Promoting audit in primary care: roles and relationships of medical audit advisory groups and their managers.
(33/2549)
OBJECTIVES: To investigate perceptions of family health service authorities and medical audit advisory groups of advisory groups' involvement in clinical audit and wider quality issues; communication with the authorities; and manager satisfaction. DESIGN: National postal questionnaire survey in 1994. SETTING: All family health services authority districts in England and Wales. SUBJECTS: Chief executives or other responsible authority officers and advisory group chairpersons in each district. MAIN MEASURES: Priorities of advisory group and authority for audit; involvement of advisory group in wider quality issues; communication of information to, and contacts with, the authority and its involvement in planning the future work of the advisory group; and authorities' satisfaction. RESULTS: Both groups' views about audit were similar and broadly consistent with current policy. Advisory group involvement in wider quality issues was extensive, and the majority of both groups thought this appropriate. Much of the information about their activities collected by advisory groups was not passed on to the authority. The most frequent contact between the two groups was the advisory group's annual report, but formal personal contact was the most valued. Most authority respondents thought their views had been recognised in the advisory group's planning of future work; only a small minority were not satisfied with their advisory groups. Dissatisfied respondents received less information from their advisory groups, had less contact with them, and thought they had less input into their plans. There was some evidence that advisory groups in the "dissatisfied districts" were less involved in clinical audit and with their authorities in wider quality issues. CONCLUSIONS: Most advisory groups are developing their activities in clinical audit and have expanded their scope of work. The quality and availability of information about progress with audit is a cause for concern to both groups. (+info)
Adapting total quality management for general practice: evaluation of a programme.
(34/2549)
OBJECTIVE: Assessment of the benefits and limitations of a quality improvement programme based on total quality management principles in general practice over a period of one year (October 1993-4). DESIGN: Questionnaires to practice team members before any intervention and after one year. Three progress reports completed by facilitators at four month intervals. Semistructured interviews with a sample of staff from each practice towards the end of the year. SETTING: 18 self selected practices from across the former Oxford Region. Three members of each practice received an initial residential course and three one day seminars during the year. Each practice was supported by a facilitator from their Medical Audit Advisory Group. MEASURES: Extent of understanding and implementation of quality improvement methodology. Number, completeness, and evaluation of quality improvement projects. Practice team members' attitudes to and involvement in team working and quality improvement. RESULTS: 16 of the 18 practices succeeded in implementing the quality improvement methods. 48 initiatives were considered and staff involvement was broad. Practice members showed increased involvement in, and appreciation of, strategic planning and team working, and satisfaction from improved patients services. 11 of the practices intend to continue with the methodology. The commonest barrier expressed was time. CONCLUSION: Quality improvement programmes based on total quality management principles produce beneficial changes in service delivery and team working in most general practices. It is incompatible with traditional doctor centred practice. The methodology needs to be adapted for primary care to avoid quality improvement being seen as separate from routine activity, and to save time. (+info)
Studies of avoidable factors influencing death: a call for explicit criteria.
(35/2549)
OBJECTIVE: To analyse studies evaluating cases of potentially "avoidable" death. DESIGN: The definitions, sources of information, and methods were reviewed with a structured protocol. The different types of avoidable factors,--that is, deficiencies in medical care that may have contributed to death--were categorised. The presence of explicit classifications and standards was examined. basic criteria for quality of the studies were defined and the numbers of studies fulfilling these criteria were assessed. SETTING AND PARTICIPANTS: 65 studies, published during 1988-93 in peer reviewed medical journal for which the title, or abstract, or both indicated that they had analysed potentially avoidable factors influencing death. Studies analysing aggregated data only, were not included. RESULTS: Only one third of the studies fulfilled basic quality criteria,--namely, that the avoidable factors examined should be defined and the sources of information and people responsible for the judgements presented. The definitions used comprised two levels, one stating that there had been errors in management (process) and the other that the errors may have contributed to the deaths (outcome). Only 15% of the studies explicitly defined what type of factors they had looked for and 8% referred to specified standards of care. CONCLUSIONS: Studies of avoidable factors influencing death may have considerable potential as part of a system of improving medical care and reducing avoidable mortality. At present, however, the results from different studies are not comparable, due to differences in materials and methods. There is a need to improve the quality of the studies and to define standardised explicit definitions and classifications. (+info)
A natural survey of audit activity across the primary-secondary care interface.
(36/2549)
OBJECTIVE: To document the nature of audit activity at the primary-secondary care interface; to explore participants' experiences of undertaking such interface audit; to identify factors associated with these experiences; and to gather views on future interface audit activities. DESIGN: A three phase national survey by postal questionnaire with a cascade sampling approach. SETTING: England and Wales. RESULTS: Response rates were: 65% to the first questionnaire; 34% to the second questionnaire; and 45% to the third questionnaire. 56% of the audits covered some element of management of patients or disease; only 33% of the audits were within a single topic area. Most audits had more than one trigger: for 61% the trigger was a perceived problem; for 58% it was of mutual interest. Only 18% of audits were initiated collaboratively; doctors were the most frequent initiators (72%), and most audits (63%) involved collaborative groups convened specifically for the audit. 58% of groups had between three and eight members, 23% had 12 or more. Doctors were the most frequent group members. There was differential involvement of group members in various group tasks; the setting of guidelines was highly dominated by doctors. Of reportedly complete audits, only two fifths had implemented change and only a quarter had evaluated this change. There was widespread feeling of successful group work, with evidence of benefit in terms of the two sectors of care being able to consider issues of mutual concern. Levels of understanding of the group task and of participation were positively related to the duration of meetings. Joint initiation of audits facilitated greater understanding of the group task. Larger group sizes allowed primary and secondary carers to discuss issues of common concern; however, larger groups were more likely to experience disagreements. Having previously worked with group members increased trust and good working relations. The main lessons learnt from the experience included the importance of setting clear objectives and good communications between primary and secondary carers. Factors identified as important for future audit activity at the primary-secondary care interface included commitment, enthusiasm, time, and money. CONCLUSIONS: Audit at the primary-secondary care interface is taking place on a wide scale and has been an enjoyable experience for most of the respondents in this study. IMPLICATIONS: Despite being a positive experience most audits stopped short of implementing change. Care must be taken to complete the audit cycle if audit at the primary-secondary care interface is to move beyond the roles of education and professional development and to fulfil its potential in improving the quality of care. (+info)
Audit in the therapy professions: some constraints on progress.
(37/2549)
AIMS: To ascertain views about constraints on the progress of audit experienced by members of four of the therapy professions: physiotherapy, occupational therapy, speech and language therapy, and clinical psychology. METHODS: Interviews in six health service sites with a history of audit in these professions. 62 interviews were held with members of the four professions and 60 with other personnel with relevant involvement. Five main themes emerged as the constraints on progress: resources; expertise; relations between groups; organisational structures; and overall planning of audit activities. RESULTS: Concerns about resources focused on lack of time, insufficient finance, and lack of access to appropriate systems of information technology. Insufficient expertise was identified as a major constraint on progress. Guidance on designing instruments for collection of data was the main concern, but help with writing proposals, specifying and keeping to objectives, analysing data, and writing reports was also required. Although sources of guidance were sometimes available, more commonly this was not the case. Several aspects of relations between groups were reported as constraining the progress of audit. These included support and commitment, choice of audit topics, conflicts between staff, willingness to participate and change practice, and concerns about confidentiality. Organisational structures which constrained audit included weak links between heads of professional services and managers of provider units, the inhibiting effect of change, the weakening of professional coherence when therapists were split across directorates, and the ethos of regarding audit findings as business secrets. Lack of an overall plan for audit meant that while some resources were available, others equally necessary for successful completion of projects were not. CONCLUSION: Members of four of the therapy professions identified a wide range of constraints on the progress of audit. If their commitment to audit is to be maintained these constraints require resolution. It is suggested that such expert advice, but also that these are directed towards the particular needs of the four professions. Moreover, a forum is required within which all those with a stake in therapy audit can acknowledge and resolve the different agendas which they may have in the enterprise. (+info)
Comparison of appropriateness of cholesterol testing in general practice with the recommendations of national guidelines: an audit of patient records in 20 general practices.
(38/2549)
OBJECTIVE: To compare the profiles of those patients selected by general practitioners for measurement of serum cholesterol with the recommended profiles for opportunistic cholesterol testing described in the national practice guidelines published by the Dutch College of General Practitioners. DESIGN: Retrospective audit of general practitioners' records. MATERIALS: Practice records of 3577 adult patients systematically sampled from 20 general practices. MAIN MEASURES: With criteria set by the national guidelines, the proportion of patients per practice (a) for whom cholesterol testing would be considered justified, and (b) for whom cholesterol testing would be considered unjustified, and the proportion of patients within each of these groups who had had a cholesterol measurement recorded. RESULTS: Cholesterol tests were performed on 415 (11.7%) of the 3577 patients. National guidelines on the management of hypercholesterolaemia state that a positive cardiovascular risk profile is an indication for cholesterol measurement. Just under one fifth (668) of the patients in this study were recorded as having a positive cardiovascular risk profile, but only 31% of these had had their cholesterol measured. Of the patients without recorded evidence of a positive cardiovascular risk profile cholesterol had been measured in 8%. Restricting the analyses to the age group 18-65 (n = 3060) of whom 12.5% had a positive risk profile, did not improve the results. In practices with a computerised information system 37% of patients with recorded evidence of a positive cardiovascular risk profile had had their cholesterol measured. CONCLUSIONS: Cholesterol testing was not targeted as selectively as recommended by the national guidelines. The major problem was failure to test those likely to benefit. Improving the targeting of cholesterol measurements would undoubtedly increase the workload of general practitioners. If the national guidelines are to have an effect on health promotion the first step must be to increase the proportion of patients with positive cardiovascular risk profiles who get their cholesterol tested. A major factor in successfully selecting cases seems to be that practices are equipped with a computerised medical information system. (+info)
Randomised controlled trial of reminders to enhance the impact of audit in general practice on management of patients who use benzodiazepines.
(39/2549)
OBJECTIVE: To determine whether reminder cards in medical records enhance the effectiveness of audit with feedback in improving the care of patients taking long term benzodiazepine drugs. DESIGN: Randomised trial, practices receiving feedback only in one group and practices receiving feedback plus reminder cards in the other group. SETTING: 18 general practices in Leicestershire. SUBJECTS: Random samples of patients who had been taking a benzodiazepine anxiolytic or hypnotic drug for four weeks or longer. MAIN OUTCOME MEASURES: Entries in medical records indicating compliance with five criteria of care: assessment of suitability for withdrawal; being told about dependency; withdrawal being recommended; withdrawal or continuing medication; and a consultation with the general practitioner in the past year. Data were collected before and after feedback or feedback plus reminders. RESULTS: Of a total population of 125,846 registered with the 18 practices, 2409 (1.9%) had been taking a benzodiazepine for four weeks or longer. Of the 742 in the first samples, 543 (73.2%) were women, the mean (SD) age was 68.7 (14.9) years, and they had been taking a benzodiazepine for 10.1 (6.7) years. The number of patients whose care complied with the criteria rose after the interventions to implement change. The increase was greater in practices receiving feedback plus reminders for only two of the five criteria "told about dependency" increasing from 52 (11.1%) to 118 (25.8%) in the feedback only group, and from 27 (10.5%) to 184 (43.0%) in the feedback plus reminders group; odds ratio (OR) 1.46 (95% confidence interval (95% CI) 1.32 to 5.21); and "consulted in the past year" increasing from 434 (93.1%) to 411 (95.8%) in the feedback only group and 255 (96.6%) to 400 (99.8%) in the feedback plus reminders group, OR (95% CI) 13.5 (2.01 to 330.3). CONCLUSIONS: Reminder cards had only a limited effect and cannot be recommended for routine use. There were improvements in the care of patients of both groups of practices and further studies are indicated to determine the impact of both systematically developed criteria and reminders embedded into restructured medical records. (+info)
Use of the critical incident technique in primary care in the audit of deaths by suicide.
(40/2549)
OBJECTIVE: To explore the usefulness of the critical incident technique in primary care to improve policy and practice to prevent cases of suicide. DESIGN: Inviting all primary care teams in County Durham with a patient who committed suicide between 1 June 1993 and 31 May 1994 to take part in a critical incident audit with an external facilitator. RESULTS: 49 cases of suicide were available for study, registered with 31 practices. 19 (61%) practices accounting for 27 (55%) cases agreed to take part. Case discussions showed areas where practice could be improved, but no substantive preventive measures were identified within primary care, which would reduce the number of people committing suicide. The wider social and economic context was thought to be more important. CONCLUSIONS: The use of the critical incident technique in primary care may have only a limited role in improving the management of people at risk from suicide. However, one of the potential strengths of this approach is to encourage reflection on practice in a difficult emotional area. (+info)