It is often easy deciding on a topic to audit, running a computer search that might churn out much of your audit data, or perhaps roping someone in to trawl through patient records and collect the data for you. But do you always believe the findings? When the data is analysed and results produced, do you move onto the next step in the audit cycle and make any necessary changes to your current practice?
Making changes is one of the hardest things to do. It is human nature to dislike change. When I asked GPs if they had any problems implementing changes after an audit on the management of diabetes "work load implications of the change" or "just trying to get other people on board" were two of the problems cited.
In 1995, the Eastern Health and Social Services Board (EHSSB) GP Audit Team launched an inter-practice audit on the management of diabetes. We were delighted when 32 practices out of 147 registered to participate but were even happier when, a year later, two thirds decided to do it all over again.
One of the major problems often cited with the audit cycle is people's failure to complete it.1,2,3 We wanted to find out if there were any triggers for change as well as what influenced participation in audit.
It was assumed that if the healthcare professionals chose to re-audit they had made changes in practice and wanted to see if these had been effective.
A qualitative research method was adopted to identify any triggers for change and how these were implemented. A semi-structured interview schedule was drafted and piloted before securing interviews with GPs or practice nurses from 18 of the 23 practices.
The interviews revealed some important insights into the working of the audit cycle:
- Practices participated in the audit because it was organised for them
- Since the GPs or nurses collected the audit data, they identified areas for change this subsequently triggered change
- In large multi-practice audits it is important that participants retain ownership of the project. This can be achieved through facilitation, discussion and enabling participants to set group standards of care, rather than being dictated to
- As participants argue re-audit is beneficial they do it
The audit team had undertaken the 'leg work' for practices in that the audit was organised for them. The British Diabetic Association guidelines were used, and there was consultation with local primary and secondary care experts in the field to formulate the criteria and subsequently design the data collection form.
As one GP said "having the audit organised for us just made it that bit easier". GPs did not have to spend valuable time researching and devising suitable audit tools for the topic, often the lengthiest stage in the audit process.
Many MAAGs have the expertise to undertake searches for best available evidence and can help design audits to suit individual practices. Publications such as Guidelines are an excellent place to start looking for current evidence and often MAAGs have gathered together 'off the shelf' audits, which can be easily adapted to meet local circumstances. It is vital to remember that your audit group is there to help you.
We encouraged practices to undertake their own data collection which had a significant impact on the audit process. For some professionals it identified aspects of care "where you were defective, enabling mistakes to be picked up far easier". As one GP said the audit is "serving two purposes, it's not just doing an audit, it's bringing our charts and clinic records up to date as well".
As the doctor or nurse directly involved in the care of the diabetic patient collected the data they in turn identified any weaknesses or gaps in patient care, often making changes on the hoof. It made it harder for them to deny the results of the audit because the people who have to make the changes themselves saw the need for change.4
Collecting data also proved to be educational, highlighting forgotten aspects of care. It raised awarenesss of the importance of thinking about outcome measurements, rather than just process measures. As one GP said, "we started looking at the results we were getting and our HbA1s were quite high, so from the initial audit we were trying to reduce the level of the HbA1s."
Various strategies were used to disseminate audit results back to practices. Each practice received a report of their results and a report with the aggregated results of the 32 practices so that they could compare their performance with that of their peers.
Some reports were discussed at practice meetings, others were studied by the doctor and nurse but unfortunately in other cases reports were not always utilised effectively.
Dissemination of results was, on occasions, poor among GP and nursing colleagues and often results were not circulated to the wider diabetes team, with the chiropodist and dietician forgotten.
As GPs and practice nurses had identified changes which were often made on the hoof, this could have a detrimental effect on ensuring lasting and effective change as other members of the practice team also needed to be updated, so that patient care overall could be enhanced. Once identified, gaps in care need to be rectified, not just for a single patient, or in the sample audited, but for the entire group.
Good communication is vital to the change process 5 but if a GP merely tells his partners "that our care was sub-optimal and we had to change" it does not necessarily enable them to see the need for change. Practices also need to consider an action plan as an integral part of the audit process. This should take into account the discussion and dissemination of results and who will be responsible for implementing the change. As one GP discovered "If I don't drive it we will not make any changes".
To back up the reports, an educational evening meeting was organised where participants set standards to be achieved in the re-audit. Involving the practices in this stage of the audit ensured they retained ownership of the project. It also gave them the opportunity to discuss results with their peers, which most found beneficial.
The practice nurses, who often feel isolated, appreciated having "the opportunity to discuss issues with nurses in the same situation".
There are a number of areas the audit team need to consider in future multi-practice audits.
- Initially individual practice reports were non-directive, with no attempt made to interpret the results. However, we are considering offering this option for 1998/99 as practices do not always have the necessary skills to take the audit results forward.
- Practices may also need facilitation to enable discussion of results within the primary care team. As a team they would decide on what and how to change but as audit facilitators we could become the change agents helping to drive and guide the practices through the process.
Although barriers and resistance to change were encountered within many of the 18 practices interviewed, the audit team were pleased to see changes had been successfully implemented.
This is reflected in the graph that compares the initial audit results with the re-audit for patients who are managed solely in the practice by the GP and practice nurse (figure 1).
|Figure 1: Comparison of 1995 and 1996 audit results|
It will be interesting to see if these results have been sustained or further improved upon, when the audit is revisited later this year.
- I wish to thank all the GPs and practice nurses within the EHSSB who participated in the audit and especially those who assisted with this research. My thanks are also extended to my colleagues in the GP audit team, particularly Dr Jean McClune and Mrs Denise Taylor, for their advice and support.
- Eastern Health and Social Services Board, Belfast. GP Audit Annual Report (1995-96)
- Derry J, Lawrence M, Griew K, Anderson J, Humphreys J, Pandker KS. Auditing Audits; the method of Oxfordshire Medical Audit Advisory Group, Br Med J 1991: 303: 1247-9
- Webb SJ, Dowell AC, Heywood P. Survey of general practice audit in Leeds. Br Med J 1991:302:390-2
- Stewart V. (1983). Change the Challenge for Management. McGraw-Hill Book Co.(UK) Ltd.
- Plant R. (1987). Managing Change and Making it Stick. Gower Publishing Company Ltd.