Audit: Why and How

Fig. 20.1.

(a, b) Impact of ERP compliance on the development of complications and length of stay. (Adapted from ERAS Compliance Group. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Annals of Surgery 2015 Jan 23, with permission).

However, compliance can go up as well as down and just as important as implementation is sustainability. Innovations, such as ERP, require continual work, and it is often challenging to maintain early positive results. Around 40 % of public health interventions are not maintained after the implementation phase, and after funding has ended. ERP is a complex, multimodal, multidisciplinary intervention and presents a particular challenge for sustainability. A single center study in Holland demonstrated that during the implementation phase of ERP, significant improvements in hospital stay and reduction in complications were seen following colectomy for cancer [8]. However, in the 2 years after implementation, the compliance with a number of fields fell and there was a concomitant increase in overall length of stay. This unit would have had excellent ERP protocols and surgical ERP pioneers, and one of the Dutch authors concluded, “a protocol is not enough.” Audit together with continual monitoring and analysis of data is essential to deliver and maintain the improvements in perioperative care that are offered by ERP.

Practical Tips on How to Conduct an Audit

What Makes a Good Audit?

Prior consideration of an aspect of surgical care that is measurable and in which a change/improvement in practice will be beneficial.
Formulating a question that is as simple as possible to aid clarification for others.
Delivery of the outcome within available resources (staff, time, IT).
By gaining local support, an alignment with the organization’s overall audit priorities and early involvement of the local hospital clinical audit department can greatly improve quality.
Contributing to national, regional or international audit has the significant benefits of per-to-peer comparisons so that local activity can concentrate on high quality data submission and actions arising from the findings.

Finding and Setting the Standards

In establishing standards, a number of national reference sources/guidelines are available, e.g., “Guidelines for perioperative care in elective colonic surgery” and “Consensus guidelines for enhanced recovery after gastrectomy,” both published by the ERAS Society.
Having agreed a standard, define a baseline or criterion with the minimum expected level of performance.

Collecting the Data

Minimize the collection of new data by using existing sources of collected data, possibly networking systems to allow access to data.
Be clear about methodology before designing data collection proformas.
Define who is collecting data—enhanced recovery facilitators are likely to be both motivated and accurate, but if other members of the team are involved the shared responsibility can be an advantage. NSQIP uses specially trained nurse data collectors.
Collect the minimum amount of data to answer the audit question, opt for prospective collection whenever possible and avoid “mission creep” for “interesting” questions.
Discuss with colleagues to avoid pitfalls and repetition, and to maximize benefit.
Ensure that the audit collection and storage are compatible with local information governance procedures with regards to patient confidentially and data protection.

A highly developed database is commercially available from the ERAS Society that has many useful functions to help units to set up enhanced recovery care and track outcomes (www.erassociety.org/index.php/eras-care-system/eras-interactive-audit-system). Should teams not wish to use this then we suggest a minimum dataset of the enhanced recovery elements be measured as listed in Table 20.1. Compliance with these “interventions” can then be measured and benchmarked with established standards. Outcomes should include postoperative hospital stay, readmission, and reoperation as a minimum. If possible, an assessment of complications within 28 days of surgery should be included in order to allow a more sophisticated analysis of the effect of the program on outcomes, and thus quality.

Table 20.1.

A suggested minimum dataset to audit for compliance to enhanced recovery care pathway.

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