The Professional, Legal and Ethical Perspectives of Clinical Audit - Literature review Example

Clinical Audit – the case of NHS Introduction Clinical Audit is a concept developed just in 1991 and primarily “evolved as an attempt to clarify the confusion created by uniprofessional audit; the idea was to bring the professional groups together to design and conduct audit, based on a collectively agreed clinical outcome” (Antony et al., 2002, 171). The development of clinical audit in the area of medical practice has helped the particular sector to improve its performance. More specifically, the continuous monitoring of the services provided to patients and the skills of the persons involved in this industry (doctors, nurses, social workers and so on) helped towards the elimination of ‘malpractice’ in the specific industry. In accordance with a definition developed by Antony et al. (2002, 171) Clinical Audit can be defined as: “A systematic, critical analysis of the quality of clinical care, including procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient”. On the other hand, Jenicek (2002, 251) referred to the issue of ‘medical audit’, i.e. of the evaluation of “the process of treatment representing already accepted methods, techniques, and therapeutic procedures”. Medical audit (otherwise clinical audit as mentioned above) is mainly used in order to improve the quality of the medical services provided to the public and can be defined as “an examination or review that establishes the extent to which a condition, process or performance conforms to predetermined standards or criteria quality of production assessment”, once the product is developed” (Jenicek, 2002, 251). From a similar point of view, Lumby et al. (2000, 34) noticed that “a systematic clinical audit of actual practices is suggested as a means of monitoring and evaluating quality outcomes”. All the above definitions lead to the same outcome. The priority of clinical audit is the improvement of medical services provided to the public. In other words, quality is one of the most significant issues for clinical audit. Throughout the years many theoretical approaches of clinical audit have been developed. In this context, Dent et al. (2002, 42) refers to the study of Power (1994, 9) who noticed that “clinical audit – considered as referring primarily to a style A - has in fact been associated with a complex bundle of gains and losses; however, these gains are likely to be most in evidence when audit is: used in conjunction with, rather than in opposition to, elements of control style B; one example of this is when medical audits help practitioners reflect on clinical methods and management as well as offering a mechanism for external evaluation”. The relation of clinical audit with quality has been proved through all the relevant theories presented above. However, it should be noticed that the existence of high quality should not lead to the assumption that clinical audit is necessarily related with a high cost. In fact, the study of Antony et al. (2002, 172) showed that “clinical Audit has continued to emphasize high quality at the lowest cost, pressing for greater performance rather than necessarily the best and has had limited patient involvement, despite the membership being supposedly multiprofessional/agency and the focus being on the improved clinical outcome for the patient”. In current paper the issue of clinical audit is examined specifically in relation with NHS (UK). The existence of relevant programs that promote the application of clinical audit in the institutions operating within the particular healthcare system is examined analytically using as examples specific cases, i.e. institutions or schemes that use the concept of clinical audit in specific areas of Britain. 2. The particular aspects of clinical audit a. Professional framework Issues for consideration by medical practitioners Practitioners in the healthcare services have to consider many issues when involving in a clinical audit procedure. In fact, it has been found by Flynn (1992, 46) that “clinical work may be complex and difficult to plan, but performance indicators, medical audit, quality assurance and resource management are already beginning to provide the means for detailed managerial control”. In other words, the existence of medical autonomy can create constraints to the completion of the relevant task. Therefore, medical practitioners should consider carefully their engagement in the relevant activity particularly in relation with the target set by the particular organization (healthcare services provider). Because of the potential limitation of their role when participating in the clinical audit procedure, medical practitioners should consider their involvement in the particular task. Medical practitioners as ‘managers’ When conducting the clinical audit, medical practitioners, can proceed to activities that present similarities with those of managers. Indeed the study of Flynn (1992, 50) showed that particularly in the case of NHS “the changes associated with ‘scientific management’ in the particular organization have weakened medical dominance, through managerial challenges to clinicians’ control of resources and patterns of service delivery; however in medical services there are great difficulties in dealing with professionals’ technical indeterminacy - the discretion which constitutes clinical freedom”. For this reason, medical practitioners that are going to participate in clinical audit have to obtain specific skills/ characteristics, especially a well developed communication ability and a thorough knowledge of the strengths and weaknesses of the particular organization. On the other hand, there is also the view that even if not having particular competencies, medical practitioners can respond to the demands of the particular task. However, in this case it should be preferable for the medical practitioners to use specific strategies in order to improve the effectiveness of the particular institution. These strategies have been summarized by Gabe et al. (1994, 11) to the following ones: a) First, it is possible to encourage self-help among doctors to raise professional standards by medical audit, the use of standards and guidelines, and the accreditation of hospitals and other services; b) A second strategy is to seek to involve doctors in management by delegating budgetary responsibility to them and c) A third strategy seeks to strengthen external management control of doctors by changing their contracts and encouraging managers to supervise medical work more directly”. The above strategies can guarantee the success of the attempted clinical audit within a particular organization. However, there is always the case of unexpected turbulences especially regarding the appropriateness of resources employed in the relevant activity and a failure can be considered as a possible outcome mostly because of the significance of the relevant task for the development of organizational performance. Assessment of professional skills/ competencies Regarding the issues stated above it is necessary for any organization to proceed to the thorough control of any medical practitioner who is going to be involved in a clinical audit procedure. Moreover, because quality is the main issue of the relevant effort (clinical audit) it is necessary for the medical practitioner to understand the particular aspects of quality and its relevance with clinical audit. For this reason, it has been supported by Davis (1998, 12) that “in health promotion, practitioners and service providers strive to provide a service based on consumer need that is effective and efficient and is subject to performance measures of some kind”. Moreover, in order for the specific institution to find out whether a medical practitioner is suitable for the completion of a particular clinical audit it has to proceed to the evaluation of the doctor’s performance either in the short or the long term. The problem with NHS in this case is that the data stored in this organization are sometimes incomplete misleading the medical practitioners that review them. Indeed the study of Dent et al. (2002, 66) proved that “the NHS outcomes data are very poor; it might work for surgery but is harder for other specialties while self-review is promoted but it is not systematic”. For this reason, it should be noticed that the assessment of the professional skills of medical practitioners involved in a specific clinical audit cannot be completed without the necessary data. In case that their retrieval is not feasible, then the completion of a clinical audit procedure is not feasible. b. Clinical Audit and law Legal standards in medical practice Medical practice is highly regulated by specific legal provisions. On the other hand, because of the intervention of management practices in the procedure of clinical audit it is very likely that rules and ethics that apply in management in general are also going to be used if disputes appear in cases of clinical audit within a particular organization. The intervention of law in the cases of clinical audit could be made under the scheme of ‘governmental rationality’ as stated by Henderson et al. (2002, 137). In accordance with the above researcher this system “impacts on all levels of health care culture and organization covering a broad set of laws, policies and government actions it is materialized practically and in the thoughts and utterances of officials and political agents as performance measurement, quality assurance, care evaluation, clinical audit, clinical budgeting, and case-mix”. The application of general rules and ethics included in the relevant Code of Practice could be also helpful in cases of disputes in the particular area. Legal framework applied in clinical audit Generally, the operation of medical institutions is governed by specific laws and regulations. At a first level, every medical institution should obtain a relevant licence from the Ministry of Public Health which grand this licence only in the case that the particular institution is found to be complied with all legal rules related with the operation of healthcare institutions. Specifically in the UK, these standards are relatively severe prohibiting healthcare institutions from violating the rules related with the provision of healthcare services. However, clinical audit is not applied on medical institutions in Britain. The reasons are many however, the turbulences related with such an initiative and the lack of appropriate financial support by the country for the completion of this effort, are considered to be the main causes of the avoidance of clinical audit by medical institutions in UK. Moreover, the study of Luck et al. (2000, 213) showed that “many of the hospitals now have ISO9002 as their quality standard and the Ministry of Public Health is developing accreditation based on the Canadian system”. However, more provisions should be taken in order to ensure the increase of use of clinical audit as a ‘tool’ of monitoring the performance of institutions in the healthcare industry. c. Ethics in Clinical Audit The intervention of audits in organizational activities cannot be doubted. In fact the study of Reamer (2000, 355) showed that “audits of various types are conducted in many organizations; both proprietary and nonprofit organizations routinely conduct audits for accounting purposes, quality control and assurance, and utilization review; audits typically focus on essential aspects of an organizations functioning, such as its bookkeeping procedures, service delivery, personnel and financial records, and billing practices”. In accordance with the above audits can be met in all industrial sectors and for this reason their appearance in the healthcare industry should be absolutely justified. Under these terms, clinical audit (as particular type of the audit procedure applied in general in the business sector) will be based on the common ethics of the market (principles and ethical rules governed the commercial transactions). However, in the case of clinical audit a series of ethics applied in the healthcare industry should also be applied. Medical ethics and clinical audit Clinical audit should be conducted in accordance with the ethics applied in the medical industry. These ethics are usually differentiated in accordance with the sector to which they refer. In this context, it has been found by Reamer (2000, 356) that in the case of audit in the social work area, the following issues should be examined: “(1) the extent of social workers familiarity with known ethics-related risks in practice settings, based on empirical trend data summarizing actual ethics complaints and lawsuits filed against social workers and (2) current agency procedures and protocols for handing ethical issues, dilemmas, and decisions”. As for the other areas of medical practice, the ethics applied are going to be retrieved mainly through the relevant Code of Practice. The application of practices usually followed in a specific field of medical research cannot be excluded. Professional ethics and clinical audit When participating in the clinical audit procedure, medical practitioners need to make sure that they follow all appropriate practices as they have been developed by the relevant laws and the empirical research. Regarding this issue, it has been stated by Gabe et al. (1994, 11) that “doctors feel a degree of ambivalence in assuming an active role in management; moreover they face a real ethical dilemma in deciding whether to accept responsibility for budgets and to participate in management; their professional values, motivation and training all point in the direction of doing what is best for the individual patient rather than for groups of patients, which would require making explicit trade-offs between individual patients”. Because of the above situation, the role of the state in the development of appropriate tools of monitoring of the practices followed by medical practitioners in clinical audit is crucial. In fact the state can set specific guidelines for the appropriate completion of clinical audit within all medical services providers. However, because the appropriate monitoring of such an activity is rather difficult, there should be specific mechanisms for the control over the medical practitioners’ policies during clinical audit. In fact, the practices followed by all persons involved in the particular industry should be included in the material for investigation by the clinical audit. 3. Clinical Audit in NHS Historical development of clinical audit in NHS Clinical audit has a relatively short history in NHS. In fact the particular procedure has been introduced in 1990s in order to measure the performance of healthcare institutions and to indicate the most appropriate strategies of clinical practice. However, after the elections of 1997 “the internal aspiration to raise standards converged with the external imperative to modernise the NHS by strengthening managerial control and diminishing professional autonomy” (Fitzpatrick, 2001, 131). Throughout the years, clinical audit has been established in NHS as a necessary part of the managerial activity in all sectors of the particular organization. The ‘star ratings’ scheme in NHS One of the most known policies for the evaluation of performance of healthcare institutions operating under NHS has been the ‘star ratings’ scheme. This scheme was introduced in 2001 by the Department of Health and had as a main target ‘to give each organisation in the NHS in England a single summary score from zero rating to three stars’ (Bevan, 2006, 67). However, the British Government has not used this scheme in accordance with its potentials but preferred to support the development of pluralism in the British market. A possible explanation for this outcome could be the fact that “since the abolition of Regional Health Authorities in the early 1990s, the NHS has lacked both the analytic capacity and system of governance that can, given local variations, develop different sets of targets that are equally challenging for each NHS organisation” (Bevan, 2006, 67). Throughout the years the inability of NHS to appropriately use the resources and the strategies available led the British health industry in a continuous crisis. Moreover, the lack of specific targets by NHS led the ‘star-ratings’ system into failure. Evidence-based medicine Currently the method used for the evaluation of the quality of the healthcare services provided to the public is the evidence – based medicine. The particular method has created through the interaction of health economics with Clinical Audit. In accordance with the evidence – based medicine “empirical research could be used in order to determine effective clinical standards for practice and treatments” (Antony et al., 2002, 174). The main problem of the above method is related with the fact that in many cases the data used for the evaluation of the quality of healthcare services provided to the patients of specific healthcare institutions are not reliable. Allocation of resources in NHS NHS is an organization with a complex administrative structure. Moreover, any decision related with the funds available for the completion of specific tasks has to be taken primarily by the British government. In this context, the study of Klein (1989, 3) showed that “the basis of resource allocation in the NHS is simple; it is a tax-financed service and the central government annually determines the global budgetary allocation to the NHS; once the global allocation has been made, however, the process of distribution is much more technical”. In accordance with the above the evaluation of the quality of the services provided by the specific organization should be made at a first stage by the state which will have to decide on the potential restructuring of the corporate strategy in accordance with the business targets in the long term. The ability of NHS to ‘absorb’ the funds offered by the state is crucial. The appropriate use of these funds can lead to the improvement of the services provided by the relevant organization while any adverse outcome should be primarily examined thoroughly in order to retrieve the potential ‘connection’ between the funds spent on a specific service and the quality of services provided by the employees in the particular organization. The Health Promoting Hospital (HPH) initiative The Health Promoting Hospital (HPH) scheme is based on a relevant initiative of the NHS executive. In accordance with the above scheme, organizational structure is based on a series of criteria: “management issues; customer care; healthy workplaces; hotel services and environmental issues; community and health alliances; clinical audit and effectiveness” (Davies et al., 1998, 137). The above scheme has not led to the required results mostly because the data related with the six ‘key areas’ of HPH scheme are very likely to be disorganized. However, this ‘scheme’ has been a significant tool towards the development of corporate performance both in the short and the long term. 4. Conclusion Generally, it could be stated that “changing the way that people are treated by the NHS to improve the health of individuals and the population as a whole, in the most cost effective way, is a complex process involving clinicians, managers and patients themselves” (Keaney et al., 1999, 117). From a different point of view, it has been found that “the process of any therapeutic intervention, either in a clinical trial or in general practice (treatments already at work), must be evaluated given the fact that the patients outcome depends not only on the stage, spectrum, and gradient of the disease or on the potency of treatment, but also on the quality of diagnostic tests, clinical performance (competence, motivation, barriers), and patient compliance” (Jenicek, 2002, 251). Under these terms, clinical audit is found to be closely related with the strategies followed by employees in order to identify and evaluate the ‘borders’ of the firm’s activities. If strictly reviewed, the corporate strategy is quite complex and for this reason the strategy chosen should be clear and understandable by all residents in a particular country. From another point of view, because of the dependence of medical audit by the corporate governance, any strategy proposed should be evaluated in accordance with its feasibility and the level of the consumers’ response as measured through the appropriate research. References Antony, J., Preece, D. (2002) Understanding, Managing and Implementing Quality: Frameworks, Techniques and Cases. London: Routledge Bevan, G. (2006) Setting Targets for Health Care Performance: Lessons from a Case Study of the English NHS. National Institute Economic Review, 197, 67-84 Davies, J., MacDonald, G. (1998) Quality, Evidence, and Effectiveness in Health Promotion: Striving for Certainties. London: Routledge Dent, M., Whitehead, S. (2002) Managing Professional Identities: Knowledge, Performativity and the "New" Professional. London: Routledge Fitzpatrick, M. (2001) The Tyranny of Health: Doctors and the Regulation of Lifestyle. London: Routledge Flynn, R. (1992) Structures of Control in Health Management. New York: Routledge Gabe, J., Kelleher, D., Williams, G. (1994) Challenging Medicine. New York: Routledge Henderson, S., Petersen, A. (2002) Consuming Health: The Commodification of Health Care. London: Routledge Jenicek, M. (2002) Foundations of Evidence-Based Medicine. New York: Parthenon Publishing Keaney, M., Lorimer, A. (1999) Clinical Effectiveness in the National Health Service in Scotland. Journal of Economic Issues, 33(1), 117-128 Klein, R. (1989) From Global Rationing to Target Setting in the U.K. The Hastings Center Report, 19(4), 3-6 Luck, M., Pocock, R., Tricker, M. (2000) Market Research in Health and Social Care London: Routledge Reamer, F. (2000) The Social Work Ethics Audit: A Risk-Management Strategy. Social Work, 45(4), 355-366 Appendix STYLE A STYLE B Quantitative Qualitative Single measure Multiple measures External agencies Internal agencies Long-distance methods Local methods Low trust High trust Discipline Autonomy Expost control Real-time control Private experts Public dialogue Table 1 – Styles of Audit (source: Dent et al., 2002, 42) Read More