This section owes a great deal to my co-author Gillian Skoulding who developed the concept of using audit not just as a clinical tool, but also as a business tool to determine the effect on your bottom line. The next section Audit II is principally her work, which i am delighted to acknowledge.
In my first article ‘Effectiveness and efficiency’ I described that the effectiveness of any medical treatment is best determined by a double blind cross-over trial, something which is outside the scope of the majority of dentists, me included.
In contrast efficiency is within our control and can be measured. It may be as simple as increasing turnover and an improving bottom line, but these alone may be masking areas where performance is less than optimum and resources are being wasted. One method of assessing performance in depth is Audit.
Audit may be defined as ‘systematic appraisal against predetermined standards’. Audit should be:
This implies that there are several elements to a successful audit result.
- A clearly defined methodology or protocol to collect and document data
- These data need to be analysed against standards to determine performance
- The standards must be set as part of the protocol before data collection commences.
- Requires measurement and measurable criteria.
- Leads to agreed action for improvement.
Measurements can be Quantitative, for example how many, how much, how long etc, or Qualitative. The latter is usually measured on a five point Likert scale for example:
‘How did you rate the new waiting room decorations?’
Very poor poor satisfactory good very good
There are several types of audit methods which can be grouped:
Analysis of Dental Records
This is a long established method to examine the acre given and is usually retrospective. It may involve random sampling for example to evaluate a selection of patients with the same clinical presentation.
Criteria Based Audit
This is the most common type of audit and identifies measurable criteria, defines standards and enables comparisons to take place. This type of audit may be retrospective or prospective.
Adverse Occurrence Screening
This method looks at things that should happen and did not, or things that should not happen and did, and is usually carried retrospectively. An adverse occurrence may be clinical or business based but often with too few numbers.
Surveys can be used to obtain feedback information from users of your service and are carried out using a questionnaire. Questionnaire design is critical in achieving satisfactory results and is an art in itself. The questionnaire needs an objective structure and provision for clear unambiguous answers from simple questions. If this is chosen, a pilot study with a small group is a worthwhile preliminary to the main study.
You should consider sample size; the minimum is N = 30. It could also be
- The next 100 with
- The last 100 with
- In age bands
- By gender
- By postcode
The Audit Cycle is shown in Figure 1 and is self explanatory.
After notifying results then
- Change the standard and re-audit again
- Accept the outcome and implement change
In either case there will be management decisions to make about the audit outcome to maintain or improve patient care.
Classically the audit cycle is shown in two dimensions as above. I suggest it would be better envisaged in three dimensions as a spiral, down which you move to reach your goals.
The number of audit topics is potentially inexhaustible, as each dentist will want to consider a different aspect of patient care. For simplicity they can be grouped as:
- Structure – anything relating to the working environment
- Process – anything relating to patient care
- Outcome – anything relating to the results of patient care, prospective or retrospective
The final stage is setting standards This is a key step in the preparation for audit and can be set as:
- A percentage to achieve – a target.
- 100% compliance with defined exceptions.
Determining and appropriate standard for your audit will require imput from several sources. They may be professional/ ideal , pragmatic, derived or absolute
- Standards set by professional societies and Royal Colleges
- Standards set by Government
- Standards set by banks, financial advisors etc
- Standards set by discussions with colleagues/per review
- Standards set through current practice
- Personal standards
- These are based on published standards modified to suit local practice
- An absolute standard applies in situations where only 100 per cent compliance is acceptable. A good example is the taking of a complete medical history and ensuring it is kept up to date.
Having collected the data the next stage is presentation. All results must be anonymised and all individual patient details removed. Your report should show, your name, title of the audit, date commenced and completed, standards used, sample sizes, comparison with standard and a write up. You might consider including the results of your audit(s) in any practice newletter or website.
The final stage is implementing change to improve your efficiency. This will be considered in more detail in Audit II, my next article.