Births – a basic comparison

Deliveries by type at ADK and IGMH

Births are a common occurrence at the hospital. In fact in the Maldives, the most births occur either at IGMH or at ADK Hospitals. During the first six months of this year, a total of 2119 births, of which 855 (40%) occurred at ADK Hospital and 1264 (60%) occurred at IGMH.

When we look at the modes of delivery the combined rate of normal deliveries for both hospitals stand at 52%. The rate of normal deliveries at ADK is 46% while the figure for IGMH if 55%. When assisted deliveries are taken the rate stands at 0.7% with the ADK Hospital’s figure at 0.2% and at IGMH 0.9%.

In the case of vacuum deliveries, the combined rate for both hospitals stand at around 4%. However, a further breakdown shows that this figure is higher with 9% of all deliveries requiring vacuum at ADH Hospital while only 1% required the same at IGMH.

Cesarean sections can be said to be on the increase in the country as a whole. The combined cesarean rate for both hospitals is 43% for the referred period. Also the comparison between the two hospitals also does not differ with 44% and 43% at ADK Hospital and IGMH respectively. Over a year back, the cesarean rate for ADK Hospital was around 35% and although we do not have proper figures, anecdotal evidence suggests that it was the same case at IGMH as well.

This comparison was done as part of an analysis of services provided in the Maldives for the purposes of the ADK Hospital’s development project currently being undertaken. It is unfortunate that these types of analysis are not done more often. This little analysis already gives some light to the situation of deliveries and the modes of if for the two major hospitals. It gives a learning opportunity for both hospitals, to see where each other is doing better or worse and to look positively and identifying and improving any shortcomings.

The available data allows more indebt analysis that can be used as further evidence for quality improvement. The Hospital intends to conduct similar analysis for different specialties in future. Unless evidence and information use increases in healthcare, quality cannot be improved. There are indications in this very basic analysis, where ADK Hospital can attempt to further improve and also to identify areas for patient education as well.

However, it is not enough for hospitals alone to do patient education on matters such as this. There needs to be national guidelines and recommended rates of Caesarean sections for the country. As I understand, the WHO standard for Caesarean sections is 10%. This is a figure way below the Maldives average. In fact this is a rate that no country in the world probably would achieve at this day and age. Perhaps, WHO should look at revising this rate and also this matter is now on the books of that organisation.

For the Maldives, we need to gather experts and brainstorm on the reason for this higher rate of Caesarean sections. In some countries, it is said that Caesareans are comparatively higher in private sector where doctors are incentivised to conduct surgeries and hence produces a supply induced demand whereas in the public sector salary based employment, there is no incentive to do surgeries. However, in the Maldives, there is no difference among the sectors as can be seen from the data.

More needs to be done of patient education and encouraging families to opt for normal deliveries. Obviously the natural process of birth will have many advantages compared to a more risky surgery. Also, in case women opt to take up Caesareans due to pain, in the modern world normal deliveries can be pain free with local anaesthesia or epidurals. Also new concepts such as water births could also be tried out.

The time factor: my doctor is in a hurry!

Many a time when we go and see a doctor, there is a feeling that the doctor is in a hurry or rushed, distracted or doesn’t really care about the patient. Health systems are increasingly facing the issue of inadequate time being given to patients by doctors. It is a global phenomenon. Proper interactions between the patient and the doctor are an integral part of medical care. Research shows that outcomes of medical care are more successful when a trust is gained between the patient and doctor through spending adequate time and understanding the life and health of the patient.

Ironically, at present many of the doctors do not give adequate amount of time to the patients. In our efforts to improve patient care, we developed and implemented a Code of Professional Conduct for clinicians at ADK Hospital. In the Maldives, this is the first such initiative taken by a healthcare provider. One of the key factors of the Code is to spend enough time with the patients. Subsequent protocols of the hospital also reiterate this matter since if the Code and the Protocols are to be adhered, a significant change in the time spent with patient should happen. A change in a culture is always a challenge.

We conducted an audit at doctors’ OPD’s to determine the amount of time doctors spend with patients. Given that the doctors have to take a patient history, examine the patient, write the records and produce a prescription, obviously time is needed to ensure all these are done. In most cases the average time spent per patient is 5 minutes or less for the departments that the audit was conducted. This is a very little amount of time spent on patient care. Efforts need to be put into to ensure that this is changed. Continuous monitoring and making doctors to understand the importance of the time factor is crucial. In fact, it is the doctors who gain from a little change in their current habits.

There are many reasons why this change needs to occur. It should occur across the whole health system in the Maldives as well. For example, the time factor contributes to

Patient satisfaction. Patient’s who visit doctors who spend more time and involve patient in care are seen to be more satisfied with the care that they got and are less likely to leave that practice of that doctor.

Outcome of diseases. Although no concrete evidence is shown in research, there are some research findings that indicate that longer consultations have lead to more understanding of the disease by the patient and hence lead to better outcomes.

Rational prescribing. Studies have shown that shorter consultations have longer prescriptions. Doctors who spend more time with patients are shown to prescribe medication and investigations more rationally than those who spend less time.

Doctor satisfaction. There is ample research that shows longer visit lengths foster better patient interactions that lead to better satisfaction for doctors. In fact, studies show that good patient relationships increase doctor’s confidence and satisfaction and hence lead to better quality of care as well.

Lower risk of malpractice/negligence claims. It is also seen that doctors who tend to have better patient relationships, given the above factors as well, have found to be less likely to face malpractice and or negligence charges.

So what is the ideal amount of time a doctor should spend with the patient on a visit? There is no concrete evidence as to what it the optimal time for a doctor’s visit. What is seen is that longer visits allow time for more attention to many aspects of care. Patient participation and education increases thus leading to better outcomes.

For us, understanding this aspect of care and adhering to existing protocols and standards addressing the issue will be a start towards an improved quality of care.

Alignments with new OPD protocols

Continuous efforts to orient our services and care to a patient centred one, in April 2012, we have developed and implemented a new set of protocols to ensure better OPD services provided at ADK Hospital. The purpose of the protocol is to ensure that patients who seek out patient consultations at ADK Hospital get an adequate and quality care during their visit to the Hospital.

It is envisaged that by implementing this protocol, the hospital can establish a consistent and cohesive process the will help the OPD’s to perform smoothly. In the meantime, the protocol will also help doctors to spend a reasonable time with the patient to ensure better and quality care to the patient.

The main areas that the protocol address are

Consultations: The aim of this area is to ensure proper and adequate assessment of the patient and understanding the patients’ problem fully before so that a proper and sound treatment regime can be prescribed to the patient.

Medications and investigations: This area aims to ensure rational use of medications and investigations as well as other diagnostics.

Patient privacy: aims to ensure that patients are confortable and confident that their privacy and confidentiality will be maintained when they consult a doctor.

Recording: aims to ensure that proper medical information is collected and kept in order to provide adequate information for the continuity of patient care in future.

Apart from the above core areas, other areas such as patient load benchmarks, break timings and attending to emergencies as well as issuing of certificates and documentations are covered in the protocol. It is important that these protocols are adhered to at all times and hence a mechanism to monitor the implementation is also implemented simultaneously. These protocols will only help to improve the way we do things and move towards a better position in what we do. Any change will have adjustments that are required to make it even better. There will be close monitoring of the implementation including orientation of staff towards these protocols.

It is always important that health care institutions continue to produce new standards and benchmark their services. The current OPD protocols have been developed based on past evidence. Research in to OPD records, patient contact times and loads have been studies extensively before these protocols are laid out. We will continue to develop and improve our services by introducing many more protocols and standards based on international practices and research into what we do. Monitoring of these protocols and facilitating the adherence to them through training and empowerment of staff is imperative to the successful implementation of such initiatives.



Clinical Incident Management

In the healthcare setting more and more people are treated safely and successfully everyday and there is no exception here in the Maldives.  However, despite the dedication and hard work of the teams of healthcare professionals, in the complex health system things can and do go wrong placing patients at risk or harm. According to international studies, about 10% of patients will suffer an incident during their episode of care at a healthcare setting. In the Maldives, there are no such statistics available to understand the extent of the matter. It is though evident that there are such incidences in the entire healthcare setting here in Maldives as well.

One question that comes to mind is that why don’t we have such statistics? And the answer is very simple. We simply don’t have the mechanisms and the facilitations to identify and manage such incidences. There are many reasons for this. The first and the obvious reason is that, in Maldives any incidence puts the healthcare professional into situation of blame and accusation from the public. The culture is that the health professional intentionally does harm to the patient, which, of course is not the case.

Secondly, there is no protection to the health professionals and health providers through regulation and or Laws. Hence, the motivation for development and implementation of incident management systems are bleak due to the fear of litigation. Especially, the experience in Maldives is that healthcare mishaps are tried as criminal cases, whereas in the established systems, healthcare mishaps are tried as civil cases unless a criminal intent is established.

Established statistics in the world indicate that patient safety incidents are almost always unintentional. The key to establishing an incident management system in the healthcare setting is to identify and manage such incidences and minimizing all risks to the patient. It is imperative for the creation of a learning culture where the professionals and the institute learn form incidents and near misses. It is used to review practice, train staff and improve their competency, assess equipment and communication gaps and make continuous improvements to the system of healthcare delivery.

There is a need for the Maldives to establish a proper legal and regulatory framework to facilitate risk management strategies such as incident management in healthcare settings. This will be a key factor to improve the quality of services and care provided in the country. There is a need to shift the mindset of the regulatory bodies and the public, as well as those within the health system to do away with the blame culture and move towards a learning culture.

Given the above reasons, we are having a challenge to implement an incident management system and standard here at ADK Hospital. There is apprehension and reluctance among clinical staff to champion a change in the paradigm in which we have been working. Establishing such a system and testing it out can only overcome this challenge. We have to start to gain our confidence by doing it and facing it.

Hence, the ADK Hospital’s clinical incidence management system is now ready for implementation. In the recent past we have used the aspects of this tool to assess some incidents and so far has proven to be satisfactory. With the implementation of this mechanism, we hope to see positive improvement in quality as well as care processes.

The main purpose of implementing this mechanism is to minimize patient harm through identifying and treat hazard before they lead to patient harm, identify when patients are harmed and promptly intervene to minimize the harm caused to a patient as a result of the incident and to ensure that lessons are learned from the clinical incidents and applied through taking corrective actions.

Code of Professional Conduct

Patients are entitled to good doctors. Good doctors make the care of patients their first concern; they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy and act with integrity.

According to the American Medical Association (AMA) the medical profession has subscribed to a body of ethical standards primarily for the benefit of the patients. As a member of the profession, any clinician should recognize responsibility first and foremost to the patients, and then to the society, other health professionals and to self. Along this ethical guidance, in many countries, codes of professional conduct are developed to ensure that beneficial practices are carried out across all practitioners.

The Code describes what is expected of all doctors. It sets out the principles that characterize good medical practice and the standards of ethical and professional conduct are made more explicit. In countries where there is high compliance to these standards, well-established legal and regulatory mechanisms in healthcare are also in place.

Irrespective of the existence of such a code or legal framework, clinicians already, historically, take an oath, the Hippocratic oath to do no harm. This of course could be the basis of the modern developments.

I will prescribe regimes for the good of my patients according to my ability and my judgement and never do harm to anyone. (part of the Hippocratic oath, 12th century)

So the patient is at the forefront even then. And today, the new versions of the oath and standards and guidelines all revolve around the patient.

Coming to a state where there is minimal medical regulations and literally no laws to govern the profession and its practice, in the Maldives, the need for these developments are immense. Indeed, professionals,

institutions and individuals can take initiatives to change the existing culture. It is very easy to declare that nothing is there, but to put an effort to develop proper Codes is what is needed. Of course, the legal process of a healthcare act is on the bench, but when these legal frameworks are made, the sensitivities and specificities of the community in which it will be practiced will also have to be looked into. Such regulations and legislation should aim to mutually protect both the patient and the provider.

In the Maldives, the change process can happen concurrently. While the Laws are being developed, guidelines and codes can also be developed. The Maldives Medical Council and the healthcare providers together can play an important role to ensure that these practices are made the norm in the country.

Here at ADK Hospital, we believe that we cannot wait hoping that these documents and practices will be developed, but rather, we believe that we can we can set these standards in the country. It is with this aim, the Hospital has developed a Code of Professional Conduct that has been issued and put to practice at the Hospital. The standards in the Code sets out principles in relation to a practitioner’s

  • Clinical competence and performance
  • Professional and ethical obligations
  • Relationships with colleagues and
  • Probity in professional practice

It is now expected that all doctors practicing in the Hospital to follow this code. This will also be used as part of the performance assessment of clinicians in the future.

It is noteworthy that this code was developed based on a set of guidelines adapted from the Australian and New Zealand Codes with the permission from the Australian Medical Council, the New South Wales Medical Board and the Medical Council of New Zealand.

Respect for colleagues …

An organization’s work doesn’t revolve only about what is done in the organization. Having guidelines and protocols on how to do things in an organized manner is no doubt an important part of any organization to optimize its efficiency and output. It seldom though that organizations, especially in these parts of the world including Maldives, that organizations really dwell onto the softer side of its operations. The softer side of the working environment. How we treat each other.

In healthcare this becomes even more important. let alone the respect that you have to show to your patients, respect among the professional team is equally important. The sad truth, though is that our work place cultures have to undergo a radical improvement in this front. Unfair discrimination, bullying and or behavior considered harassment, are in fact very apparent in most of our work places. It makes it worse when managements and the staff find it hard to accept these facts, which again is commonplace in our workplaces.

At ADK Hospital, being a large and growing organization, we believe that such behavior by some staff members towards others, knowingly or unknowingly are evident. And it is in this respect that we believe that we should take proper action to minimize such behavior in the workplace. We believe that there should be proper awareness among staff on such issues, and there should be proper mechanism to register such complaints and address it too.

Getting along with your colleagues are important. Good workplace relationships can help you perform better in your job and make going to work an enjoyable experience. It is no different in the healthcare setting. Given the stress and tension that we work through each day, these relationships help reduce stress and improve our diligence at work. Respect is the foundation of such relationships.

In this regard, the Hospital has published a guideline on Respect for Colleagues. It is of course and achievement for the organization but it can only be celebrated when the staff are are acquainted to this guideline and the actual practice of these become everyday norm. Good patent care is no doubt enhanced when there is mutual respect, fairness and clear communication between all professionals involved in the care of patients. We believe that this guideline will lay the stone to develop and enhance the culture of respect with in the organization. Appropriately, our first core value of the organization states, “PEOPLE – we RESPECT each person as a member of the hospital community.”

Hospital Waste Management

In a hospital, most of the time, everyone is occupied with the services that is being provided and how good they are delivered to the service seeker. Well this would be true for any service for that matter. Often, one important aspect of service delivery that does not get enough attention, but equally important, the processes that go behind the scene, the Back Room.

Clinical waste desegregation bin at ADK Hospital

A number of activities are carried out behind the scenes. Waste management, laundry services, maintenance, power, IT and many more are kept intact by the efforts of many staff throughout the 24 hour operations.

Waste management is a serious activity for any hospital. Apart from just waste, hospitals generate hazardous waste. Hazardous waste are also further categorized and can be desegregated and treated and/or disposed off differently. Hazardous waste includes sharps, anatomical waste, clinical waste, contaminated waste, infectious waste, human tissue, cytotoxic, pharmaceutical waste, laboratory waste, chemical waste and radioactive waste.

In order to ensure that accidental exposure to such hazardous waste, for both staff and patients, hospitals have to ensure a proper process of managing such waste, including collection, handling and disposal. In the Maldives, clinical waste disposal is one aspect of health care that needs immense improvement. Lots of effort is required to ensure that hazardous waste is disposed safely.

At present, none of the health facilities in the Maldives have an exceptionally good waste management system. In many institutes, the collection and desegregation is present but at disposal all the waste get mixed up again. This means that there is no establishment that would collect the disposed waste on a desegregated manner and destroy them properly.

Hazardous waste, shredded and sterilized ready for mainstream disposal

It is thus important that, health facilities take an initiative to ensure that such mechanisms are put in place. Also, regulatory authorities should develop and implement guidelines to the effect.

In its endeavors to set standards in health related matters, ADK Hospital has initiated a new policy of improving its waste management. The main strength of the Hospital is that it has onsite incineration facilities. Though this may not be the best solution, it is a standard which is recognized adequate. Furthermore, in the Hospital waste is collected in a desegregated manner. Clinical waste is collected separately and incinerated on site. Similarly sharps are collected separately in sharp bins and incinerated too. Only general waste is what gets disposed of to the mainstream.

In the modern world, incineration has now been replaced by shredding and sterilizing hazardous waste so that it can easily be disposed off to the mainstream. Some of degrades by itself while others can be recycled. Perhaps thats what new investments in waste management should be headed towards.

Clinical nurses’ experiencing occupational burnout within the health care setting

This article was contributed by Ms. Niyaza Abdul Rahman to the ADK Hospital Newsletter “TeamTalk” Issue 2o, November 2011. With her permission I share this article on my blog.

This is a systemic review based on selected ten research papers out of 100 papers for which the aim was to find out answer for the question of :

How do clinical nurses perceive their experiences in living with burnout within the clinical area setting?

This review was my dissertation for the course which I would like to share the result of it with you all, since it is very much related to our working field and might benefit our nurses in the long run.

The term “Burnout” which appeared around (1975) in scientific literature, is referred as a low job satisfaction in many cases (Lauderdale,1982,p35). There is no specific definition for burnout in terms of medical condition, but it is well recognised and defined as a psychological condition. As a matter of fact burnout is said to be the final stage of stress when everything else fails (IMCARES), 2008

Nurses assisting in surgery

Comparatively health care professionals are at higher risk of getting burnout than any other profession, because of the nature of their work (Erikson & Grove 2008) and as well as the life and death decisions they take (Potter 2005). The main reason why nurses move out of the industry is because they experience stress,sadness, powerlessness, exhaustion, and frustration as their daily routine (Erikson & Grove 2008). From a health care commission report on Maidstone and Tunbridge wells NHS (National Health Service) revealed that staff shortage, ill health and heavy work load are contributory factors for failure of effective dealing with the patients. In addition staffs are also unaware of their own wellbeing for the safety of the patients (Bence 2008, p28). This shows that there is a link between nurses’ burnout and patient satisfaction.

A Nursing Times survey, conducted on 2000 nurses revealed that seven out of ten suffered from work related stress, where sick leaves were increased  by 30 or more sick days for the previous years as a result of job threats, increased workload and staff shortage (Jones 2007).

Burnout in nursing effects not only the organisation but also to the patients as well as the nurses’ well being. As a result of burnout, nurses’ job turnover has been increasing day by day

All these things  consequently leads to a low morale, high absenteeism, high job turn over and other personnel conflicts and thereby  reducing the job satisfaction causing low performance in work ( Carson & Fagin 1996, Cited in Fothergill & Hannigan 2000).

The emerged themes from all ten papers were, Unsupportive management,  Physiological and psychological aspects of burnout, Inadequate availability of resources,  Experience of work place alienation,  Excessive and heavy work load, Strategies for coping mechanism

For the theme of unsupportive management a vast negative perceptions were given by nurses. This theme was supported by nurses’ perceptions and experiences of negativism towards their work, lack of recognition, encouragement, support, poor supervision, high expectation from nursing management and unsupportive administrations.

All we want from management is some recognition for our hard work. Just a ‘Thank you, you’re doing a good job!’ will go a long way to motivate us. – Smit (2005, p26, col 2, lines 27 -29)

Physiological and psychological aspects of burnout were apparent from 9 out of 10 papers. Most frequently expressed psychological consequences from all of the papers were frustration, hopelessness, powerlessness, helplessness and emotional exhaustion.

But I still think in a way, I’ve complained several times but it’s not taken seriously. It’s swept under the rug. So then it really feels, what you say, it’s not worth much. In the long run I don’t think this is good for people. You need to feel involved and that you can change things. – Olofsson and Bengstsson and Brink (2003, p355 col 2 lines 16-21)

For the theme of inadequate availability of resources, mainly highlighted within the studies were, inadequacy of staff, time, high responsibilities with limited resources, skilled staff and basic resources for preventive measures.

Experience of work alienation was highlighted as unfamiliar work environment and equipments, inexperience and incompetency in work and lack of knowledge.

Difficulty in handling the advance equipments and operating the new machines were time consuming for them as they do not have the proper guidance and exposure to it.

Most leading issue from all ten papers were experiencing excessive and heavy workload.

This was highlighted in papers as multitasks with frequent interruptions within a limited time or performing multiple interventions at a limited time which further causes staff fatigue and exhaustion.

You never get any peace; never get done with anything, always interrupted by ringing telephones. During all this an assistant nurse comes and some patient is ill and you have to run. Then run from that to talk on the phone with a relative who’s calling and worried. Then rounds have to be done. These constant interruptions. While I’m supposed to do these things I want to get out and see the patients, what am I sitting here and documenting? How is the patient? How is he or she really feeling? – Olofsson and Bengstsson and Brink (2003, p354 col 2,  lines 39-52)

As for the final theme, strategies for coping mechanism, they have provided perceptions and experiences of how they relived and coped with the stressors faced within the care setting. Apparent strategies were; attempting to reduce stress by remaining calm and quite during the stressful situations, relieving by individual interests, using support and assistance from peers and family members, communicating with co workers, getting involved in something else ignoring the situation and reflecting back the situation and communicating with a colleague.

Findings suggest that nurses’ working under heavy workload pressure experiencing high level of burnout affecting them mentally and physically, which is a serious issue to consider. Consequently this leads them to move out of the industry or with a low performance in their work. Thus health care managements should be more cautious about staff satisfaction and their wellbeing in order to restrain nurses. Additionally it is vital for the supervisors and nurse managers to conduct supervisory sessions and meetings to consider nurses’ problem and to assess their workload. Within the light of this review nurses’ should be able to identify and recognise their stressors early in order to prevent them from burnout or post traumatic stress. Moreover nurses should focus on their own health and well being, caring for themselves which would consequently decrease the level of burnout and promote a quality care.

Hospital Observation Services

In hospitals, observation services are mainly referred to as

The use of a bed and periodic monitoring and/or short term treatment by a hospital’s nursing or other staff  (BCBSNC)

Observation is a reasonable and necessary process to evaluate a patient’s condition to determine whether there is a need for the patient to be admitted hence is recognized as an alternative method of evaluation and treatment to inpatient hospitalization. It can even be classified as an outpatient service rather than a hospitalization.

The allocated length of stay at observation services may not be the same in different institutions. Ideally, the earlier a patient is discharged from an observation service, the better. The time allowed at an observation service may vary from few hours to a maximum of about 48 hours. Observations services, in some hospitals may even be developed separately with separate policies for different conditions, while in others common policies with common observations services are also provided. In the Maldives, it is mainly the latter that is practiced.

Different categories of patients can be put under observation for the reasons specified below.

  • Patients who arrive in the hospital in an unstable medical condition would be placed for observation till a definitive care plan can be determined.
  • Patients who develop unusual reactions to procedures and or medicines after minor outpatient surgical procedures are also placed for observation for further assessment and treatment.
  • Diagnostic testing that require a specific preparation or an invasive procedure maybe placed at observation before and after the intervention.
  • Some patients are also placed in observation for planed routine therapeutic services that require the patient to be observed after the treatment.

Given the above categories, patients who utilize the observation services should mainly be discharged after observation. Hospitalization an inpatient should be very low from the observation room.

Utilization statistics of ADK Hospital observation services, Jul-Oct, 2011

At ADK Hospital, the observation services are utilized heavily. As a result the demand for increased observation beds have been almost consistent. In august 2011, the hospital expanded its observation services from 3 beds to 6 beds, a 100% expansion. However, expansion alone is not enough. It is important to assess the utilization of these services. In this regard, an analysis of observation service utilization was assessed.

From July to October, observation service utilization has increased by almost 58% with 184 patients in July to 320 in October. This obviously is a sign of the expansion in beds and hence more patients have benefited from this intervention.

Also, it can be said that the observation service has been managed efficiently. On average, 95% of the patients utilizing observation services were discharged home and only about 5% required an admission. This is a clear sign of proper determination by the clinical staff on who actually requires observation services. The graph shows the utilization of the observation services at ADK Hospital.

In order to keep this service further efficient, a lot needs to be done. Some actions that can be implemented in the near future could be as follows.

  • Improve the current observation service policy by reviewing and strengthening it.
  • Attempt to provide slightly more complex services at observation so that more people can be treated without full hospitalization.
  • Start to take statistics on return rates to observation services or for hospitalization after being released from observation services.

Continuous monitoring and assessment of the service would still be crucial to continuous maintenance of quality of service provided in observation.

Clinical Audit

This article was contributed by Dr. Nitin Srinivasan to the ADK Hospital Newsletter “TeamTalk” Issue 2o, November 2011. With his permission I share this article on my blog.

OPD consultations follow an established process

Audit is well recognized as a fundamental and compulsory part of clinical practice for quality assurance to attain international standards. To achieve this there must be a well defined and smooth protocol in place comprising of on-going treatment starting from patient attending the hospital for the first time to discharge and further follow up. A multidisciplinary input and monitoring of outcome for all variables which could potentially affect the patient care should also be included. Important areas of assessment within this framework also include patient outcomes (treatment results), appropriateness of care, institutional performance, resource management and patient/health care provider satisfaction.  The objectives of Audit can be summarized as

  • To serve as a basis for continuous and sustainable improvement in patient outcomes. A systematic review of untoward results will allow s clinicians to monitor the clinical outcomes and to bring about improvement in service.
  • To support research and development of clinical policies.
  • To provide insight and feedback to clinician’s performance.
  • To serve as a tool of accountability on clinical outcomes and use of resources.

History of Audit

Florence Nightingale was the first to initiate systematic audit during Crimean War of 1853-1855 with her team of 38 nurses. The results were excellent with her input resulting in mortality rates dropping down to 2% from an earlier of 40%.Ernest Codman (1869 – 1940) was the pioneer of modern Surgical Audit. His work anticipated contemporary approaches to quality monitoring and assurance, establishing accountability, and allocating and managing resources efficiently.

Staging of Audit Process-

Stage 1: Identification of  problem or issue

This stage involves the selection of a topic or issue to be audited, and is likely to involve measuring adherence to surgical practices that have been shown to produce best outcomes for patients. Selection of an audit topic is important in:

  • Where national standards and guidelines exist; where there is conclusive evidence about effective surgical practice (i.e. evidence based medicine).
  • Areas where problems have been encountered in practice.
  • Patient and public recommendations to be considered.
  • Looking for improvement in service delivery.
  • Improvement is needed in areas of high volume, high risk or high cost.

Stage 2: Defining criteria & standards

  • Audit Criteria– Decisions regarding the overall purpose of the audit, either as what should happen as a result of the audit, or what question you want the audit to answer, should be written as a series of statements or tasks that the audit will focus on. Collectively, these form the audit criteria. These criteria are explicit statements that define what is being measured and represent elements of care that can be measured objectively. A criterion is a measurable outcome of care, aspect of practice or capacity.
  • Audit Standards- The standards define the aspect of care to be measured, and should always be based on the best available evidence. A standard is the threshold of the expected compliance for each criterion (these are usually expressed as a percentage).

Stage 3: Data compilation

To ensure that the data collected are precise, and that only essential information is collected, certain details of what is to be audited must be established from the outset. These include:

  • The user group to be included, with any exceptions noted.
  • The healthcare professionals involved in the users’ care.
  • The period over which the criteria apply.

Stage 4: Comparison of performance

This is the analysis stage, whereby the results of the data collection are compared with criteria and standards. The end stage of analysis is concluding how well the standards were met and, if applicable, identifying reasons why the standards weren’t met in all cases. These reasons might be agreed to be acceptable, i.e. could be added to the exception criteria for the standard in future, or will suggest a focus for improvement measures.

Stage 5: Implementation of change

Once the results of the audit have been published and discussed, an agreement must be reached about the recommendations for change. Using an action plan to record these recommendations is good practice; this should include who has agreed to do what and by when. Each point needs to be well defined, with an individual named as responsible for it, and an agreed timescale for its completion.

Action plan development may involve refinement of the audit tool particularly if measures used are found to be inappropriate or incorrectly assessed. In other instances new process or outcome measures may be needed or involve linkages to other departments or individuals. Too often audit results in criticism of other organisations, departments or individuals without their knowledge or involvement.

Re-audit: Sustaining Improvements

After a set period, the audit should be repeated. The same strategies for identifying the sample, methods and data analysis should be used to ensure comparability with the original audit. The re-audit should demonstrate that the changes have been implemented and that improvements have been made.