What about a national clinical audit results database?
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1303 (Published 05 February 2014) Cite this as: BMJ 2014;348:g1303
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We have noted Dr Smith’s [1] and Prof Black’s [2] letters regarding the creation of a central clinical audit database, and would like to highlight NICE’s ongoing work in this area. NICE currently has a database collating information on the uptake of our guidance, drawing on evidence from abstracts, journals and national audits and reports. This is available on the website [3].
We recognise, however the importance of clinical audit – the view put forward by Dr Smith - and to this end we are redeveloping our uptake database. In future, instead of reporting audit at guidance level, we will present individual metrics from the published data and map this to individual recommendations, creating a database of all published audit that relates to NICE recommendations. As referenced in Dr Smith’s and Prof Black’s letters we are also aware that many valuable insights often remain confined within departments and we are considering introducing a facility to enable those who have completed local audits related to NICE guidance to share this through the uptake system.
We would like to emphasise that this database is not designed to enforce uptake, but to track improvements related to NICE guidance. We hope that by demonstrating where there is evidence of people being able to put our recommendations into practice, this will act as a springboard for others to follow.
References:
1. Smith MD. What about a national clinical audit results database? BMJ 2014;348;g1303
2. Black N. How to improve clinical audit. BMJ 2014;348;g1305
3. http://www.nice.org.uk/usingguidance/measuringtheuseofguidance/evaluatio...
Competing interests: No competing interests
Re: What about a national clinical audit results database?
We agree with the idea of creating clinical audit results national database as put forward by Smith MD (1). The situation in resource limited countries like India is different. We are still struggling for development of clinical audits in our hospitals specially the Government funded ones. Clinical audit provides information and a basis for improving patient care. It is considered to be “A systematic approach to quality improvement that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change”. (2)
Several types of clinical audit are described (3). These are:
(a) Standards based audit in which standards are defined, data are collected to measure current practice against those standards thereby bringing about a change in the practice to the best available evidence.
(b) Adverse occurrence screening and critical incident monitoring – in this peer-review is done for cases resulting in adverse events, unexpected outcome leading to better understanding for future guidance in management. It is also considered to be a ‘significant event audit’ in the primary care setting.
(c) Peer review – in this, the quality of care provided by a clinical team is assessed by peers with a view to discuss the best possible care and improve clinical care. Here, interesting and unusual cases are presented and discussed rather than problematic cases. Such a system exists in some Indian public hospitals where clinico-pathological conference is held routinely once a week and several clinical and diagnostic departments come together and review a case for the best possible treatment approach.
(d) Patient surveys and focus groups – in these, users’ views about the perceived quality of care are undertaken as a feedback for the clinical care.
Although clinical audit exists routinely for quality of care assessment in developed countries, the situation in India is dismal. Although there is a focus on improving quality of care in several big private hospitals using clinical audit, its use in public funded hospitals is limited. There is no organized system for clinical audit except for some reported clinical audit in specialized disciplines for specific service provision or diseases such as obstetric care in Tibetan Delek hospital in North India (4), analyzing radiotherapy practice in a centrally funded autonomous institute in India (5), assessment of outcomes of Cochlear Implantation (6), for improving quality of prescriptions in psychiatric setting in South India (7) etc.
There is a growing concern among hospitals about accreditation by quality assurance boards such as National Accreditation Board for Hospitals and Healthcare Providers (NABH) in India since 2007 which requires stringent quality measures for hospitals including patient care, records maintenance and clinical audit. However, there is a need for developing a team and essential guidelines for clinical audit in the Indian hospitals specially the Government funded hospitals which can ultimately aim for a national database on clinical audits. But it requires strong hospital governance, funds, manpower and infrastructure.
References
1.
Smith MD. What about a national clinical audit results database? BMJ 2014;348;g1303
2. Debnath UK, Subramanian KN. Clinical audit in orthopaedics. Indian Journal of Orthopedics 2006;40(2):63-69.
3. Jones T, Cawthorn S. What is clinical audit. Evidence based medicine, Hayward Medical Communications. 2002.
4. Mercer SW, Sevar K, Sadutshan TD. Using clinical audit to improve the quality of obstetric care at the Tibetan Delek Hospital in North India: a longitudinal study. Reproductive Health 2006, 3:4 doi:10.1186/1742-4755-3-4.
5. Kaur J, Mohanti BK, Muzumder S. Clinical Audit in Radiation Oncology: Results from One Academic Centre in Delhi, India. Asian Pacific Journal of Cancer Prevention. 2013;14:2829-2834.
6. Kameswaran M, Raghunandhan S, Natarajan K, Basheeth N. Clinical Audit of Outcomes in Cochlear Implantation- An Indian Experience. Indian Journal of Otolaryngology and Head and Neck Surgery 2006;58(1):69-73.
7. Chaturvedi SK, Sinha P, Chandra PS, Desai G. Improving Quality of Prescriptions with Clinical Audit. Indian J Med Sci 2008; 62(11):461-464.
Competing interests: No competing interests