How can we improve outcomes for patients
and families under palliative care? implementing clinical audit for
quality improvement in resource limited settings
Lucy Selman, Richard Harding
King's College London, Department of
Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute,
Bessemer Road, Denmark Hill, London SE5 9PJ, United Kingdom
| Date of Web Publication | 11-May-2010 |
Correspondence Address:
Lucy Selman
King's College
London, Department of Palliative Care, Policy and Rehabilitation, Cicely
Saunders Institute, Bessemer Road, Denmark Hill, London SE5 9PJ
United Kingdom
 | 3 |
Palliative
care in India has made enormous advances in providing better care for
patients and families living with progressive disease, and many clinical
services are well placed to begin quality improvement initiatives,
including clinical audit. Clinical audit is recognized globally to be
essential in all healthcare, as a way of monitoring and improving
quality of care. However, it is not common in developing country
settings, including India. Clinical audit is a cyclical activity
involving: identification of areas of care in need of improvement,
through data collection and analysis utilizing an appropriate
questionnaire; setting measurable quality of care targets in specific
areas; designing and implementing service improvement strategies; and
then re-evaluating quality of care to assess progress towards meeting
the targets. Outcome measurement is an important component of clinical
audit that has additional advantages; for example, establishing an
evidence base for the effectiveness of services. In resource limited
contexts, outcome measurement in clinical audit is particularly
important as it enables service development to be evidence-based and
ensures resources are allocated effectively. Key success factors in
conducting clinical audit are identified (shared ownership, training,
managerial support, inclusion of all members of staff and a positive
approach). The choice of outcome measurement tool is discussed,
including the need for a culturally appropriate and validated measure
which is brief and simple enough to incorporate into clinical practice
and reflects the holistic nature of palliative care. Support for
clinical audit is needed at a national level, and development and
validation of an outcome measurement tool in the Indian context is a
crucial next step.
Keywords: Audit, Outcomes, Quality improvement, Quality of care
How to cite this article:
Selman
L, Harding R. How can we improve outcomes for patients and families
under palliative care? implementing clinical audit for quality
improvement in resource limited settings. Indian J Palliat Care
2010;16:8-15 |
How to cite this URL:
Selman L,
Harding R. How can we improve outcomes for patients and families under
palliative care? implementing clinical audit for quality improvement in
resource limited settings. Indian J Palliat Care [serial online] 2010
[cited 2014 Jul 20];16:8-15. Available from: http://www.jpalliativecare.com/text.asp?2010/16/1/8/63128 |
| » Introduction | |  |
Palliative
care in resource-poor settings has made enormous advances in providing
better care for patients and families living with progressive disease.
Now that innovative, sustainable palliative care facilitates are in
place in India, these clinical services are well placed to begin
considering how to implement simple ways to strive for quality
improvement. Clinical audit
* is recognized globally to be
essential in all healthcare, enabling quality of care to be monitored
and improved. While clinical audit is common within palliative care in
the developed world, it is far less common in developing country
settings, including India.
[1] In
this article we outline some of the reasons why clinical audit is so
important in palliative care, and make suggestions for how Indian
palliative care services can successfully engage with the audit process.
Many of our suggestions come out of experience managing the Encompass
study (2006-2008), during which the first clinical audit of palliative
care services in sub-Saharan Africa was conducted. Working with
principal investigators and local research nurses at four palliative
care services in South Africa and one in Uganda, we developed a model
for palliative care clinical audit in developing country settings which
may be relevant to the Indian setting.
Here, we aim to introduce
the concept of clinical audit within the palliative care setting, and
share some of the lessons learnt during that project.
| » Measuring Quality in Healthcare | | |
The
quality of a healthcare system (or organization) relates to how
effective that system or organization is in achieving it aims. The
quality of an organization can be represented and assessed using a
four-part model of structure, process, output and outcome
[Figure 1].
Each of the four aspects of quality assessment interact, e.g. good
structure increases the likelihood of good process, and good process
increases the likelihood of good outcome.
[2]
It can be useful to collect and reflect on process and output data,
e.g. the time between referral and a patient being seen, or the number
of referrals to a service, in order to demonstrate or understand the
demand for services and practical issues of meeting that demand.
However, while assessing how many home care visits are made on each day,
or how many patients are seen in a month may provide useful information
about how a service is run, does not tell us anything about patients'
or family members' experience of care (for example, having received home
care, did the patient's pain improve?). Only assessing outcomes of care
can provide this kind of information. The outcomes of care (i.e. (4.)
in the model) are therefore of particular relevance in measuring
quality, as they measure directly the relevance of care for patients,
families and society as a whole.
| » What is Clinical Audit ? | | |
Clinical
audit is one way to measure quality in healthcare. It can be defined as
the 'systematic critical analysis of the quality of clinical care
including procedures used for diagnosis and treatment, the use of
resources and resulting outcome and quality of life.'
[3]
In other words, clinical audit means a) looking at how well we
currently perform something (e.g. pain management or psychological
support), b) setting a target for how well we want to do it, c) deciding
how we will make the improvement, d) putting this in place, and e)
measuring again to see if we have achieved the target (see Box 1 for
more details)-
[Additional file 1].
Clinical audit is a cyclical activity, although this is often
misunderstood: evaluation on its own is not audit, as the data collected
are not used being used to inform changes in service provision which
are implemented and evaluated. As Stephen Connor has said, 'Quality
assessment must be tied to quality improvement'.
[4]
For service providers, this could mean conducting a clinical audit
every year to make sure the service is always working to improve the
care that is delivered. Clinical audit thus becomes a process of
continuous improvement in the quality of care provided by a service,
embedded within routine clinical practice and helping to bring about
change for the better in terms of patient and family care. Because of
its cyclical nature and the dynamism it brings to a healthcare
organization, clinical audit has been described as its 'vital signs' or
'pulse', evidence that the organization is living rather than
stagnating.
[5] Importantly,
clinical audit is not a process of comparing one service with another
and finding one or the other to be lacking in some way. Services will
have different aims and philosophies, and, as Stjernswald says, 'You
should not compare chocolate with mango'.
[6]
Clinical audit is ultimately about service providers being aware of
the quality of their own service's care, including areas for potential
improvement, and putting steps in place accordingly. The targets for
improvement that services set themselves should reflect their stated
aims as well as the areas of care currently requiring extra attention.
Only when services are sufficiently similar in terms of their aims and
the population cared for is comparison meaningful. In this instance,
collecting data for audit does enable the effects of implementing
different service models to be better understood. However, actual
services will always be more complex than the service models they
utilize, and should be considered in the context of the specific
characteristics of the communities they serve. Clinical audit should not
therefore be seen as a threat, but rather as a facilitator that enables
more accurate reflection on service provision.
| » Outcomes in Palliative Care | | |
Outcomes can be understood as any end result that is attributable to health service intervention,
[7]
where health is defined as a state of complete physical, mental (which
may include spiritual) and social well-being and not merely the absence
of disease or infirmity.
[8]
Clearly, this fits in well with the model of palliative care. In a
general healthcare context, the outcome of primary interest is often
morbidity; e.g. how many patients died from having an operation of type X
at hospital Y in one year. Within palliative care, this aim is less
relevant, as the focus of care shifts from extending life to improving
the quality of life. A range of outcomes of relevance to palliative care
arise out of the holistic aims of palliative care as stated, for
example, by the World Health Organization (WHO)
[9] (Box 2, also see
[10] )-
[Additional file 2].
Any of these outcomes would be an appropriate focus for measurement and
improvement in a clinical audit, depending on the stated aims and
priorities of the service.
| » Why Should Specialist Palliative Care Measure Outcomes of Care ? | | |
Measuring
the outcomes of palliative care has five main benefits. Firstly, it
enables improvement of patient and family care on a holistic and
individual basis. By obtaining more detailed information about the
patient and family by using formal assessment methods in day-to-day
practice, healthcare providers are able to tailor and improve their care
on a case-by-case basis.
Secondly, assessing the outcomes of
care in a formal way enables evidence to be gathered on the impact of
care on the patient and family and the effectiveness of the service at
meeting its aims. As palliative care is a relatively new specialty, it
has much to prove! If systematically collected data is aggregated,
analyzed and reviewed, it can be used as evidence of, for example,
efficacy or cost-effectiveness. Through measuring the outcomes of care,
studies in the US and UK have shown that palliative care improves
quality of life, physical well being and symptoms including pain,
spiritual well being and psychological well being.
[11],[12],[13]
Such evidence of effectiveness can be used to justify the continuation
or expansion of services and secure resources for future services, e.g.
by convincing potential funders.
[14]
Thirdly, and most crucially in the context of this article, measuring
outcomes is fundamental to clinical audit, enabling quality of care to
be assessed and improved. Routine collection of data on the outcomes of
care in diverse domains enables potential areas for improvement to be
identified when the data are reviewed. Service managers can then utilize
this data to improve practice, decide where resources should be
focused, and set locally-relevant targets for quality of care for the
future. Through ongoing audit the achievement of these targets can be
monitored, and effective techniques to improve care can be shared with
other services.
Fourthly, at the national level, measuring
outcomes across a range of services builds an evidence base for setting
quality standards and quality indicators appropriate and feasible for
different types of service across India. Quality indicators (also called
quality markers) are explicitly defined and measurable items referring
to the outcomes, processes, or structure of care.
[15]
As quality indicators are adopted voluntarily, they offer a framework
for a palliative care organization to define and track its progress
against its own action plans.
[16]
In India, where quality indicators have not yet been set and service
evaluation is at an embryonic stage, there is the chance to learn from
omissions in developed countries,
[17],[18]
and ensure that cultural and spiritual aspects of palliative care, and
the needs of family carers, are taken into account in national guidance
and audit. Ultimately, national standards and quality indicators also
need to be subjected to testing through well-designed trials.
[19] Finally,
the most important reason to do audit is that patient and family have a
right to quality care, matter where they receive care, how that care is
delivered, or who delivers the care. Whether a patient is receiving
care in a hospital or at home, from trained community volunteers or from
medical personnel, the quality of care should be assessed, and the
service provider should be committed to its improvement.
| » Clinical Audit in Indian Palliative Care | | |
There
has been some debate regarding the utility of conducting research,
including service evaluation and audit, in developing country settings,
where the funds used for such activities would, it is suggested, be
better placed in feeding a hungry population.
[20]
However, in resource-limited contexts it is perhaps even more crucial
that available resources, such as staff time and available funds, are
used effectively, and that service development is evidence-based.
[21],[22],[23]
As Higginson and Bruera state, measurement and clinical audit are one
way to minimize the risk of failure, learn at an early stage about
potential problems, and identify successful strategies.
[21]
Without auditing the outcomes of care, some important domains of
palliative care may be neglected. Costs of not conducting clinical audit
include providing extra, inappropriate treatment, which wastes
patients' and families' time as well as staff time and resources;
providing underutilized or inappropriate services; uncontrolled symptoms
which are distressing for patients and families, and may lead to
delayed discharge or preventable emergency admissions; and other
unresolved problems that may cause preventable suffering.
[3] For example, research indicates that in the US and UK the needs of family members are often unmet.
[24],[25],[26]Failure
to audit family outcomes (such as family worry, confidence in caring
for the patient, and adequacy of information received) may mean that
they continue to be neglected.
[27] The
need for evaluation and monitoring of quality of care in the Indian
setting has been recognized by several authors writing in this journal.
[1],[6],[28]
Anil Kumar Paleri reports that the Pain and Palliative Care Policy of
the Government of Kerala 'favors locally relevant audit and research at
various levels for improving the programs and sharing useful experience.
[29]
Given the recognition of the importance of evaluation, what is now
needed is a clear and concrete action plan, with a commitment from the
Indian Association of Palliative Care (IAPC) and service providers to
create the conditions necessary for clinical audit to be carried out
across palliative care services in India. While there are organizational
factors which facilitate successful audit [Box 3]-
[Additional file 3], an essential first step is the selection of an outcome measurement tool.
| » Choosing an Outcome Measurement Tool | | |
In
the UK, a range of measures are used in palliative care service
evaluation, the most common being the Support Team Assessment Schedule
(STAS).
[3],[27]
However, many palliative care service managers report that they have
developed their own assessment tools, or used more informal methods of
evaluation such as staff meetings and daily log books.
[27]
A disadvantage of, using informal methods of assessing outcomes Is
that it is difficult to set concrete and meaningful targets which
reflect the experience of care by patients and families without inviting
them to participate through the use of self-completion (or assisted
completion) questionnaires. Using an assessment questionnaire developed
in an informal way at your own service is also problematic, as the
validity and reliability of the tool is unknown. Established tools used
for audit and research purposes have undergone formal psychometric
testing to ensure they are valid and reliable, i.e. measure what they
set out to measure, and are appropriate in palliative care populations
(for example, not too long and burdensome). The validation process aims
to identify and eliminate problems in tools, such as systematic bias
introduced by wording which leads the respondent to answer one way
rather than another, or measurement inadequacies such as floor and
ceiling effects. In addition to giving more accurate and valid results,
the use of a validated and standardized outcome measurement tool across
services means that results from sites with similar service models can
be pooled, and results from services or service models with sufficiently
similar aims can be meaningfully compared. This can contribute towards
the setting of national quality standards, and may also eventually
elucidate some of the strengths and weaknesses of specific service
models.
[4],[23]
In Africa, we were able to conduct audit as part of the Encompass
project because of careful collaborative science beforehand to develop
the APCA African Palliative Outcome Scale (POS).
[33],[34]
The APCA African POS was based on the Palliative Outcome Scale, a tool
to assess quality of care that was originally developed and validated
in the UK.
[35],[36],[37]
Working with the African Palliative Care Association (APCA) and
services across Africa, this outcome measurement tool was developed and
validated in a range of different settings, producing a tool that is
tailored to and reliable in African palliative care. Services across the
continent are therefore able to use the same tool in the knowledge that
it is psychometrically valid and reflects their goals of care.
Development of a similar tool in India is an essential task.
The
use of a questionnaire such as the POS that is specifically designed to
measure the quality of palliative care helps to ensure that a wide range
of relevant outcomes are assessed.
[38]
A survey of palliative care services in Britain and Ireland found that
although physical aspects of care were audited relatively frequently
(by 61% of services), other core aspects of care were rarely audited,
including bereavement care (17%), training (13%), and psychological and
spiritual care (12%).
[27]
One of the reasons for this is that the latter domains are considered
more difficult to assess formally than physical aspects of care. In the
UK survey, 28% of services stated that difficulty of assessment was the
reason for not auditing bereavement, 33% gave that response regarding
psychological and spiritual care, and 15% regarding training.
[27] However, well-validated measures do exist for the assessment of these more intangible concepts, such as quality of life,
[39],[40] spiritual well being,
[41],[42] the impact of training,
[43],[44] and bereavement outcomes.
[45],[46]
As Charlton says, 'Unless these aspects are evaluated regularly,
service providers cannot be confident they are successfully achieving
their mission to promote optimal palliative care and, where possible, a
good death'.
[27] Given
the proliferation of palliative care outcome measures in recent years,
it would beneficial to build on previous work and revalidate an existing
measure in the Indian context. The choice of an appropriate tool would
depend on the goals of the IAPC and the properties of the existing
tools. However, it is important that the tool chosen for adaption and
revalidation meets certain criteria [Box 4]-
[Additional file 4].
| » Conclusion | | |
Collaboration
at regional, national and possibly international levels may be required
in order to establish the necessary conditions for audit in India.
Establishing relevant audit systems will require close interaction
between local programs with specific needs and those with audit
experience and methodological skills.
[21]
The development and validation of an Indian palliative care outcome
measure will also necessarily be a collaborative process, in order to
ensure that the resulting measure is applicable and appropriate across
the subcontinent. However, there are also concrete steps that service
providers can make in terms of staff education and training about
quality improvement, prioritization of research and clinical audit, and
collaboration with the IAPC and other services to ensure quality
improvement remains high on the national agenda.
The IAPC has an important role to play in fostering increased service evaluation and improvement of existing services,
[1]
including supporting services conducting audit nationally. As a step
towards this, the IAPC and Pallium India are to be congratulated for
developing national standards for palliative care, reproduced in the
Appendix to this paper. One of the desirable standards is that a
palliative care service has a commitment to continuous quality
improvement through ongoing use of a standardized audit tool (Point 34
[51]
). In order to meet this standard, the adaptation and validation of an
appropriate outcome measurement tool is an essential next step, as
recognized by the Declaration of Venice.
[22]
Only with such tools can relevant and applicable information regarding
the effectiveness of palliative care in India be produced, and
evidence-based standards and quality indicators be developed nationally.
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