Professionalism E. Knowledge and understanding of Clinical Audit and Peer Review

PE

Domain: Professionalism

Competency:

E. Knowledge and understanding of Clinical Audit and Peer Review

Recommended for assessment:

Evidence of audit and/or peer review experience.

Evidence Included for assessment.

Radiograph Audit with reflective commentary.

Additional evidence: see Section PB- Reference from Dentist XYZ.

Evidenced Clinical Management

Clinical Audit

• Audit: purpose, methodology, results, conclusion.

• Evidence 1. Audit cycle 1, original log book.
• Evidence 2. Audit cycle 2, original log book.

Evidenced Clinical Management

Clinical Audit

Introduction

What is clinical audit?

Audit is a method of reviewing or testing current practices or policies within an organisation to identify protocol weakness or good practice.  A specific topic is selected, tested, the results reviewed and changes implemented

What is the role of clinical audit in general practice?

The overall role of clinical audit should be primarily to improve patient care directly or indirectly.

What aspects of practice should be audited?

If there is already a concern about an element of practice- then this is a good place to start and audit. Alternatively a commonly performed procedure could be audited to identify specific ways of improving the procedure. E.g. An audit of the success of inferior alveolar nerve blocks.

Methodology.

As part of The Dental Clinic's Radiography Quality Assurance Policy an annual audit of radiographs should be carried out.  The framework for the audit is similar to the examples given in the FGDP's Selection criteria for dental radiography. The audit was prospective and a sample of 25 intra-oral films reviewed on a 3 point scale i.e.

• ‘excellent’ ≥ 70% no errors and with a diagnostic yield sufficient to support treatment decisions
• ‘acceptable’ ≤ 20% some errors but which do not detract from the diagnostic utility.
• ‘unacceptable’ ≤ 10% errors which give an unacceptable diagnostic yield

The criteria is clearly defined and gives numeric standards to work to.

Critical appraisal of methodology

Sample size: I think 25 films is a fair sample size and a larger sample size would be unnecessary and burdensome, a smaller sample would not be representative.  

Design: The audit would be carried out prospectively. The inherent weakness of prospective studies is that they may incorporate bias.  However, given that there are few good reasons for consciously taking  non-diagnostic image I do not feel it necessary to alter the design to say a retrospective study.  The advantage of a prospective study is that it can also be easily integrated into the routine of the dentist and thus easier to carry out whereas a retrospective study would be more time consuming.

Film assessment:  The audit provides an excellent and clearly defined criteria for rating the films.  It could be suggested that some films would be debatable between clinicians e.g. whether a film was diagnostically acceptable or not.  Thus in addition to The Dental Clinic's QA procedure a post-audit meeting should be organised and sample films taken randomly from the audit and judged by a fellow dental professional/dentist.  This would help clarify that those involved in the audit where calibrated correctly to the assessment criteria.

Results:

The results of the audit are displayed in the below table:

Audit Cycle 1:

Rating 1  "excellent "       (target >70%)	64%
Rating 2  "acceptable"     (target <20%)	24%
Rating 3  "unacceptable"  (target <10%)	12%

*Original log documents can found at Audit Evidence 1.

 
Conclusion:

My score of 'Excellent' radiographs was below the expected standard.  Most failures, according to the audit were due to coning off.  The greatest failure I feel is not the number of excellent or satisfactory- but the number of 'unacceptable' films which usually means a  repeat x-ray and double the dose for the patient.  This area was marked as the most important area for improvement.

Having the presence of a coning device reduces the effective dose to the patient, but means that correct positioning of the beam is paramount.  Though I currently use beam-aiming devices, I reflected on why my score was not as high as it should have been.  There were three conclusions/contributing factors I identified.

1. I was fairly new to the clinic and intra-oral machine arm can feel different initially. 

2. Perhaps I was not taking enough time in evaluating the position of the x-ray machine.

Changes Implemented

1. Allowed more time to become accustomed to the existing machinery

2. Took more time in positioning the x-ray machine.

A second audit was carried out with the changes identified.

Audit Cycle 2:

Rating 1  "excellent "       (target >70%)	88%
Rating 2  "acceptable"     (target <20%)	12%
Rating 3  "unacceptable"  (target <10%)	0%

*Original log documents can found at Audit Evidence 2.

Discussion

This time the results showed considerable improvement over the last audit. With no unacceptable radiographs and 88% at grade 1 or more.  Most importantly there were no unacceptable radiographs.  This denotes a demonstrable benefit to the patient of improvement through audit methods.  Although pleased with the result I think the result is probably generous as audit 1 had a higher concentration of periapical radiographs which tend to have a higher risk of coning/missing target etc.  The audit spans less time also than the previous audit, again limiting its accuracy.  

I was quite amazed at the difference just taking a little more time in position the unit has made cumulatively.  I think previously I was trying to minimise discomfort to the patient by trying to take the x-ray too quickly resulting in poor positioning..

Conclusion:

By implementing the changes for the audit I was able to improve the standard of patient care.

Evidence 1 – First clinical audit