(1993 30. 3?3-
1
I
Editorial Audit matters
stages or levels: structure. process and outcome (Donabedian. 1969). Medical audit is concerned with criteria (things to be measured) and standards (levels to be achieved) which may bc applied to any of these three levels. Design of successful audit projects must be prospective, with the clear purpose of answering specific questions. Standards must be set prior to the study, criteria must be justified and objective (measurable) and targets (the estimated proportion of casts achieving the criterion) stated. Methodology should be simple, utilising only essential data and the possibility of bias should be considered. In interpreting results, any deficiency of care should be idcntihed, specific solutions proposed and a planned programme of change instituted and later evaluated (Gardner et al., 1986; Crombie & Davies. 1992). These, then are the essential features of the Audit Cycle--WC should already be on our bikes! Clearly, the scope for audit is enormous and may address any issue from out-patient waiting times to the optimum treatment for cleft lip and palate. Equally clearly, deticicncies may bc identified very rapidly or may take (as in cleft lip and palate) very many years. The selection of a topic should be because of its importance in terms of frequency, high risk or high cost, or arise from concern because of known variations in practice or outcome. Audit itself should be audited. For example, we arc all aware of the impact of NCEPOD, but there is major criticism of the terms of reference of this exercise as thcrc are no denominators by which one may judge adverse outcome objectively. To support audit, central funds are still available for projects fulfilling certain criteria. Of the f42.1 million allocated by the Department of Health for medical audit for 1992 -93. some f4 million (1991-92) is for centrally funded projects. It is likely that the remainder will devolve in the future to District level. Regional budgets largely disappearing. This has serious implications for the smaller specialties who more than others need to be involved in supra-district projects (EL(92)2 I). BAOMS Audit sub-committee via the Faculty (RCS Eng) Audit committee has been granted f25K for an audit into condylar fractures organiscd as a multi-centre study, and has applied for f60K to fund a National audit of wisdom tooth activity which will involve the entire spectrum of hospital and general practice. A regional network of audit co-ordinators is being established for the specialty, by which means it is hoped to conduct inter-regional audit projects, selecting those which arc of greatest urgency, and in particular to prc-cmpt and answer any major ques-
‘There will he time to audit (the accounts) luter, there will he sunlight later and the equation will come out at last Louis Macneice Bagpipe Music The length of the educational and training pathway in oral and maxillofacial surgery in the UK produces highly competent consultants who have been tested by formal examination, in-training assessment and the everyday rigours of clinical life. The traditional reward of clinical freedom is as exciting a prospect for the individual trainee as it is an illusion to the established streetwise consultant (Hoffenberg, 1981). Embodied in the NHS reforms is the philosophy that it is no longer acceptable for an individual clinician to do whatever he or she pleases when treating patients. One of the main thrusts of these reforms, and one which the profession endorses, is accountability, whcrcby individual clinical freedom is subsumed by a corporate freedom in which the profession has the responsibility for monitoring standards (McKee, 1989). How do we therefore reconcile Government’s recognition that medical audit should be professionally led with the emergence of for example, the Clinical Standards Advisory Group, a free-standing Government committee set up to monitor standards of clinical care? How do we reconcile the requirements of the Patients’ Charter and the business aspirations of Trust status hospitals with our own perception of quality of cart? Should the Dcpartmcnt of Health or management have the right of access to the results of audit conducted by clinicians or should they be allowed to see only that which we wish them to? Whether the profession likes it or not, the Dcpartment of Health is looking for cheaper, more effective health care delivery. The fact is, that unless the profession accepts the responsibility for setting its own standards of care, those standards will be imposed by government agencies. Audit is the acceptable face by which the profession can identify its own standards and insist that they be met. When clinicians raise genuine concerns resulting from audit, they have a right to expect a positive response from both their peers and management. Availability of case-notes: clerical and sccrctarial support, excessive case-load jeopardising safety standards or time for training of junior staff, adequacy of cquipmcnt and working environment are all issues upon which management must demonstrate its support for audit. Such issues are much more likely to receive remedial attention if shortcomings arc identified by open audit than by the strident call of an individual from the wilderness. Quality of cart can be examined at three different 353
354
British Journal
of Oral and Maxillofacial
Surgery
lions relating to the activity of Oral and Maxillofacial Surgeons. Ry this means it is hoped that our specialty may set its own standards of care and demonstrate to others what is required to meet those standards and above all to ensure that we continue to deliver the goods! These issues will require universal cooperation of our membership, but are vital to be able to demonstrate within the new Health Service and are equally vital to succeeding generations of oral and maxillofacial surgeons and their patients.
BAOMS
Audit
P. J. Leopard Chairman Subcommittee
References Crombic, 1. K. & Davies, H. T. 0. (1992). Towards good audit. Brirish Journal ofilospirul Medicine, 48, 182. Donabedian. A. (1969). A Guide IOMedical Cure Adminisfration. vol. Il. Medical Care Appraisal. Washington DC: (American Public Health Association). Ciardncr, M. J.. Machin, D. & Campbell, M. J. (1986). Use of checklists in assessing the statistical content of medical studies. British Medical Jounwl. 292,810. IIotTenberg, R. (1981). Clinical Freedom. London: (Nutheld Provincial Hospitals Trust). McKee. C. M. (1989). Can medical audit be implcmentcd by 19YI? Postgraduate Mcdicul Journal. 65,645. Medical Audit-Allocation of Funds 1992-93. XIIS Muna~ement Execufire L.etfer. EL(92)2 I.
1
I
Editorial Audit matters
stages or levels: structure. process and outcome (Donabedian. 1969). Medical audit is concerned with criteria (things to be measured) and standards (levels to be achieved) which may bc applied to any of these three levels. Design of successful audit projects must be prospective, with the clear purpose of answering specific questions. Standards must be set prior to the study, criteria must be justified and objective (measurable) and targets (the estimated proportion of casts achieving the criterion) stated. Methodology should be simple, utilising only essential data and the possibility of bias should be considered. In interpreting results, any deficiency of care should be idcntihed, specific solutions proposed and a planned programme of change instituted and later evaluated (Gardner et al., 1986; Crombie & Davies. 1992). These, then are the essential features of the Audit Cycle--WC should already be on our bikes! Clearly, the scope for audit is enormous and may address any issue from out-patient waiting times to the optimum treatment for cleft lip and palate. Equally clearly, deticicncies may bc identified very rapidly or may take (as in cleft lip and palate) very many years. The selection of a topic should be because of its importance in terms of frequency, high risk or high cost, or arise from concern because of known variations in practice or outcome. Audit itself should be audited. For example, we arc all aware of the impact of NCEPOD, but there is major criticism of the terms of reference of this exercise as thcrc are no denominators by which one may judge adverse outcome objectively. To support audit, central funds are still available for projects fulfilling certain criteria. Of the f42.1 million allocated by the Department of Health for medical audit for 1992 -93. some f4 million (1991-92) is for centrally funded projects. It is likely that the remainder will devolve in the future to District level. Regional budgets largely disappearing. This has serious implications for the smaller specialties who more than others need to be involved in supra-district projects (EL(92)2 I). BAOMS Audit sub-committee via the Faculty (RCS Eng) Audit committee has been granted f25K for an audit into condylar fractures organiscd as a multi-centre study, and has applied for f60K to fund a National audit of wisdom tooth activity which will involve the entire spectrum of hospital and general practice. A regional network of audit co-ordinators is being established for the specialty, by which means it is hoped to conduct inter-regional audit projects, selecting those which arc of greatest urgency, and in particular to prc-cmpt and answer any major ques-
‘There will he time to audit (the accounts) luter, there will he sunlight later and the equation will come out at last Louis Macneice Bagpipe Music The length of the educational and training pathway in oral and maxillofacial surgery in the UK produces highly competent consultants who have been tested by formal examination, in-training assessment and the everyday rigours of clinical life. The traditional reward of clinical freedom is as exciting a prospect for the individual trainee as it is an illusion to the established streetwise consultant (Hoffenberg, 1981). Embodied in the NHS reforms is the philosophy that it is no longer acceptable for an individual clinician to do whatever he or she pleases when treating patients. One of the main thrusts of these reforms, and one which the profession endorses, is accountability, whcrcby individual clinical freedom is subsumed by a corporate freedom in which the profession has the responsibility for monitoring standards (McKee, 1989). How do we therefore reconcile Government’s recognition that medical audit should be professionally led with the emergence of for example, the Clinical Standards Advisory Group, a free-standing Government committee set up to monitor standards of clinical care? How do we reconcile the requirements of the Patients’ Charter and the business aspirations of Trust status hospitals with our own perception of quality of cart? Should the Dcpartmcnt of Health or management have the right of access to the results of audit conducted by clinicians or should they be allowed to see only that which we wish them to? Whether the profession likes it or not, the Dcpartment of Health is looking for cheaper, more effective health care delivery. The fact is, that unless the profession accepts the responsibility for setting its own standards of care, those standards will be imposed by government agencies. Audit is the acceptable face by which the profession can identify its own standards and insist that they be met. When clinicians raise genuine concerns resulting from audit, they have a right to expect a positive response from both their peers and management. Availability of case-notes: clerical and sccrctarial support, excessive case-load jeopardising safety standards or time for training of junior staff, adequacy of cquipmcnt and working environment are all issues upon which management must demonstrate its support for audit. Such issues are much more likely to receive remedial attention if shortcomings arc identified by open audit than by the strident call of an individual from the wilderness. Quality of cart can be examined at three different 353
354
British Journal
of Oral and Maxillofacial
Surgery
lions relating to the activity of Oral and Maxillofacial Surgeons. Ry this means it is hoped that our specialty may set its own standards of care and demonstrate to others what is required to meet those standards and above all to ensure that we continue to deliver the goods! These issues will require universal cooperation of our membership, but are vital to be able to demonstrate within the new Health Service and are equally vital to succeeding generations of oral and maxillofacial surgeons and their patients.
BAOMS
Audit
P. J. Leopard Chairman Subcommittee
References Crombic, 1. K. & Davies, H. T. 0. (1992). Towards good audit. Brirish Journal ofilospirul Medicine, 48, 182. Donabedian. A. (1969). A Guide IOMedical Cure Adminisfration. vol. Il. Medical Care Appraisal. Washington DC: (American Public Health Association). Ciardncr, M. J.. Machin, D. & Campbell, M. J. (1986). Use of checklists in assessing the statistical content of medical studies. British Medical Jounwl. 292,810. IIotTenberg, R. (1981). Clinical Freedom. London: (Nutheld Provincial Hospitals Trust). McKee. C. M. (1989). Can medical audit be implcmentcd by 19YI? Postgraduate Mcdicul Journal. 65,645. Medical Audit-Allocation of Funds 1992-93. XIIS Muna~ement Execufire L.etfer. EL(92)2 I.
