individual Fellows who are interested in designing their own performance assessment strategy using data recorded in their charts or health records

Transcription

1 Ryal Cllege Guidelines Develpment f Clinical Audit Activities Intrductin Clinical audit activities are designed t prvide individual physicians, grups f physicians, r inter-prfessinal health teams with data and feedback n their perfrmance. Clinical audit activities prvide a prcess fr data cllectin and prvisin f feedback t assess current perfrmance against established perfrmance measures r practice standards. Clinical audit activities cntribute t the cntinuing prfessinal develpment f individuals, grups r teams by prviding an pprtunity t identify areas where perfrmance meets r exceeds expectatins and areas where imprvement is either desirable r required t imprve the patient care. Clinical audit is a valued assessment activity included within Sectin 3 f the MOC Prgram and is assigned 3 credits per hur. Chart audit activities are nt required t be reviewed and apprved by an accredited CPD prvider rganizatin prir t recrding these activities fr credit within MAINPORT. This dcument prvides a descriptin f Ryal Cllege guidelines fr the develpment f a chart audit prcess and/r tl. These guidelines are intended t prvide assistance t: individual Fellws wh are interested in designing their wn perfrmance assessment strategy using data recrded in their charts r health recrds CPD prvider rganizatins that are explring the design and implement a chart audit prcess r chart audit tl t supprt specialists in participating in Sectin 3 f the Ryal Cllege s Maintenance f Certificatin Prgram. Dcumentatin required Beynd the standard dcumentatin f recrding the fcus, key findings and reflecting n the utcmes identified frm cmpleting the chart audit activity in MAINPORT, specialists shuld be able t prvide upn request: 1. A descriptin f the perfrmance measures selected t assess perfrmance. 2. A cpy f the chart audit tl that was used t cllect the data 3. A descriptin f hw feedback n perfrmance was btained 4. Any learning bjective that was develped based n the chart audit The Ryal Cllege f Physicians and Surgens f Canada. All rights reserved. Page 1 f 5

2 Ryal Cllege Guidelines Develpment f Clinical Audit Activities Develpmental Guidelines Clinical Audit Activities Clinical audit activities shuld be develped t meet the fllwing Ryal Cllege guidelines. Define the assessment fcus fr the clinical audit activity Guideline 1: Clinical audit activities shuld be fcused n aspect f clinical practice that is relevant t an individual, grup r healthcare team. Selecting an aspect f clinical practice that is relevant shuld cnsider cnditins, disrders r diseases: That are frequently assessed r managed in a specific practice cntext. (prevalence) With an established scientific evidence base. (evidence-infrmed) Where the physician is in direct cntrl f decisins. (attributin) Where actins r decisins may have a direct impact n r be relevant t the clinical utcme experience by patients. (utcme-fcused) Guideline 2: The clinical audit activity shuld be designed t address a defined assessment questin(s) Develping an assessment questin(s) a clinical audit can address r answer shuld cnsider each f the fllwing: The ppulatin f interest. The specific aspects f perfrmance being assessed. The key utcme(s) that will be measured. Select the measures, quality indicatrs r prfessinal standards Guideline 3: Clinical audit activities shuld cmpare current perfrmance against a minimum f 3 selected perfrmance measures, quality indicatrs r standards f care. Selectin f perfrmance measures shuld cnsider each f the fllwing: Perfrmance measures that have been reviewed r validated by the prfessin The Ryal Cllege f Physicians and Surgens f Canada. All rights reserved. Page 2 f 5

3 Ryal Cllege Guidelines Develpment f Clinical Audit Activities Perfrmance measures that reflect established prcess f care standards. Perfrmance measures that crrelate with patient utcmes. Perfrmance measures that include measures f patient experiences f care. Access and Cllect perfrmance data Guideline 4: Clinical audit activities shuld be based n a minimum f 10 cnsecutive cases A minimum f 10 cases will prvide a reasnable assessment f usual perfrmance upn which t make judgements and guide future learning in practice. Case selectin can either be based n a: Review f the last 10 cases assessed r managed in practice (retrspective clinical audit) Cllecting selected perfrmance measures ver the next 10 cases assessed r managed in practice (prspective clinical audit) Summarize and cmpare perfrmance against selected measures Guideline 5: Clinical audit activities shuld prvide a detailed summary f perfrmance in cmparisn with established standards A summary f the data will depend in part n the type f perfrmance measures r quality indicatrs that were selected. Cmparisns can either be based n Dichtmus variables (test rdered / nt rdered) shuld fcus n degree f adherence t established standards Cntinuus variables (degree f cntrl f BP in relatin t established standards) shuld fcus n the percent f patients wh meet established targets Obtain Feedback Guideline 6: Clinical audit activities must include a strategy t btain feedback frm clleagues, peers r mentrs Feedback btained frm clleagues, peers r mentrs assists t reflect n and making sense f the data; identify areas f strength; and aspects f practice where perfrmance can be imprved. Identifying the Outcmes fr Practice 2015 The Ryal Cllege f Physicians and Surgens f Canada. All rights reserved. Page 3 f 5

4 Ryal Cllege Guidelines Develpment f Clinical Audit Activities Guideline 7: Clinical audit activities shuld result in identifying the impact f the identified utcmes fr future learning and practice imprvement. Defining the specific utcmes frm the clinical audit shuld cnsider each f the fllwing: Identifying areas f strength that can be further enhanced. Identifying areas where imprvement is required. Develping ne r mre learning bjective(s) as part f a perfrmance imprvement plan Dcumenting the prcess and utcmes in MAINPORT Guideline 8: Clinical audit activities shuld receive credits fr the time spent reviewing, reflecting and identifying the utcmes fr learning r practice imprvements The hurs that qualify fr credit under Sectin 3 shuld nly cnsider the fllwing: The time spent reviewing the summary f perfrmance against specific perfrmance measures The time spent receiving feedback frm a clleague, cach r mentr The time spent identifying an utcme fr future learning r practice imprvement The Ryal Cllege f Physicians and Surgens f Canada. All rights reserved. Page 4 f 5

5 Ryal Cllege Guidelines Develpment f Clinical Audit Activities Ryal Cllege Guidelines Clinical Audit Activities At-A-Glance Guideline 1: Clinical audit activities shuld be fcused n aspect f clinical practice that is relevant t an individual, grup r healthcare team. Guideline 2: The clinical audit activity shuld be designed t address a defined assessment questin(s) Guideline 3: Clinical audit activities shuld cmpare current perfrmance against a minimum f 3 selected perfrmance measures, quality indicatrs r standards f care. Guideline 4: Clinical audit activities shuld be based n a minimum f 10 cnsecutive cases Guideline 5: Clinical audit activities shuld prvide a detailed summary f perfrmance in cmparisn with established standards Guideline 6: Clinical audit activities must include a strategy t btain feedback frm clleagues, peers r mentrs Guideline 7: Clinical audit activities shuld result in identifying the impact f the identified utcmes fr future learning and practice imprvement. Guideline 8: Clinical audit activities shuld receive credits fr the time spent reviewing, reflecting and identifying the utcmes fr learning r practice imprvements //cmc 2015 The Ryal Cllege f Physicians and Surgens f Canada. All rights reserved. Page 5 f 5