Acting on the results of clinical audit

Once you have the results, it is time to act on them! If you started off by establishing criteria by which you will assess your new protocol or practice, then it is a simple matter of comparing your results with those criteria.

When you start an audit, the most difficult part will probably be collecting the data. Do not be surprised if you find that the action that needs to be taken is the systematic collection of relevant data so that you have something to compare to in the next audit!

Most audits will involve calculating some simple descriptive values (means, proportions, percentages), as discussed previously in this chapter. Some simple analysis will allow you to decide if your results show that the changes you have made are as good as, or better than, your defined criteria.

In many cases, the audit process may well indicate that no change is required. For example, an audit of peri-operative fatalities, or post-surgical wound breakdowns/infections, may indicate that rates have not changed recently and that they remain at levels that are similar to those in other clinics. The point of clinical audit is that it provides baseline data or reference points for comparison. Clinical audit also ensures that a process is in place that will likely result in early identification if things start to go wrong.

Part of the audit process should be for you and your colleagues to identify thresholds that might trigger you to further action. That action might involve further in-depth investigation, or it may involve an increased frequency of the audit cycle to see if preliminary results are indeed a trend in the wrong direction, or just an anomaly that should be monitored but perhaps not acted on at this time. On the whole, a common sense approach is required. However, an explicit and systematic process can help veterinary clinics avoid falling into complacency or inertia.

There are two important things to remember. Firstly, don’t worry if the first attempt at data collection isn’t successful; if you’ve given it your best on the first try and discover you need more data, try and implement changes that will make things better on the next attemp. Being able to generate accurate, interpretable data the first time around is not common, and the first step is often to develop ways to obtain data that will help you assess what you are doing in your clinic!

A second pitfall is the temptation to over-analyse or over-interpret the data that is obtained. Always try and retain a focus on the question that was originally addressed – you need first of all to reflect on whether this question was answered by the data you collected. For example, if you are looking at anaesthetic or peri-operative mortality rates for elective surgery, you may need to consider how to interpret the numbers for when it was decided that an animal would be best served by being euthanised during surgery. On the whole, it is best not to attempt to look at a number of factors (surgery type, anaesthetic protocol, species of animal, etc.) during the first audit cycle.

However, in subsequent audit cycles, you may choose to expand the data collection and analysis, if that is appropriate. For example, it may well be of benefit to consider colic surgery in equine practice separately to any other types of equine surgery, as it is likely to have a greater mortality risk (including a greater chance of euthanasia). The results of such an audit also enable you to include these figures in the decision-making process when discussing treatment choices with owners using pertinent data from your own clinic.

Example Scenario 1: Dry cow therapy

Rachel and her colleagues were able to identify only six farms that met the criteria for pathogen profiles that were likely to benefit from use of the new dry cow therapy. Of those farms, only two chose to participate – the others thought they might wait for the results from these participants before deciding whether or not to switch to a new product, as they were happy with the effectiveness of their current dry cow therapy.

After six months of using the new dry cow therapy, the practice administrator reported that one farm’s overall SCC had risen by 10%, although the other farm’s SCC had fallen by 12%. Clinical mastitis rates in the post-calving period were the same on the first farm, but had increased by 7% on the second farm. Based on these figures, and the fact that the new therapy was slightly more expensive than the products the two farms had previously been using, Rachel calculated that there was no financial benefit to either farm.

Although these numbers were disappointing, the farmers and veterinarians realised that the outcome measures were affected by a number of factors, of which dry cow therapy was only one. Both farms were happy with the new therapy and decided to continue using it, and two other farms also decided they would switch products after culture results revealed pathogens which were resistant to the dry cow therapies they had been using. Rachel agreed to work with those farms as well, and to report back on the numbers in another six months to further evaluate the new treatment.

Example Scenario 2: Small animal dental imaging

Two hundred dental cases per year occurred in both years that Tom assessed. Over the year following implementation of dental radiography, there was a 20% increase in total extractions, which was consistent with radiography identifying additional diseased teeth in dogs and cats.

During the period of the audit there were 95 responses to the animal welfare questionnaire: 60 from dog owners and 35 from cat owners. 85% of dog owners indicated a positive response, with dogs showing increased activity levels (‘acting years younger’) and/or owners reporting reduced halitosis. Only 60% of cat owners indicated a positive response, however, with changes mentioned primarily associated with improved appetite. There were no negative responses (indicating no reports of worsening of conditions), but respondents that did not reply positively indicated that they did not notice any particular response to dental treatment in their pets. No client queried the bill (although a practice policy of providing clear estimates for dental work had been instituted concurrently).

The average dental invoice increased by 36% which, over the 200 patients seen in the previous 12 months, provided a noticeable increase in gross income. This represented a margin of double the purchase price of the dental radiography investment.

The implementation of dental radiography was considered beneficial from both an animal welfare and financial aspect, and client feedback was good, despite the increased cost. Tom’s practice decided to continue to monitor client feedback, dental invoices and the numbers of extractions they perform, with a view to reviewing the data again in 12 months’ time.