Clinical audit has become such an integral part of the day job, that many of us don’t really think about it anymore. It has become an accepted thing, and, for ward leaders, is often done as a response to a senior dictat. I would be very surprised if any of the ward leaders who read this don’t have a requirement to do some form of audit, from hand hygiene, to something around pressure ulcers or falls. Do you feel you are ‘audited out?’.
Relax. This isn’t about giving you more work, but giving you back some control. In week one of this series, I talked about incidents. In week 2, it was small investigations, a measured response to some incidents that was a cut down root cause analysis, focused just on the key principle (why). But if you want your ward to be improving safety, you do need a way to measure that improvement. Given that I’m trying to lose weight at the moment, think of it like dieting. You can spend months thinking you are trying to cut back, only to find your clothes getting tighter. It’s only when you start to step on the scales that improvements really happen. Measuring helps.
But clinical audit isn’t just about measuring. That’s where much of the current audit work falls down. Its really about the cycle, the audit cycle. Measure where you are, consider a change, then measure again.
Your incidents may give you an idea of areas which need looking at, or it may be obvious from talking to the team. Perhaps you have done an investigation and established a ‘why’, you may even have an idea of the change that would help. You could just go ahead and implement it, but that doesn’t always work in the long term. I used to work in a clinical environment where change would be introduced, along with knowing glances and smiles. Three months down the line, and everyone just went back to the way they had always done it. The key to improvement is embedding change – and that doesn’t just happen, it takes effort. Measurement and clinical audit can help here.
Think about doing a small audit before the change, and, ideally, get one of your team to do it. That way this won’t be an ‘imposed’ change, it will be something they will have planned with you – and that engagement in the process is more likely to help them shift their mindset to embrace the change. Even the most positive people can resist change when they feel it has been imposed without good cause. So do the audit; a small sample – ensure the questions are geared towards measuring the issue you have concerns about. For example, if we are talking omitted medication, it may be observational about how the medication round is done (but that can mean a member of staff is taken out of the numbers temporarily), or it could be a retrospective look at the medication charts, noting how many missed medications there were, what time they were due (are they happening more at certain points in the day?), what staffing was like on those days etc… Bring in the key aspects which might impact on this.
Once you have the results, discuss them with the team. What do they think about the findings? What do they feel would make a difference? If the idea for the change comes from them, they are far more likely to stick with it. Agree the changes, then agree a date when it starts. It could be the next day, but is the whole team aware? You may need a week to ensure the message has got to everyone who needs to be involved. Make the change, let it run for a week or so, then measure again. Same questions (you could add a couple more, but don’t take any away), try to replicate the original audit as much as possible, even down to the same person doing it, particularly if its observational. For example, the results of a hand hygiene audit can vary by 30% simply based on who the observer is (yep, some of us are far more forgiving than others…).
Once the results are in, compare them to the originals. Or, better still, get the person doing the audit to compare the results with another team member. Let your team own the audit. Then discuss the findings as a team. Has the change worked? Is a different change needed? A further change? Or leave the existing change in place and audit again in a months time? To really embed something, you need to keep the measurement going for around 4 months, otherwise you risk old habits and routines sliding back in place.
Clinical audit can be a very powerful tool for the ward leader to drive real change, and demonstrate just how effective you are, and it doesn’t necessarily involve more work on your part either. This is just a brief overview; your Trust will have a team who can talk you through how to frame your audit and record it on the Trust systems (most Trusts have a way to record all clinical audits that take place).
Next week, do you have any risks? Risk assessments and then leading to risk registers.