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Getting clinical audit right requires time

Clinical audit is needed for health services to measure errors in care to help ensure they don’t reoccur. Given its importance, the manner in which an audit compiles and assesses data has to be beyond reproach. An audit that is not fit-for-purpose will not tell you whether the health service is fit-for-purpose.

Examining mortality data is perhaps the most sensitive area of clinical audit. Determining the exact cause of death is not easy, especially if the patient had significant comorbidities, which is the case with many elderly patients. And judging whether that death was avoidable or preventable can be onerous work.

The NHS recently established a programme focused on publishing data on and learning from avoidable deaths. At its launch, the UK’s then Health Secretary Jeremy Hunt hailed the move as ushering in a new era of transparency, with the NHS becoming the first health service in the world to introduce such an initiative.

For a structured judgement review (SJR), which is the process the NHS is employing, multiple reviewers are necessary to get a reliable judgement on determining whether a death is avoidable. A SJR is conducted as a first-stage review by a consultant not directly involved in the patient’s care. If any phase of care has a low quality rating, then these records go for a second review. The second review is usually undertaken by a group of senior figures in the Trust, such as the medical director and chief nurse. It is at this stage that a judgement is made as to whether the death was avoidable. Even after these steps, it is sometimes difficult to determine if a death was avoidable, due to inadequacies in the case notes and other issues.

It is clear why such a process could be difficult in the Irish hospital system, suffering as it does from a chronic deficit of senior clinical staff. The Director of the National Perinatal Epidemiology Centre in Ireland, Prof Richard Greene, told this newspaper that data collection is burdensome and there is a lack of protected time for clinical audit. Also speaking to the Medical Independent, Clinical Lead and Chair of the National Audit of Hospital Mortality (NAHM) Governance Committee Dr Brian Creedon cast doubt on the ability of Ireland’s health service to employ SJRs in the way they are being implemented across the UK, precisely because of the lack of staff, especially consultants.

Currently, the NAHM uses standardised mortality ratios (SMRs), which is a method of determining excess deaths across the sector. SMRs have been criticised as a performance measure in relation to the quality-of-care overall, because issues such as coding practices and the number of deaths occurring in one hospital compared to another all have significant impacts on the data.

However, no tool is perfect, and many experts agree it is important to use a mix of measures to assess the quality of a health service. Whatever these measures are, staff need to have the time necessary to ensure they are utilised correctly so that data produced stands up under scrutiny and is sufficiently robust to drive change.

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