Clinical Audit Awareness Week 2023 with Pam Mosedale

Knowledge Natter: Clinical Audit Awareness Week 2023

Pam Mosedale

Helen Silver-MacMahon

RCVS Knowledge:

Welcome to This Knowledge Natter by RCVS Knowledge. Here we have friendly and informal discussions with our knowledge award champions and those who are empowered by quality improvement in their work. Whether you’re a veterinary surgeon, veterinary nurse receptionist, or member of management, quality improvement will and can positively impact your everyday life. Listen and be inspired.

Helen Silver-MacMahon:

Hi, Pam. It’s great to be chatting to you this morning. It’s Clinical Audit Awareness Week here at RCVS Knowledge, and we thought, what better way to celebrate the week than talk to you, our clinical lead for quality improvement and a clinical audit aficionado. So Pam, without further ado, I’m going to fire some questions at you, just like you do to all of your lovely interviewees, and hear what you think for a change, because we know that you’re an expert in this area. So Pam, how did you get into clinical audit?

Pam Mosedale:

Hi, Helen. Well, it was quite a long time ago. It was when I was involved in Practice Standards, but actually, it was Veterinary Hospitals Association, so it was a bit before RCVS took over Practice Standards. We were doing something with the standards, and we were looking at all this stuff that you look at, like how high does the [inaudible 00:01:19] go up the wall and have they got this bit of kit and that bit of kit, but I was really conscious that we are measuring all that.

We’re looking for all that, but what we really want to know is how people are working in the practice. So that made me start looking at ways of assessing that and really around outcomes to start with, and so that led me to look at clinical audit and start doing some very basic clinical audits in my own practice, which I found really interesting. My nurses in the practice loved it and we sort of went from there. So I sort of learned about it as I went long, I suppose, but that was quite a long time ago, but I’m so glad now to see so many more people in the factory profession embracing it.

Helen:

Definitely. It’s really taken off, hasn’t it, and become something that everybody does, which is amazing. Why do you think it’s so important that people do clinical audits though?

Pam:

Well, I think if you don’t measure what you do, how do you know how well you’re doing? So it’s very easy to become complacent, isn’t it? And think, “We do that great,” or even on the other hand to think, “We’re not very good at this particular thing,” but you and I are both involved in quality and improvement, and how can we ask practice to improve if they don’t know what their baseline is. They need to know whether they need to improve a certain area or not, and the way to do that is to measure, because without measuring, without having any data, you don’t really know how you’re doing. In a big practice, if you asked the vets or asked the nurses a question, even a simple question, ‘How many post-op infections do you get, or how many animals would you lose anesthesia in a year?” and everybody gives a different answer, you don’t know if it’s all those answers added together or if they’re all talking about the same cases, so the only way to be sure about those things is to measure.

Helen:

Brilliant. Yeah, absolutely. I think something that I found a little bit tricky to get my head around to start off with was the difference between research and clinical auditing. Would you mind just explaining that for us?

Pam:

Yeah, certainly. I think that the problem is that, often, when people start to get involved in clinical audit, sorry, they actually think let’s do something to find out the best way. For instance, they might think, “Let’s find out the best way, the best anesthetic agent to use for rabbits by having two groups and doing this and that.” Well, that’s research, okay? Clinical audit is about measuring what you do in your practice, and then talking to your team, finding out why you’re getting the results you’re getting, if they’re not that good, and then making some changes and improving.

So clinical audit is all about your own data and your own practice, and then making improvements as a result of it. Research is much more generalizable. It’s about doing something, which then can be applied in all practices, so you might do some research and then write a paper that says all practices could do this, so research is longer term, bigger, more generalizable audit to small in your own practice. Research tends to need ethical approval. An audit, generally, doesn’t. Occasionally, when you’re writing it up, some publications might ask, but we have some really good guidelines on that knowledge. But basically, the difference is, as I say, that with audit, you’re measuring what you do in your own practice.

I mean, I’ve had colleagues say to me, “Oh. We want to do this clinical audit, and we’re going to look at,” it was in a rescue center, “And we’re going to look at the dogs that come in, whether they’ve been vaccinated or not, and going to see how long before they start coughing, the kennel cough, and then we’re going to see we’re going to treat them with three different antibiotics,” and I’d like, “Stop, stop, stop. That is well far too big, and it’s not an audit. It could potentially be a research project, but it’s definitely not an audit,” so keeping it small and simple is the key with clinical audit, I think.

Helen:

Yeah, so bite size. So something that everybody can take part in and practice, really.

Pam:

Yeah, absolutely.

Helen:

So can you give us some advice if somebody’s wanting to do an audit, how do they go about doing it, and any top tips that you’ve got, please?

Pam:

Yeah. Well, I think they keep it simple thing is my very top tip, but the other thing is to choose something that you can measure, first of all, because it’s very self-destroying if you try and measure something that’s immeasurable. Something that’s relevant to your team, talk to your team, and I think that’s another really important thing; the team needs to be on board from the beginning. Nobody should be doing audit without telling their team they’re doing it, because then you get people worrying that somebody’s looking over their shoulder and is about to criticize the way they do a [inaudible 00:05:41] or whatever, or they prep for an op. So I think involve the team, find out what’s relevant to the team, what they would think would be a good thing to audit, what would make a difference, what, if we could make some changes, would make a difference to the way the practice runs and to everybody’s day?

So I think that’s the important thing, something you can measure, something that’s relevant, something you can measure within a reasonable timeframe as well. You don’t want something there. You’re going to be collecting data for months and months, because everybody will get bored of it. So you want something quite short, where you actually get a result because the really interesting bit, yes, collecting the data is interesting, but the really interesting bit is discussing it with the team and with the people who actually do it, not managers who say, “This is what we’re going to do.” The people who actually do it, and they will tell you the real reasons that this isn’t happening, because that piece of kit you thought was working doesn’t work, they haven’t got time, or whatever. They haven’t had any training. All that’ll come out in that discussion, and then make the changes.

So there’s so many little things, but you could start with depending on what’s relevant, but maybe for a reception team, they may want to do a little audit about how many consent forms actually have an estimate on them, because that’s a real source of point of contention for everybody, really, isn’t it? Especially for reception when the clients come to pay, and then it’s vastly different than what they thought it was going to be, and there was no estimate on the form. So that would be such a simple thing. They could just do looking back over a couple of weeks or whatever, so there’s lots of those really simple audits for audits around anesthetic monitoring sheets. I know quite a lot of veterinary nurses have done audits around that or around temperature during an OP, but anesthetic monitoring sheets are a really rich source of data, just to check that these things are actually being done, so you can audit processes, you can audit whether you’re complying with protocols, guidelines, or checklists, but you can also order audit outcomes of surgical procedures.

Helen:

Brilliant, brilliant. Thank you. And I can hear from you describing the audits that you can do, that there’s a strong link with patient safety here as well. Would you like to talk about that at all?

Pam:

Yes, I think there is. I think that, certainly, clinical audit in human healthcare has had a little bit of a bad press recently about being a little bit bureaucratic, et cetera, and they do have issues when they have people who have to do audits as part of their training, and then they never get to the point of actually discussing it or making changes. You haven’t done an audit unless you do the re-audit. That’s the whole, you’ve got to close the loop and do the re-audit.

But the reason I think it’s important for patient safety is it’s a little bit like preventative medicine generally. We are looking at things before they cause an issue, so we’re looking at, for instance, the one I mentioned about anesthetic monitoring, you’re looking at it in advance. Nothing’s gone wrong. You’re just looking to check how you’re doing things, and hopefully that’s before you have an issue with some animal having some problem during anesthesia, so I think it is really important for patient safety, and it just makes people think about those things. Once you start to think about those things, all sorts of other issues come up, so I think it’s important.

Helen:

Definitely. The examples that you gave are ones that we could use for small animal practice. Can you give any examples of ones that you’ve seen for large animal practice that’s worked well?

Pam:

Yes, yes. Certainly. I mean, you can use. I mean, the principle’s the same. The issues with large animal practice and, to some extent, with equine practices for the outcome, or it can be a bit trickier because you don’t often see, and it’s all right for the small animal ones; you can see your routine neutering coming back. We didn’t mention benchmarking, but you could, once you’ve done that audit, then benchmark your data against other practices then if you submit it to our national audit. But it’s a little bit harder with their equine and farm, because often you won’t see them. But there’s ways around that. You can have pharma reporting.

You can have people sending in photos of cesarean wounds, post-op or whatever. There’s lots of medicine audits that can be done in large animal and small animal practice. You can audit to see that you’re complying with legislation that actually medicines have been okayed by a vet before they’re handed over to a client, and those things can keep you safe from VMD and PSS assessments and make sure you’re doing a proper job. I know one brilliant equine practice did an audit of off license consent, which obviously even in small animal practice can be a tricky issue to remember to get informed consent for using unauthorized medicines. But even more so when vets were out on the road.

Now, this practice, they were very, very honest and did this audit and it was almost zero, their compliance with off-license consent. And then the nurse who was running it, she just basically, apart from doing some training, she also just put forms in the cars, and immediately the compliance went right up. So it’s a matter of thinking what issues are an issue for them and then how they can measure them. I mean, there’s guidelines around all sorts of things that you might have, [inaudible 00:10:52] guidelines, things like that. Are they complying with using those? It is more tricky, but it’s quite possible, and we’ve got some nice examples. We’ve got loads of small animal examples, but we’ve got some nice examples of a recent one around a cesarean and lambing audit, which is really good.

Helen:

Well, I think we’ve done a whistle-stop tour of clinical audits. I think we just wanted to pop on, really, and ask you these questions, so thank you so much, Pam. That’s been really, really helpful, and hope you enjoy listening to it.

Pam:

Yes. Thanks, Helen, and I suppose I’m going to have one last say, if that’s okay. I think the main thing with audit is just get on with it and do it for people in practice, because the only way to learn is to actually do it. Don’t wait to be perfect. Just start small, do some little audits, and you’ll learn as you go along

Helen:

And use the RCVS knowledge resources as well, because I think-

Pam:

Definitely use the RCVS resources. Definitely. I mean, we’ve got, the QI box set has got whole series around audit with podcasts, webinars, articles. We’ve also got audit walkthroughs, audit templates, and we’ve got lots of audit case examples, and the other thing of course is once you’ve done your audit, small or big, whatever you do, enter for the knowledge awards.

Helen:

Oh. Yes, yes. That would be good too, ain’t it? We’ll get lots of lovely, and we like to see different ones as well. You can be inspired by the ones that have been submitted previously. So you might want to start with one that you can replicate in your practice, but that might sort of inspire people to be novel and look beyond these things. Another thing that just popped into my head there was, when we talk about the joy in work framework, identifying the pebbles in our shoes, this is a fab way to do that, isn’t it? Then, work through those pebbles before they become boulders, so that we can all enjoy what we’re doing at work and iron out any crinkles in our day so that we’re offering our patients fantastic quality of care. We’ll leave it there. Thank you very much, Pam.

Pam:

Thanks, Helen.

RCVS Knowledge:

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