Eye on EBVM: clinical audits – uniting teams under one same goal

To keep the team and clients from Rosevean Veterinary Practice in Penzance, Cornwall safe throughout the pandemic, admission appointments were being carried out in the practice car park, from discussing procedures with clients to obtaining verbal informed consent.

It all worked until a patient was admitted for a routine castration, but it later became clear his testicles had not yet descended – this hadn’t been checked as the team member could not take the cat out of his carrier in the car park.

In September 2020, the team agreed to carry out a clinical audit to consider how many patients were getting a pre-operative check and how many admission forms had been completed.

First audit

Out of a total of 82 admission forms, only 5 had been completed fully and included patients’ vital signs. Through discussion, team members explained they often didn’t have space to fill the form outside, or couldn’t ask owners to hold the pets while they did.

Together, team members discussed the issues raised by outside admissions, as well as ways to identify surgical sites.

Key changes

Key changes included the following:

• Two nurses were allocated for temperature, pulse and respiration, and more time was allowed for the admission process, with longer time slots.
• Additional steps were introduced to try to identify masses or lumps correctly, including checking clinical notes and asking the client. Potential areas of concern were checked by shaving over the area, if appropriate, or recording the area on the diagram. The vet would then write detailed notes, including anatomical landmarks.
• Informed consent is gained from the client by reading him or her the key information aloud, and asking if he or she is clear and happy with the information.

Second audit

In November 2020, another 82 admission forms were sampled – things had changed. Now, 66 per cent of admission forms were complete – an improvement of 60 per cent in two months.

Not all were perfect – many still had missing respiratory rates, and sometimes heart rate had been noted as “okay”. But the audit allowed the team to discover where improvements could be made and identify any training needs.

The team agreed to discuss the results at the next nurse meeting, including potential new measures, such as increasing admission time to 15 minutes.

The practice continued to audit admission forms every two months until they had reached their agreed level of care. Where and when necessary, procedures are adapted to continuously improve the standard of care provided.

Impact

Allowing time and space to look at the results as a team, and decide next steps, ensured buy-in to the audit process, embedding its usefulness in the natural ways of working of the practice. It avoided falling into a culture of blame, involving all team members and sharing workload fairly. Ultimately, patient care is at a good standard, and any mistakes can be identified and addressed quickly and efficiently.

Charlotte Thomas (RVN) and her team are now highly engaged in Quality Improvement (QI). Each team member has now completed RCVS Knowledge’s free clinical audit CPD and can each lead audits in their own areas of interest.

Why an audit?

A clinical audit is a starting point to implement change, and is the core activity in the implementation of QI. It is repeated regularly to check clinical care meets quality standards and monitor any variations, so these can be addressed.

It allows practice teams to gather data in a robust, methodical manner that can then be compared against at a later stage. Most importantly, it brings the team together, working towards a common goal to ultimately improve patient outcomes.

What are the steps?

The steps of a clinical audit are:

1 Choose a topic relevant to your practice – this should be easy to measure, commonly encountered and with room for improvement.

2 Select your criteria – these should be easy to understand and measured. In the audit described in the article, 82 forms were audited, the total number in September 2020.

3 Set a target – the initial audit will be your benchmarking figure, but you should discuss and agree on what it is.

4 Collect data – who will do this, what data is needed and in what form?

5 Analyse – was the standard met? Compare your data with the agreed target or benchmark. Note why any might not have been met. Discuss findings with your team.

6 Implement change – what is going to ensure you meet your target? Create an action plan: what needs to be done, how and when? Set a time for a re-audit.

7 Re-audit – repeat steps 4 and 5 to see if changes in step 6 made a difference. If not then repeat the cycle, identifying new changes to introduce. You can still compare with previous audits to consider any improvements or differences.

8 Review and reflect – share your findings and compare your data with other relevant results. Regular team meetings allow for discussion on how the procedure can be adapted to create better results.

So, when are you getting started? To find out more about clinical audits and QI, contact ebvm@rcvsknowledge.org or visit rcvsknowledge.org/clinicalaudit

• Charlotte Thomas was highly commended in the RCVS Knowledge Awards 2021 for Quality Improvement in practice. You can apply for the 2022 Knowledge Awards until 4 December. Find out more at rcvsknowledge.org/grants/available-grants