These three related activities have the common goal of improving practice for the benefit of patients. Significant event analysis (SEA) gives you a structure to ask questions about and learn from a single event. Audit is research that lets you ask questions of your own practice, comparing it with best practice to make beneficial changes. Research asks questions and chooses tools to answer it in ways that are generalisable to wider situations.
What is Significant Event Analysis?
Case review is one of the oldest principles in medicine; by looking at cases where things have gone wrong you try to learn for the future. This has been formalised in official inquiries like the Bristol children’s heart surgery inquiry, and is based on the principles of case review.
GPs (and other specialties) use this to review their practice when something significant happens (not necessarily involving an undesirable outcome for the patient). SEA is now a requirement of the Clinical Governance provisions of the GP’s contract. It is part of the training of GP registrars and required for the Appraisal and Revalidation of qualified GPs.
Example of an SEA
You see a 4-year-old child with a headache and fever and reassure them they have flu and will get better but then subsequently that patient becomes seriously unwell and is admitted to hospital with meningitis.
Analysing a case like this should start the process of reflection (see Figure 6a), changing practice, for example reviewing guidelines for feverish illness in children and reviewing the case with colleagues and ‘safety netting’ to improve the outcome next time. Documentation is important, otherwise all the lessons learnt are lost, and there should be an action plan of recommended changes to practice and procedures. The final step is to set a deadline for reviewing whether the changes have been implemented and if this has averted similar events.
As a student you may be asked to identify a significant event as part of your practice attachment. This may be anything that raised questions in your head or perhaps made you feel uncomfortable. For example, a patient suddenly storms out of a consultation or you feel uneasy about the way the doctor has responded to an abortion request. Reflecting on the issues raised in a structured way may help to change your own thinking, or allow you to make suggestions to change the way the practice approaches the issue.
What is Audit?
Audit is a systematic way of reviewing how you practise (process audit) or what happens as a result of your practice (outcome audit) and comparing this with how others practise using professionally recognised standards. There are several key steps that make up the ‘audit cycle’ (see Figure 6b).
Example of an Audit
The National Institute for Clinical Excellence (NICE) publishes a new guideline stating that there is now good evidence that all patients who have had a confirmed thrombo-embolic stroke should be receiving aspirin and dipyridamole or clopidogrel to prevent further cardiovascular events. Your GP tutor suggests that as part of your attachment you conduct an audit of this for the practice.
Stage 1: Identifying the Question
A good audit question evolves from problems noticed in the practice, often coming from ideas from patients or the practice staff. It requires a good evidence base: you can’t see if best practice is being followed if it is not clear what best practice is. There should be a clear potential for improving service delivery. In the example, because the guideline is new, it is likely that not all patients will be on the correct treatment.
Stage 2: Defining Criteria and Standards
You should write an evidence-based statement that will form the audit criteria; for example ‘Patients who have had a stroke should be on antithrombotic therapy for secondary prevention.’ ‘Standards’ define the threshold of compliance for each criterion you are measuring. These should be explicit and measurable. In the example this could be ‘Ninety-eight per cent of all patients who have had a thrombo-embolic stroke should be taking aspirin–dipyridamole combination or clopidogrel if eligible within the past year.’ Not ‘Are patients who have had a stroke on antithrombotics?’
Stage 3: Data Collection
GPs have electronic databases that can be used to search for patients with coded diagnoses and prescribed medications. Often the notes will need to be examined manually to verify reasons why some clinical decisions were made. For example, some patients may be taking warfarin for a coexisting condition and therefore giving them clopidogrel would not be appropriate. Because audit involves direct contact with patient records, it must be conducted ethically and respect patient confidentiality.
Stage 4: Compare Performance with Criteria and Standards
How well were the standards met in your audit? Is this acceptable? If not, how could this be improved? This should be discussed with the practice team to produce an action plan.
Stage 5: Implementing Change
Recommendations should be written as clear action points and a named person who has responsibility for making it all happen with a timescale for review. Often audits will change practice for a short while then everyone goes back to doing what they were before the audit happened. Re-auditing the same topic or ‘completing the audit cycle’ can sustain the changes, although ideally you refine your criteria with new emerging evidence or lessons learned.
What is Research?
Most clinical research aims to improve scientific knowledge which can be directly fed back to improve heath or to change existing practice. It is less concerned with generating (or disproving) scientific theories in the way that basic science research does (Box 6.1). Like SEAs and audit it usually begins with defining a problem, examines the current evidence and then, rather than applying this (like audit), identifies gaps where new knowledge or theory is needed (exploratory) or tests the hypotheses that the gaps in current understanding expose (empirical or experimental research).
The Research Process
Most research follows a series of steps:
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