Eye on EBVM: getting the most from clinical audits

Clinical audits enable you to look at how well you’re doing things as a practice. I’m a believer that you can have policies and protocols in place, but they need to be reviewed regularly to remain effective. Looking at the data enables you to maintain your standards and identify how new processes may be delivered.

When I decided to carry out my first clinical audit, I didn’t know where to start. I work in a busy ambulatory practice, so I initially felt it would be difficult to find the time. But as I started, I realised it’s possible to carry out simple audits that are manageable, but can genuinely improve how you work in practice.

Process audit – cascade forms

A process audit is an easy audit that can be done by any member of your team. For our first audit, we looked at whether an off-licence cascade form was signed every time we dispensed an off-licence drug (the RCVS and VMD stipulate 100% should be signed).

I looked at two common cascade products we use and I pulled this data off the practice management system. We reviewed the dispensing list for three months, checking for a signed consent form – it was that simple.

When I first audited the forms, only 6% were signed. I was shocked as previously we’d had fantastic compliance. I asked the vets what they needed to meet the requirement, and they responded that they struggled to find the time and to remember which drugs were off licence.

I therefore made a short, generic off licensed consent form for them to fill in client details, what the drug was being used for and for the client to sign. I also downloaded stickers from BEVA’s website and stuck them on cascade products to act as a reminder.

In an interim audit shortly afterwards, our compliance level rose to 22%.

We always discuss progress in our fortnightly vet meetings, to see how we can make it easy for the team to meet the requirement and move forward together – things that are important for every audit.

Process audit – dental charts

In 2017, we introduced an excellent dental form that every vet performing dentals has to fill in, to improve the quality of care for patients.

Initially, when we audited, 57% of patients did not have a signed dental chart on their records. We implemented sufficient time allowances for each appointment and a form that was easier to follow. When we re-audited, 84% of dentals had a dental chart scanned. While this is a good improvement, I wanted to aim for 100%.

When I investigated further, it turned out that 96% of the vets involved in the first audit had filled in the forms – it was the new vets who hadn’t been part of the first audit who had lower compliance levels. Instead of assigning blame, we openly discussed the issue.

As a result, we implemented a buddy system for the newer vets until their confidence grows, as a means of encouraging compliance, and we’ll review how effective this is when we re-audit.

Outcome audit – castration

Once we’d got auditing under way, one of our vets decided to carry out an outcome audit assessing castration methods to see if we could improve our complication rates.

Currently, no national equine castration audit exists to obtain a benchmark figure, but the literature complication rate for standing castration was 22%; our rates for the previous 12 months were 29%.

We thought this wasn’t a bad result, considering we’d never audited castrations before, but with every audit, it’s important to discuss ways to improve.

Many castrations were carried out in spring when the weather was warm and wet, meaning flies could be a factor. With the help of the team we developed a castration protocol, including only carrying out castrations in colder weather when fewer flies are around. We’ll see what difference this makes at our next audit.

Auditing is a continual process – even if you’re getting good results, it’s worth repeating audits to see any changes. We now have a set of targets on that journey, and we’re aiming to get to the benchmark of 22% when we re-audit in 12 months.

Process audit – dispensing

My final example is a process audit, where we looked into whether staff were following practice protocol for dispensing medication – 100% of medication should be initially signed once dispensed, and signed again when the client collects it to confirm it’s the correct product.

When we first audited, 58% of drugs had been signed for. Initially, we didn’t change our system as we thought it was a good one that was simply not being followed. We re-audited after three months, and found 78% had been signed for, which was an encouraging improvement.

After a discussion between clinical staff and admin staff, we changed the policy of dispensing medication. We now have a vet in practice at all times who can get on with his or her paperwork, be around for clients and answer any queries.

We’ve implemented a system where the vet in practice has to countersign medication. A team member prepares and signs the drugs, which go through a box for the vet to countersign before they get sent to the dispensary desk to be handed over. We will re-audit in six months to see whether this has improved our results.

As the aforementioned examples show, we are further along with some of these audits than others, but they are all ongoing. An audit should be a constant process of improvement, and one the whole team can and should get involved with – receptionists and admin staff, as well as vets and vet nurses.

I hope these examples have inspired you to think about auditing in your practice. It can be really easy to access information needed for audits – particularly through your practice management system – and I have found RCVS Knowledge’s clinical audit resources extremely useful in getting started, so I’d encourage anyone interested to give it a go and start making a difference to patient care.

• To find out more about auditing and access RCVS Knowledge’s quality improvement resources, visit bit.ly/3043pmv