PubMed1989
The work of surgical departments involves varying proportions of investigation, diagnosis and treatment and the object of audit is to measure and monitor the outcome of this activity. It also serves as a secondary but important role in education, research and resource planning. The different methods of audit described in this symposium gave varying contributions to the definition of workload and outcome and to the education of the surgical staff. Irrespective of the audit system used, there is little doubt that weekly meetings specifically designed for the purpose are of prime importance, and the contributors used it in a variety of different ways. For Messrs. Eltringham and Espiner this meeting was seen much more as an educational exercise for the firm as a whole than a ritualistic method of collecting numerical information. Where other systems which rather more fastidiously collect numerical information are used, the weekly meeting becomes more important in ensuring the accuracy of the data collected. Some authors review the proforma on which the patient information is collected before it is entered into the computer, a point strongly made by Mr. Dunn and it does seem likely that as audit information is collected and challenged, then considerable efforts will have to be made to ensure the accuracy of the information being entered, for there is little point in defending an audit result by suggesting that the houseman who made the original entry did not do so very accurately. Many auditors used a lunch or coffee break as a convenient time to meet, but in some cases a lot of extra work was required for validation and if clinical audit is to represent a very accurate record of the work of a surgical department, this point requires careful consideration. If audit information is to be easily processed, then its means of collection is important.Most contributors used a single record card on which the information was recorded during the patient's stay and this record card can be designed to make entry into a computer system easy for a secretary.It is alos much easier to take records to a weekly meeting than 30 sets of patients' notes. In broad terms the audit systems discussed fell into 2 groups: those which used computers and those which did not. There is no doubt that the use of a computer helps in marshalling the information collected. Although a card system was very cheap and easy to use,it was very much difficult to retrieve information rapidly from it than from a computer based system.It seems that the use of computer entails the consumption of more time for entry and validation of data than a card based system, and there may be a temptation not to spend so much time on the educational aspects of audit. This problem can be overcome by holding regular meetings at which only results presented, perhaps firm by firm, in a hospital, so that discussions on policies relating to thromboembolic prophylaxis, the use of prophylactic antibiotics and similar topics can be discussed. Indeed if this kind of meeting does not take place, then it would seem that one of the principal objectives of audit is lost. For this meetings to take place a computer based system is almost certainly going to be essential. In setting up a clinical audit there is clearly a requirement for financial investment. This means first buy in a computer based system and several options are open to the prospective auditor. A simple desk top computer with a modified database system can be used but Messrs. Baird and Horrocks found it required a great deal of programming using a database programme that was already commercially available to obtain a workable system.Two or three commercial systems are now available using personal computers and it seems likely that in many hospitals this will be a popular choice. When introduced in Colchester General Hospital by Mr. Motson where such a facility had not existed in the past, computerisation has been well received and has achieved the desired result.As more hospitals develop their own sophisticated information systems, it may be possible to graft clinical audit information onto the hospital programmes in a way outlined by Mr. Marsland and Mrs. Tyndall. The advantage of this system is that there is often experienced help available for the design and implementation of the system and very powerful computers to use. The information yielded by audit needs to be kept in a confidential system. If this fails to occur,then the users of the system will cease to have confidence in it and the accuracy of the information put into the audit will lessen. As the whole object of audit is an attempt to collect accurate and detailed information about patients,then another prime objective could easily be lost. There is little doubt from the experiences presented in this review that audit is feasible.The benefits fall into two broad groups.Firstly by reviewing cases at regular weekly meeting evolving problems can be dealt with so there is an immediate benefit for that one patient and a useful learning experience for the staff.It is important not to lose sight of this in the wish to collect data on a computer.The second benefit is the ease of handling large amounts of information about patient activity. Only the Cambridge experience gave any longer term view and there was an impact on the complications of surgical treatment.It will be most important in the years to come, as audit systems are introduced, that their value is critically regarded because in order to establish and run clinical audit, a considerable amount of time will need to be devoted by everybody involved. The determination fo longer term response to surgical treatment in terms of graft patency,tumour recurrence and patient survival is not possible by any of the methods currently described. It is an undertaking of great importance and proportions and clearly has a bearing on clinical practice. Short term clinical audit will therefore be only one part of the evaluation of surgical care.