionals, and determining areas of overlap, as well as areas of potential conflict. Audit techniques for key issues can then be devised, alongside a timetable to revisit these issues at appropriate intervals. Application of this approach is illustrated by reference to our own paediatric disability service.     

Is audit research? The relationships between clinical audit and social-research

PURPOSE: Quality has an established history in health care. Audit, as a means of quality assessment, is well understood and the existing literature has identified links between audit and research processes. This paper reviews the relationships between audit and research processes, highlighting how audit can be improved through the principles and practice of social research. DESIGN/METHODOLOGY/APPROACH: The review begins by defining the audit process. It goes on to explore salient relationships between clinical audit and research, grouped into the following broad themes: ethical considerations, highlighting responsibilities towards others and the need for ethical review for audit; asking questions and using appropriate methods, emphasising transparency in audit methods; conceptual issues, including identifying problematic concepts, such as "satisfaction", and the importance of reflexivity within audit; emphasising research in context, highlighting the benefits of vignettes and action research; complementary methods, demonstrating improvements for the quality of findings; and training and multidisciplinary working, suggesting the need for closer relationships between researchers and clinical practitioners. FINDINGS: Audit processes cannot be considered research. Both audit and research processes serve distinct purposes. ORIGINALITY/VALUE: Attention to the principles of research when conducting audit are necessary to improve the quality of audit and, in turn, the quality of health care.     

浅谈医学院校领导干部经济责任审计工作

目的：促进医学院校领导干部理解和落实国家关于“党政领导干部和国有企业领导人员经济责任审计规定”。方法：学习“领导干部经济责任审计规定”的纲领性文件,提出在实施“规定”过程中的建议。结果：通过学习“规定”,提高了院校领导干部对于经济责任审计法规制度建设重要意义的认识。结论：领导干部经济责任审计的任务重、覆盖面宽,审计内容会向更深更广的方面延伸,力度会更大,应有效地发挥医学院校领导干部在经济责任审计工作中的作用。     

Home health audit tool--at last!

Dissatisfied with the use of an audit tool not applicable to home health nursing, administrators of the Missoula Home Health Agency formed a special audit committee to review audits used by agencies around the country. After examining 50 audit tools, the committee agreed that the Phaneuf public health nursing audit did not adequately emphasize nursing care and charting specific to home health agencies but did fit most of their criteria. After redesigning the Phaneuf audit and testing it through two quarterly audits, the new Missoula Home Health Audit tool has been found very satisfactory. The Missoula Audit emphasizes: 1. home health's goal of independent living and/or self-care; 2. service provider-family-patient relationship; 3. nurse-physician relationship; 4. charting and recording; 5. coordination of careproviders. Unlike many existing audit tools, the Missoula Audit is specific to home health nursing, covers the spectrum of home health services, has sensitive scoring which reflects true differences in quality of care, and initially, at least, appears to be consistent from audit to audit.     

Report of a nutritional screening audit

Background: Malnutrition in hospitals has been widely documented and nutritional screening forms part of the National Professional Standards for Dietitians. As a result of this concern, a nutrition screening tool has been incorporated into the nursing care plan documentation. Aims: To audit the use of the screening tool in nursing care plans for elderly patients and examine the communication methods concerning the need for individual nutritional care. Methods: A standard chart was used to audit patient notes. In addition, a short informal interview was conducted with nursing staff. Results: Use of the screening tool was variable and fewer than half of those identified by this tool as in need of nutritional care were referred to the dietitian. Conclusion: Ward staff are prioritizing patients referred for dietetic care, even when they have been identified by the screening tool, but this is not always done systematically. Improvements could be made in the relevant documentation. Further training of ward staff and a follow-up audit should be undertaken.     

国家、社会与内部三种审计合力探索及在卫生健康系统中的应用

在阐明了国家审计、社会审计和内部审计形成合力是党和国家战略决策的基础上,进一步明确国家审计、社会审计和内部审计的职能定位,探索三种审计的各自优势与局限以及形成合力的可行性、必要性,再通过国家卫生健康系统的相关实践,最终提出构建国家审计、社会审计和内部审计合力机制的建议。     

Book Reviews

Book reviewed in this article: The Milwaukee Evaluation of Daily Living Skills: Evaluation in Long-Term Psychiatric Care Carol A. Leonardelli Activity Analysis Handbook Nancy K. Lamport, Margaret S. Coffey & Gayle I. Hersch Patient Practitioner Interaction: An Experiemental Manual for Developing the Art of Health Care Carol M. Davis Depressive Illness: Prediction of Course and Outcome T. Helgason & R. J. Daly Right in the Middle: Selective Trunk Activity in the Treatment of Adult Hemiplegia Patricia M. Davies Occupational Therapy with Children Helen Clancy, Michele J. Clark Guidelines for the Nursing Management of Patients Who Are Intoxicated or Withdrawing From Alcohol New South Wales Department of Health, Directorate of the Drug Offensive     

管理审计在医院管理中的应用与思考

管理审计已发展成为审计领域不容忽视的一个重要分支。在我国许多医院内部审计普遍开展的仍是＂查错防弊＂的财务审计,很少开展管理审计,这对我国医院的改革与发展极为不利,严重降低了监督的效率和效果。通过对泰安市中心医院基本情况的分析,阐述了医院内部审计工作中存在的问题和不足,并应用医院内部管理审计体系设计的基本原则,构建了医院管理审计的框架。