FOR some dentists, the merest mention of ‘audit’ is enough to make them want to run and hide. Many will recall hours of useless data collection that only serves to establish that some obvious fact, that everyone knew anyway, was correct.
And don’t mention statistics. This raises a raft of other questions. Is it probable or improbable? Is it even significant? Was the group size too small? We might wonder whether we are even collecting the correct data and if our questions are too open or too closed. We are often simply amateurs having a go in someone else’s complex specialty.
So why do we attempt audit? Well primarily because we have to. The General Dental Services (GDS) terms of service require us to complete 15 hours of audit in every three year cycle – a situation that isn’t likely to change. In fact there are pretty strong rumours that the monitoring of this could be about to change in Scotland and that NHS Education Scotland (NES) may have a role in recording dentists’ audit histories.
I have recently seen the new, improved NES dental portal which will be launched in August. You will be able to print off your own NES CPD history and certificates and ultimately this may be where we will see, at a glance, our approved audit history. The e-Portfolio too is getting a facelift and here you can store, develop, share and submit audit reports. It is hoped in time this will store a data bank of audits which will become a useful resource itself. Remember that revalidation is coming and audit will be a significant part, so the easier it is for us to get our hands on our supporting evidence the better.
There are many benefits to getting involved in audit. We all do some form of audit in our practices, whether it is just taking test X-rays every day to comply with IRMER or changing something when a negative outcome presents itself.
But this informal approach runs the risk of missing that essential opportunity to make a meaningful change. We might decide to change labs because those crowns just don’t fit as well as they used to, but that problem could be the fault of your impression material, the transportation or even your deteriorating eyesight.
Clinical audit is the systematic critical analysis of the quality of care provided to our patients. It is one of the only mechanisms we have of ensuring that we are doing a good job. We change our methods as we change our materials. We get older and more experienced and adapt our techniques. We learn new skills and introduce them to our daily routine.
But how do we know if these all benefit our patients? An example of this was demonstrated to me recently at an implant course. I was surprised to learn that the long-term success of more recent modifications to an existing implant system was poorer – was this progress? It may have been easier for the practitioner to fit but surely the most important question had to be: “would it perform better than the previous version?”
We are all bound by clinical governance – a key element in revalidation. Clinical governance is a system through which we are accountable for continuously improving the quality of service and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish.
In my role at NES, I have been trying to promote relevant audit through our course programme. In it, we highlight three ways in which we can analyse the quality of care provided to our patients:
• Structural audit. We can measure the resources we have, for example: Do we have enough time set aside for emergency patients? Do we have enough adequately trained staff?
• Process audit. We can measure the procedures used for diagnosis and treatment: Can we get useful information from our X-rays such as caries detection? How robust is our record keeping?
• Outcome audit. We can measure the actual outcome for the patient. Did the patient suffer pain after a procedure? What was the patient’s satisfaction with their practice following a visit?
So how do we get started in audit? We could decide if we wanted it to be an individual audit, a practice/team audit or even join one of the larger facilitated audits that are run by regional audit committees in various regions.
We then decide on our topic. This should be relevant to what the biggest priority is to you. Consider if any change will affect a large number of staff or patients, if cost effectiveness can be improved, or if there is a potential to improve quality of care.
We must also consider if the audit will be easy to do. For this, consider if it will disrupt day-to-day practice running and if a commitment is necessary from team members. If we do not address these barriers at this stage it is less likely to succeed.
Next we have to consider what information on your audit topic already exists. Is there a recognised standard to compare against – for example SIGN guidelines, GDC guidance or BDA advice sheets? You may even have to search the internet or source some previous research or audits.
Then set aims and objectives which will relate to the reason why you chose to audit that particular subject in the first place and how this will be compared to your agreed criteria or standard. Finally, choose your method – perhaps create a data collection sheet and collect your data. Remember, keep it simple, be specific and clearly define your area of focus. Once you have completed your first round of data collection, change can be implemented and a second round of data collection can see if the change has been beneficial.
There is excellent advice on all of these stages and examples of completed audits on the NES website. Here you will also find help on sample size and suggested Clinical Audit Allowance hours. There is also information on the Department of Health website covering other parts of the UK.
Audit also has an important role in dento-legal matters. It is the only way to demonstrate monitoring of your clinical standards and building in continuous improvement. You should target weak areas of your practice (perhaps identified by a patient complaint) and investigate where you are at that point in time.
If faced with a complaint you may be able to demonstrate that your standard is in line with current best practice and the complaint is not representative of your practice. If you discover that changes require to be made then they can be implemented and you can then re-audit to demonstrate the improvement since the complaint.
If you still find clinical audit daunting then you may find Significant Event Analysis (SEA) an easier introduction. The GDS allow us to comply with our 15 hour/three year audit requirements entirely with SEAs. They often identify clinical audits. They allow us to make an instant start on an issue that is relevant to the practice.
David MacPherson is a Practice Development Plan (PDP) CPD tutor with NES