Clinical practice guidelines and Clinical audit Dr Armin Shirvani

What are clinical practice guidelines? Clinical practice guidelines are recommendations for clinicians and consumers about optimal and appropriate care for specific clinical situations

Criterion (definition) A systematically developed statement that can be used to assess the appropriateness of specific healthcare decisions, services, and outcomes (Institute of Medicine, 1992)

Definitions of a ‘standard’ An objective with guidance for its achievement given in the form of criteria sets which specify required resources, activities, and predicted outcomes (Royal College of Nursing, 1990) The level of care to be achieved for any particular criterion (Irvine and Irvine, 1991) The percentage of events that should comply with the criterion (Baker and Fraser, 1995)

Criteria structure (what you need) process (what you do) outcome of care (what you expect).

Structure criteria Structure criteria refer to the resources required the numbers of staff and skill mix organisational arrangements, the provision of equipment and physical space

Process criteria Process criteria refer to the actions and decisions taken communication, assessment, education, investigations, prescribing, surgical and other therapeutic interventions, evaluation, and documentation.

Process criteria Process criteria are more sensitive measures of the quality of care, as a poor outcome does not occur every time there is an error or omission in the provision of care. the importance of process criteria is determined by the extent to which they influence outcome

Outcome criteria Outcome criteria are typically measures of the physical or behavioural response to an intervention and reported health status

Outcome criteria Some audits focus specifically on outcomes and collect data about the outcomes of care. This is a practical possibility when outcomes are easily measurable and occur soon after the delivery of care. If the outcomes are also of major importance to users, for example postoperative complications, the direct measurement of outcome is not only appropriate but also expected

Outcome criteria When outcomes are used for comparative audit, adjustments may be needed for case mix, a process known as ‘risk adjustment’.

Developing valid criteria/ standard Based on evidence Related to important aspects of care Measurable

methods of developing criteria

Using guidelines Recommendations from clinical practice guidelines can be used to develop criteria and standards without substantial additional work

Prioritising the evidence method This method of developing criteria reviews the evidence in the source guidelines or systematic reviews for each element of care identified as important in determining outcome The criteria that have most impact on outcome are then categorised as ‘must do’ or ‘should do’

RAND/UCLA appropriateness method The findings of a literature review are submitted to a panel of clinicians, chosen for their clinical expertise and professional influence, who are asked to rate the appropriateness of a set of possible indications for the particular procedure

Examples of criteria New benzodiazepine prescriptions must only be issued for short-term relief (no longer than four weeks) of severe anxiety or insomnia

Methods for developing standards

Using levels of performance achieved in trials the levels of performance achieved in trials are helpful, but should not be regarded as uniformly achievable in unselected patient populations.

Benchmarking An organisation first identifies the areas of practice where the quality of patient care would benefit from comparison and sharing of information about the processes involved in achieving high performance Then it compares its performance with that of its most successful ‘competitors’ and considers areas for development in the light of the comparison

Care pathways Integrated care pathways define the expected timing and course of events in the care of a patient with a particular condition They describe explicitly all the expected processes of care. Care pathways are easier to introduce when there is established routine practice and little variation between users

Example for blood transfusion Donors should have a health check prior to donation(criterion). We would expect 100% compliance, it is mandatory for all donors(standard).

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