AUDIT GUIDE FOR BEGINNERS ( MEDICAL AUDIT ) [FIRST ed.]

Table of contents :
Contents
Introduction
Audit proposal form and primary results
Another example of audit proposal form and primary results
Another example of audit proposal form and primary results
Audit reporting form prior to presentation
Data collection form template
Presentation of Audit
Example Presentation of Audit 1
Example Presentation of Audit 2
Full Example of Audit
References
1
2
3
4
5
6
7
8
9
1
4
2
8
13
15
21
22
28
10
39

Citation preview

AUDIT GUIDE FOR BEGINNERS

Disclaimer This book is just a review of literature of wound care, no part of it is genuine (except for some small parts) We managed to mention every copyright and every reference as much as possible. We tried -with this book- to open the door of wound care knowledge for middle east medical staff and students, and to show them the evidence-based knowledge. This book is not and will not be for any financial benefit. We do not expect any demands about any copyrights because we do not pretend, we have any in this book, anyone can copy or take any part from it without permission as if he/she mention the original source.

Contents 1

Introduction

2

Audit proposal form and primary results

3

Another example of audit proposal form and primary results

4

Another example of audit proposal form and primary results

5

Audit reporting form prior to presentation

6

Data collection form template

1 2 4 8 13 15

7

Presentation of Audit 21

8

Example Presentation of Audit 1 22

9

Example Presentation of Audit 2 28

10

Full Example of Audit 39

11

References 55

AUDIT GUIDE FOR BEGINNERS FIRST EDITION

Editors Ibrahim Ahmed Muhammed Elsherbini General surgeon , Alexandria Medical Research Institute , Alexandria University MSc Degree in Clinical and Experimental Surgery MRCS Eng [email protected] https://orcid.org/0000-0002-1727-4476

Omnia Alaa El-Din Abd El-Salam Ali General practitioner [email protected]

Contributors Design and layout by Omnia Alaa El-Din Abd El-Salam Ali General practitioner [email protected] To my first love and pride.......My late father To my family I owe you everything To my mentors I will always be your grateful student

Ibrahim Ahmed Elsherbini , Omnia Alaa El-Din Abd El-Salam

Introduction Starting a clinical audit is challenging for young physicians and interns, they always wonder what are the steps can we have an example. In that brief paper I will put a flexible, modifiable and easy frame to help them achieve an accurate and rewarding clinical audit. I will start with the AUDIT PROPOSAL FORM, and I will follow that with AUDIT REPORT AND PRESENTATION EXAMPLE.

AUDIT PROPOSAL FORM AND PRIMARY RESULTS

AUDIT 1ST CYCLE

AUDIT REPORT FORM

OR

AUDIT FURTHER CYCLES MAY GO TO 100 CYCLE

AUDIT PRESENTATION

1

I. AUDIT PROPOSAL FORM AND PRIMARY RESULTS ***Please note that this form sections will be completed over an extended time not at once 1. Address of your audit? ……………………………………………………………………………………………………… 2. What is the thing you want to audit? ……………………………………………………………………………………………………… 3. Hospital name? Department? Audit supervisor? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 4. Audit date? ……………………………………………………………………………………………………… 5. Audit cycle number? cycle start date? cycle end date? ……………………………………………………………………………………………………… 6. Audit leader? ……………………………………………………………………………………………………… 7. Audit team? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 8. Audit type? Process (what we do) VS Structure (what we need) VS Outcome (what we expect)? Audit type local VS global? Whether it is a retrospective or prospective audit. For example: “A prospective audit assessing the first 30 patients aged over 50 who were admitted to the Hospital for inguinal hernia repair from 01/03/10”. “A retrospective audit looking at all patients aged over 50 who were admitted to the hospital for incisional hernia repair during February 2010”. ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 2

9. Identify the criteria. Which means the right thing which should be done? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 10. Standards? Means the questions you would ask to assess the application of your criteria? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 11. Identify your sample. Your target patients? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 12. Collect your data? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 13. Write your results? Try to be as simple as possible, I always write it in simple table like that example which describes how many times our interns scrub in through 4 operation lists. Intern / times of scrubbing in

Day 1

Day 2

Day 3

Day 4

Intern1

yes

No

Yes

No

Intern 2

No

No

No

Yes

14. Recommendations? 1- ……………………………………………………………………………………………… 2- ……………………………………………………………………………………………… 3- ……………………………………………………………………………………………… 15. Arrange a meeting with the people involved and talk about your results and recommendations? ……………………………………………………………………………………………………… 16. Re audit after ………… weeks? ……………………………………………………………………………………………………… 17. Either to report your audit (the second step and present it the third step or go to a second cycle with the same steps again). 3

ANOTHER EXAMPLE OF A TEMPLATE TAKEN AS COPY AND PASTE

Click here to enter your practice name and then click on the image placeholder to insert your logo Clinical Audit Template

This document is guidance only addressing a specific clinical scenario as outlined below. It should be used in conjunction with your clinical expertise, patient circumstances and owners’ values.

CYCLE 1

What would you like to improve? Click here to enter text. Choose a topic relevant to your practice, amenable to measurement, commonly encountered and with room for improvement. How will you measure improvement? Click here to enter text. Selection criteria should be easily understood and measurable. You can measure processes or outcomes.

What will your target for improvement be? Click here to enter text. Set a target using best available evidence and agreeing best practice. Who will form the practice team responsible for driving change? Click here to enter text. Data collection

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Will you be collecting the data retrospectively (from past cases) or prospectively (from now on)?

Click here to enter text.

Which forms of data will be collected?

Click here to enter text.

How will data be collected?

Click here to enter text.

Date range for the data collection:

Click here to enter text.

Date when the data will be analysed:

Click here to enter text

Data analysis

Date of data analysis:

Click here to enter text.

Was the target met?

Click here to enter text.

Were there any barriers to meeting the target?

Click here to enter text.

Explain:

Click here to enter text.

Implement change

What intervention will assist in meeting the target?

Click here to enter text.

What needs to be done to implement the change?

Click here to enter text.

Review date:

Click here to enter a date. Use arrow for date picker.

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CYCLE 2 – RE-AUDIT

Data collection 2 Repeat the data collection phase as carried out in cycle 1. Click here to add any comments. Date range for data collection:

Click here to enter text.

Date when the data will be analysed:

Click here to enter text.

Data analysis 2 If no beneficial change has been observed, implement a new change and repeat the cycle. This cycle can be repeated continuously if needed. Date of data analysis:

Click here to enter text.

Was the target met?

Click here to enter text.

Did the change made in cycle 1 affect this?

Click here to enter text.

Explain:

Click here to enter text.

Implement change 2 Is there a need for further interventions? Consider when the audit cycle should be repeated again (and if so, when). What intervention will assist in meeting the target?

Click here to enter text. This often includes the development of guidelines, protocols and checklists. Assistance in creating these can be found at www.rcvsknowledge.org/qualityimprovement/tools-and-resources

What needs to be done to implement the change?

Click here to enter text.

Review date:

Click here to enter a date. Use arrow for date picker.

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Review and reflect Share your findings – click here to enter text.

Other practices/branches this will be shared with:

Click here to enter text.

Review date (if applicable):

Click here to enter a date. Use arrow for date picker.

Follow-up date This work is licensed under a Creative Commons Attribution 4.0 International License. Feel free to adapt and share this document with acknowledgment to RCVS Knowledge. This information is provided for use for educational purposes. We do not warrant that information we provide will meet animal health or medical requirements. Interested in submitting your own case example? Email us at [email protected]

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ANOTHER EXAMPLE TAKEN AS COPY AND PASTE

CLINICAL AUDIT PROJECT PLAN

Please complete this project plan before starting your project.

1. Short Title of Audit:

2. Details of Audit Lead (Who is the person responsible for completing the audit?) Audit Lead:

Name:

Designation:

Contact details:

E-mail:

Phone:

3. Details of Audit Sponsor: (Who is the person responsible for overseeing/supervising the project and/or audit lead as required) Audit Sponsor:

Name:

Designation:

4. Date plan completed:

5. Rationale for Audit: Why is this audit needed and what are the expected benefits?

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6. Based on your audit rationale how would you classify this audit? This is an external must-do



This is an internal Trust must-do 

(e.g. National audit or contractual requirement such as CQUIN) This a Division/Service priority

(e.g arising from Trust objectives/ risks/ incidents / complaints/ NICE guidelines compliance etc)



(e.g. part of Divisional or Team Service improvement priorities)

This is an individual clinician interest



(e.g. personal interest, personal development or as part of an educational or training programme)

7. What standards will be audited? List the audit standards being measured for compliance Define the measurable standards to be audited, identify any known exceptions to the standard and include a target for compliance e.g. All patients on CPA will have a documented care plan (exception patients not on CPA); 100% of CPA patients will have a signed care plan (exceptions patients who decline/lack capacity)

8. Do the audit standards cover the practice of one or more professional groups? This is a Multi-disciplinary audit



This is an Uni-disciplinary audit

9. What methods will be used? How will you carry out the audit e.g retrospective case note review, sampling method?

9



10. What is your planned sample size? (Total sample size and if relevant any breakdowns by Teams/Services/Divisions to be included in your audit sample) Name of Service or Team and Division

Planned Sample Size

Total Sample Size:

11. What is your planned project timetable Project Activity

Person responsible

Estimated Completion Date

Audit tool and or other audit material to be completed by: Data collection to be completed by: Data inputting to be completed by: Data analysis to be completed by: Audit report to be completed by: Improvement action plan to be completed by:

12. How will service users or carers be involved in this audit? (If service users/carers are not involved are there any barriers to involving them?)

Please note if this is a re-audit you should refer to the original project plan and audit tool to re-use methods which will ensure comparability of results. 10

Completing Clinical Audit projects at Derbyshire Healthcare NHS FT.

1. Contact the clinical audit team to discuss your project. 2. Complete the Clinical Audit Project Plan and return to the audit team along with any other relevant information you may have at this stage such as your draft audit tool. 3. The project plan will be submitted for approval to the Trust R&D Governance Group via email. 4. Once approval has been obtained, send the audit team your proposed audit tool (or questionnaire or data collection form) if you have not already done this. 5. Your project will now be registered on the Clinical Audit Programme. 6. You can now start your audit and remember to keep us updated of your progress especially if your planned timescales slip.

Remember - on completion of your project clinical audit findings must be documented in a brief report and disseminated for wider organisational learning. An action plan must also be developed to improve practice where compliance is below target and a re-audit planned once the actions have been implemented and embedded into practice. Any areas of risk identified by your audit should be escalated to your line or service manager for advice on any immediate remedial actions. (Report and Action Plan templates are available for completion)

Clinical Audit Stages (HQIP – Healthcare Quality Innovation Partnership) Stage 1 - Preparation and Planning (including for re-audit) This involves selecting the topic of the clinical audit, ensuring that it is a priority agreed by all those involved in the process and that the standards by which current practice is measured against are evidence based. A clear project plan needs to be developed, making sure structures, responsibilities and timelines are in place and that it is properly resourced with all relevant participants. Any financial costs associated with running the clinical audit should be identified and agreed, with those responsible for enabling necessary changes in practice committed and providing the necessary leadership. Stage 2 - Measuring Performance A detailed methodology and data collection process is designed and tested, including a sufficient sample size and a clear and concise data set. Data are analysed using appropriate statistical

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measurements and reported in a way that maximises the impact of the clinical audit by ensuring that results are communicated effectively to all key stakeholders. Stage 3 - Implementing Change Once the results of the audit and recommendations for change have been published, an action plan should be produced to monitor implementation of these recommendations. Stage 4 - Sustaining Improvement (including re-audit) After an agreed period, the audit should be repeated. The same strategies for identifying the sample, methods and data analysis should be used to ensure comparability. The re-audit should demonstrate that the changes have been implemented and that improvements have been made. Further changes may then be required, leading to additional re-audits.

PLEASE RETURN YOUR COMPLETED PROJECT PLAN ELECTRONICALLY to [email protected] or [email protected]

Clinical Audit Team (Centre for Research & Development , Kingsway, Derby DE22 3LZ) Ranjit Badhan, Clinical Audit & Research Coordinator: 01332 623700 ext. 33756 Jacinda Atwal, Clinical Audit & Research Assistant. 01332 623700 ext. .33579 Rubina Reza, Research & Clinical Audit Manager: 01332 623700 ext. 33439

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II . AUDIT REPORTING FORM PRIOR TO PRESENTATION ***Please note that the action plan part will be completed after the presentation 1. Name of the organization and name of division/specialty ……………………………………………………………………………………………………… 

Audit title

……………………………………………………………………………………………………… 

Project lead/s (and name of the person who wrote the report, if different) and team members

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 

Date of audit start /report/ presentation

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 2. BACKGROUND (explain to us why did you do this audit)? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 3. AIM, RECOMMENDATIONS & STANDARDS This section sets out the aim, objectives and standards of your clinical audit project. 

Aim - Defines what you hope to achieve i.e. the overall purpose of the project.

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………………………………………………

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

RECOMMENDATIONS - Defines the individual steps that need to be taken in order to achieve your aim.

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 

Standards - The (RIGHT THING) specific aspects of patient care and/or management that you measure current practice against. You should specify the audit criteria

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 

Exception(s)

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… …………… 

Source(s) of evidence.

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 4. METHODOLOGY This section should outline: 

The population for your audit project. For example:

“Patients aged over 50 years of age admitted to the hospital with colon cancer”. ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………………………………………………

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

How these patients were identified, e.g. from the hospital system, laboratory systems, radiology database etc. (patient admission number)

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 

Sample size.

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 

Time period audited.

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………………………………………………  

The data collection method. For example: “Data was collected from patients’ case notes using a data collection form.

You can use this form as a template if you want ……

DATA COLLECTION FORM TEMPLATE SECTION 1. GENERAL INFORMATION Please note that patient consent must be obtained ------------------------------------------1.1* Patient number ……………………………… 1.2* Date of Birth (DD/MM/YYYY) 1.3* Gender: Male/ Female 1.4* Home address / 1.5* Ethnicity: □ White □ African □ White and Black African □ Any other Black background □ Indian □ Pakistani □ Bangladeshi □ White and Asian □ Any other Asian background □ Chinese □ Any other ethnic group □ Any other mixed background □ Not stated 1.6* Date of referral to hospital (DD/MM/YYYY) 1.7 Date of admission (DD/MM/YYYY): □ Tick here if not known

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1.8* Where was the patient referred from? □ Hospital Consultant (or member of clinical team) □ Hospital Specialist □ Community Services □ GP/practice team □ Other (specify)

SECTION 2. KEY CLINICAL INFORMATION AT TIME OF ASSESSMENT 2.1* Smoking Status: □ Current smoker □ Ex-smoker □ Never smoked □ Not recorded 2.2* Does the patient have any significant medical conditions? (tick all that apply) □ No other medical condi8ons □ Alcohol-related condition □ Atrial fibrillation □ Cor pulmonale □ Demen8a / confusion □ Diabetes □ Gastro-intestinal condition □ Hearing impairment □ Hypertension □ Ischemic heart disease □ Kidney disease □ Learning disability □ Left heart failure (LVF) □ Locomotor problems □ Lung cancer □ Mental health disorder □ Neurological condi8on □ Osteoporosis □ Stroke □ Thromboembolic disease (PE, DVT) □ Visual impairment □ Other cardiovascular disease □ Other endocrine disorder 16

□ Other malignant disease □ Other respiratory disease □ Other 2.3 How many times has the patient been hospitalized for AECOPD in the past 12 months □ past surgical and anesthesia history □ Tick here if not known

SECTION 3. KEY CLINICAL INFORMATION RELATING TO THE PROGRAMME Ask the questions related to your audit here 1) 2) 3) 4)

…………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… ……………………………………………………………………………………………

(CONT. AUDIT REPORTING FORM PRIOR TO PRESENTATION ) “Patients were asked to complete a patient survey following their consultation 

Mainly if they are satisfied or not

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 

Who was responsible for data collection.?

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 

The method of data input (if appropriate) and analysis e.g. data was input into and analyzed using Microsoft Excel.

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………………………………………………

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5. Results 1) Use simple tables 2) Use simple graphs 3) Do not mention names ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ 6. Conclusions 1) 2) 3) 4)

list the key points that flow from your results Use bullet points Ensure your conclusions are supported by the data Never make claims that are not supported by the evidence

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 18

7. Recommendations Make sure these are realistic and achievable. If money is needed to implement your recommendations, you should have already investigated whether there are suitable funds available. ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 8. Action plan Your action plan should be finalized after you have presented your project e.g. at a clinical audit presentation meeting. It is as a result of your presentation that your recommendations will either be accepted or revised. Following this, an action plan should be agreed, preferably at that meeting, to confirm what changes will be implemented, who will be responsible and when they will be implemented by Your action plan should be included in either the body of the report, or if the report has already been completed, as an addendum to the full report. If appropriate a date for a re-audit should be included in order to complete the audit cycle. ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 19

……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………………………………………………

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9. REFERENCES a) Write any literature used ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ 10. APPENDICES A copy of your data collection form should be included in the appendix.

III . PRESENTATION

Your presentation should get the message(s) of your clinical audit project across to key staff, generate discussion and then agreement about changes to practice (in light of the audit results). Use Microsoft PowerPoint where possible. 1. Planning What are your objectives? 2. Writing Use your slides to convey your key messages, using bullet points to punctuate your talk. Do not read straight from the slides, talk around the text on the slide; this will help the audience to see that you know what you are talking about, and to maintain their interest. The bullet points should be sufficient to prompt you if you lose your thread halfway through the talk. Try using a 1-6-6 template for each slide: have no more than one main idea on each slide, expressed in no more than six lines of text, with no more than six words per line; this is only a guideline, use your judgment as to whether a completed slide can be easily read and understood or not.

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Example 1

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Example 2

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Ibrahim Elsherbini, Eslam Hassan, Prof. Mohamed Ibrahim

Full of audit Fullexample Example Of Audit I. Audit proposal form and primary results ***please note that this form sections will be completed over an extended time not at once 1. Address of your audit? Cancer cervix awareness between nursing staff in medical research institute Alexandria university. 2. What is the thing you want to audit? The awareness of nursing staff regarding cancer cervix and the awreness that there is a vaccine available 3. Hospital name? Department? Audit supervisor? Medical research institute – Alexandria university – ass.prof Muhammad Ibrahim (chief of training and technical assistance) 4. Audit date? 12/ 06 /2021 5. Audit cycle number? Cycle start date? Cycle end date? Two cycle audit 12/06/2021 first cycle 26/06 /2021 second cycle 14 /07/2021 presentation 6. Audit leader? Ibrahim Ahmed Elsherbini 7758870 7. Audit team? Eslam Hassan 8016670 8. Audit type? Process (what we do) vs structure (what we need) vs outcome (what we expect)? Audit type local vs global whether it is a retrospective or prospective audit. For example: “a prospective audit assessing the first 30 patients aged over 50 who were admitted to the hospital for inguinal hernia repair from 01/03/10”. “a retrospective 39

audit looking at all patients aged over 50 who were admitted to the hospital for incisional hernia repair during February 2010”. Outcome/ prospective/ local 9. Identify the criteria. Which means the right thing which should be done? That the nursing staff know about cancer cervix guidelines and the vaccine 10. Standards? Means the questions you would ask to assess the application of your criteria? Do they know about it? 11. Identify your sample. Your target patients? The nursing staff of MRI, 100 nurse 12. Collect your data? Data collection was done in three successive days by the audit members 13. Write your results? NURSE 95

NURSE 96

NURSE 97

NURSE 98

NURSE 99

NURSE 100

32 married yes no no no no no no no no no no

43 married yes no no no no no no no no no no

29 married yes no no no no no no no no no no

34 married yes no no no no no no no no no no

30 married yes no no no no no no no no no no

25 single no no no no no no no no no no no

%

45% MARRIED 6% 0% 1% 1% 1% 2% 1% 4% 3% 1%

14. Recommendations? 1. Meeting with nurse chief to arrange a presentation and a meeting with nursing staff to increase awareness about it 2. Arrange screening tests with o&g depart 40

3. Arrange vaccination with vaxira

15. Arrange a meeting with the people involved and talk about your results and recommendations? Yes 16. Re audit after .. Weeks? Two weeks 17. Either to report your audit (the second step and present it the third step or go to a second cycle with the same steps again).

Second cycle *was done with the same data collection form on the same sample Results were that more than 50 % of nursing staff and their families are aware of cancer cx. 30 % of them arranged a swab 35 % asked about the vaccine.

II. Audit reporting form prior to presentation ***Please note that the action plan part will be completed after the presentation 1. Name of the organization and name of division/specialty MEDICAL RESEARCH INSTITUTE – ALEX UNI 

Audit title

Cancer cervix awareness between nursing staff in medical research institute alexandria university. 

Project lead/s (and name of the person who wrote the report, if different) and team members

IBRAHIM AHMED ELSHERBINI 

Date of audit start /report/ presentation 41

12 June 2021 – reported at the 14th of July and presented

2. Background (explain to us why did you do this audit)? I had a patient who had a final stage cancer cx in my ward, when I was doing my ward round I was advising her daughter about cancer cx, the nurse was listening carefully and told me that we do not know that, so I asked another two nurses who said the same. So I decided to start the audit 3. Aim, recommendations & standards This section sets out the aim, objectives and standards of your clinical audit project. 

Aim - Defines what you hope to achieve i.e. the overall purpose of the project. Increase awareness about cancer cx among nursing staff and their families.



RECOMMENDATIONS - Defines the individual steps that need to be taken in order to achieve your aim. 1) Meeting with nurse chief to arrange a presentation and a meeting with nursing staff to increase awareness about it 2) Arrange screening tests with o&g depart 3) Arrange vaccination with vaxira



Standards - The (RIGHT THING) specific aspects of patient care and/or management that you measure current practice against. You should specify the audit criteria exception(s) Every female should be aware of that.



Source(s) of evidence. According to the latest WHO data published in 2020 Cervical Cancer Deaths in Egypt reached 625 or 0.12% of total deaths. The age adjusted Death Rate is 1.68 per 100,000 of population ranks Egypt #175 in the world

4. Methodology This section should outline: 

The population for your audit project. For example: “Patients aged over 50 years of age admitted to the hospital with colon cancer”. 100 nurses were asked about cancer cx



How these patients were identified, e.g. from the hospital system, laboratory systems, radiology database etc. (patient admission number) Nursing staff working at MRI

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

Sample size. 100



Time period audited. 4 weeks



The data collection method. For example: “Data was collected from patients’ case notes using a data collection form. You can use this form as a template if you want ……

DATA COLLECTION FORM TEMPLATE

‫ االحرف االولي من االسم؟‬FIRST LETTERS OF NAME? ‫ المهنة؟‬THE PROFESSION? ‫ السن؟‬AGE? ‫ الحالة االجتماعية؟‬THE MARITTAL STATUS? ‫مانع الحمل؟‬CONTRACEPTION?

IN ENGLISH

‫ال‬ NO

‫نعم‬ YES

‫باللغة العربية‬

HAS ANYONE IN YOUR SURROUNDING BEEN DIAGNOSED WITH CANCER CERVIX? HAVE YOU EVER HEARED ABOUT ANY AWARENESS CAMPAIGNS FOR CANCER CERVIX DO YOU KNOW WHAT CAUSES CANCER CERVIX ?

‫هل سمعت او تعرف اي احد من محيطك تم تشخيصه من‬ ‫قبل بسرطان عنق الرحم ؟‬

DO YOU KNOW THAT HUMAN PAPILLOMA VIRUS IS THE CAUSE NUMBER ONE FOR CANCER CERVIX ?

‫هل تعرف ان الفيروس الحليمي هو المسبب االول لسرطان‬ ‫عنق الرحم ؟‬

DO YOU KNOW IT'S PREVENTABLE?

‫هل تعرف انه يمكن منعه ؟‬

‫هل سمعت عن اي حمالت توعيه من قبل لسرطان عنق‬ ‫الرحم ؟‬ ‫هل تعرف ما الذي يسبب سرطان عنق الرحم ؟‬

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‫هل تعرف ان هناك تطعيم يقي من سرطان عنق الرحم ؟‬

DO YOU KNOW THAT THERE IS A VACCINE FOR IT ? DO YOU KNOW OF ANY SCREENING TEST FOR EARLY DETECTION OF CANCER CERVIX? HAVE YOU EVER BEEN INVITED TO THE SCREENING TEST ? HAVE YOU EVER BEEN INVITED TO THE VACCINE ? DO YOU KNOW THAT SMOKING INCREASES THE CHANCES YOU GET CANCER CERVIX?

‫هل تعرف ان هناك فحص للكشف المبكر عن سرطان عنق‬ ‫الرحم ؟‬ ‫هل تمت دعوتك من قبل للفحص الدوري ؟‬ ‫هل تمت دعوتك من قبل للتطعيم ؟‬ ‫هل تعرف ان التدخين يزيد فرص اصابتك بسرطان عنق‬ ‫الرحم ؟‬

NURSE 1 NURSE 2

Q1 AGE 38 57 Q2 MARITAL STATUS (married or divorced or widow )( single ) single married Q3 CONTRACEPTION no no Q4 HAS ANYONE IN YOUR SURROUNDING BEEN DIAGNOSED WITH no CANCER CERVIX? yes Q6 HAVE YOU EVER HEARED ABOUT ANY AWARENESS CAMPAIGNS FOR CANCER no CERVIX no Q7 DO YOU KNOW WHAT CAUSES CANCER CERVIX ? no no Q8 DO YOU KNOW THAT HUMAN PAPILLOMA VIRUS IS THE CAUSE NUMBER no ONE yes FOR CANCER CERV Q9 DO YOU KNOW IT'S PREVENTABLE? no no Q 11 DO YOU KNOW THAT THERE IS A VACCINE FOR IT ? no no Q 12 DO YOU KNOW OF ANY SCREENING TEST FOR EARLY DETECTION no OF CANCER no CERVIX? Q 13 HAVE YOU EVER BEEN INVITED TO THE SCREENING TEST ? no no Q 14 HAVE YOU EVER BEEN INVITED TO THE VACCINE ? no yes Q 15 DO YOU KNOW THAT SMOKING INCREASES THE CHANCES YOU no GET CANCER no CERVIX?

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NURSE 95

NURSE 96

NURSE 97

NURSE 98

NURSE 99

NURSE 100

32 married yes no no no no no no no no no no

43 married yes no no no no no no no no no no

29 married yes no no no no no no no no no no

34 married yes no no no no no no no no no no

30 married yes no no no no no no no no no no

25 single no no no no no no no no no no no

%

45% MARRIED 6% 0% 1% 1% 1% 2% 1% 4% 3% 1%

(CONT .. Audit reporting form prior to presentation) “Patients were asked to complete a patient survey following their consultation Mainly if they are satisfied or not Nurses were satisfied 

Who was responsible for data collection.? Ibrahim Ahmed Elsherbini Eslam Hassan

The method of data input (if appropriate) and analysis e.g. data was input into and analyzed using Microsoft Excel. Into excel sheet

5. Results 1- Use simple tables 2- Use simple graphs 3- Do not mention names

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NURSE 95

NURSE 96

NURSE 97

NURSE 98

NURSE 99

NURSE 100

32 married yes no no no no no no no no no no

43 married yes no no no no no no no no no no

29 married yes no no no no no no no no no no

34 married yes no no no no no no no no no no

30 married yes no no no no no no no no no no

25 single no no no no no no no no no no no

6. 1) 2) 3) 4)

%

45% MARRIED 6% 0% 1% 1% 1% 2% 1% 4% 3% 1%

Conclusions List the key points that flow from your results Use bullet points Ensure your conclusions are supported by the data Never make claims that are not supported by the evidence

Less than 5% of nurses knew about cancer cervix and its cause, vaccine.

7. Recommendations Make sure these are realistic and achievable. If money is needed to implement your recommendations, you should have already investigated whether there are suitable funds available. 1) Meeting with nurse chief to arrange a presentation and a meeting with nursing staff to increase awareness about it 2) Arrange screening tests with o&g depart 3) Arrange vaccination with vaxira

8. Action plan Your action plan should be finalized after you have presented your project e.g. at a clinical audit presentation meeting. It is as a result of your presentation that your recommendations will either be accepted or revised. Following this, an action plan should be agreed, preferably at that meeting, to confirm what changes will be implemented, who will be responsible and when they will be implemented by Your action plan should be included in either the body of the report, or if the report has already

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been completed, as an addendum to the full report. If appropriate a date for a re-audit should be included in order to complete the audit cycle. 1) 2) 3) 4) 5)

Arrange a meeting with nursing staff Spread posters throughout the hospital Contact o&g Contact vaxira Re audit in two weeks

9. References Write any literature used No lit used 10. Appendices A copy of your data collection form should be included in the appendix. Included above and a sample of the excel sheet.

III . PRESENTATION

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‫االحرف االولي من االسم؟‬FIRST LETTERS OF NAME? ‫المهنة؟‬THE PROFESSION? ‫السن؟‬AGE? ‫الحالة االجتماعية؟‬THE MARITTAL STATUS? ‫مانع الحمل؟‬CONTRACEPTION?

IN ENGLISH

‫ال‬

‫نعم‬

‫باللغة العربية‬

NO YES HAS ANYONE IN YOUR SURROUNDING BEEN DIAGNOSED WITH CANCER CERVIX?

‫هل سمعت او تعرف اي احد من محيطك تم‬ ‫تشخيصه من قبل بسرطان عنق الرحم ؟‬

HAVE YOU EVER HEARED ABOUT ANY AWARENESS CAMPAIGNS FOR CANCER CERVIX

‫هل سمعت عن اي حمالت توعيه من قبل لسرطان‬ ‫عنق الرحم ؟‬

DO YOU KNOW WHAT CAUSES CANCER CERVIX ?

‫هل تعرف ما الذي يسبب سرطان عنق الرحم ؟‬

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DO YOU KNOW THAT HUMAN PAPILLOMA VIRUS IS THE CAUSE NUMBER ONE FOR CANCER CERVIX ?

‫هل تعرف ان الفيروس الحليمي هو المسبب االول‬ ‫لسرطان عنق الرحم ؟‬

DO YOU KNOW IT'S PREVENTABLE?

‫هل تعرف انه يمكن منعه ؟‬

DO YOU KNOW THAT THERE IS A VACCINE FOR IT ?

‫هل تعرف ان هناك تطعيم يقي من سرطان عنق‬ ‫الرحم ؟‬

DO YOU KNOW OF ANY SCREENING TEST FOR EARLY DETECTION OF CANCER CERVIX?

‫هل تعرف ان هناك فحص للكشف المبكر عن‬ ‫سرطان عنق الرحم ؟‬

HAVE YOU EVER BEEN INVITED TO THE SCREENING TEST ?

‫هل تمت دعوتك من قبل للفحص الدوري ؟‬

HAVE YOU EVER BEEN INVITED TO THE VACCINE ?

‫هل تمت دعوتك من قبل للتطعيم ؟‬

DO YOU KNOW THAT SMOKING INCREASES THE CHANCES YOU GET CANCER CERVIX?

‫هل تعرف ان التدخين يزيد فرص اصابتك بسرطان‬ ‫عنق الرحم ؟‬

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12. Ghosh R, editor. Clinical Audit for Doctors. Nongham: Developmedica; 2009. 13. Starey N. What is clinical governance? Evidence‐based Medicine. Kent, UK: Hayward Medical Communica_ons; 2001. 14. Swage T. Clinical governance in health care prac_ce. Oxford: BuerworthHeinemann, 2000, 2009 15. Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional prac_ce and health care outcomes. Cochrane Database Syst Rev. 2006;19:CD000259. 16. Crockford N, editor. An Introduc_on to Risk Management, 2nd ed. Cambridge, UK: Woodhead‐Faulkner; 1986.

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