Editorial II: Audit—using both the good and the bad news to improve patient care

P. Simpson1,* and M. Harmer2

1 President, Royal College of Anaesthetists 2 President, Association of Anaesthetists of Great Britain and Ireland

* Corresponding author. E-mail: president{at}rcoa.ac.uk

Audit has become a familiar part of everyone's clinical practice. Since its introduction into mainstream clinical care, the importance of audit in identifying the current standard of practice and endeavouring to make improvements has become clear, as one looks at an increasing number of areas. Over the years, we have learnt a number of lessons from audit, some of them not entirely welcome. Given the diversity, complexity and variability within modern health care, one thing has become clear: audits that reveal only good news should be viewed with some suspicion. Given the subject, it was perhaps inevitable that the first National Audit conducted by the Royal College of Anaesthetists, reported in this issue of the British Journal of Anaesthesia,1 would contain both the good news and the not so good. Its topic, ‘Supervision and responsibility’, was chosen by anaesthetic audit coordinators (ACs) in hospitals throughout the United Kingdom, and they must have thought that there was room for improvement. It would seem that they were right.

On initial inspection of the article, one might quite reasonably be concerned over the reported levels of supervision and the means by which this is provided. However, before one decides that these findings represent unacceptably poor practice, it is appropriate to note that the response rate to the questionnaire was only 43% and the actual survey was conducted some 2–3 years ago. That should not allow us to be complacent, but perhaps gives us an opportunity to reflect on what the situation might be in those hospitals that did not make a return, and on what changes have occurred in the last few years that might have altered, and hopefully improved, the situation.

On the positive side, one might feel that the open-mindedness and commitment of ACs, and the manifest willingness of the many anaesthetists who took part, is perhaps more important than the specific findings of the audit. If we are not prepared to deal with difficult issues, what value is there in audit in the first place? It is also worth noting that many of the adverse findings within the survey were ‘minority’ ones, implying that overall there were acceptable standards. Despite this, there is still cause for concern.

At the heart of the matter of supervision is the non-negotiable principle that all clinical services must be under the supervision of a consultant.2 Since the inception of the National Health Service, it has been a requirement that every patient's care is undertaken either by a consultant or, in their name, by a trainee or non-consultant career grade. Although this principle is more apparent in ‘bed-owning’ specialties, it applies to all. The problem for service specialties such as anaesthesia is how to identify that line of responsibility and supervision. Unlike the situation in surgery of ‘Mr X’s registrar', we have no such linking arrangement. There are clear examples where care is delivered by a trainee ‘in the name’ of a consultant that have always existed during periods when there is clinical activity and the consultant is not in the hospital. The on-call consultant, either explicitly or implicitly, has always carried that responsibility, although some may choose to ignore the fact. The situation during normal working hours can be less straightforward. Whilst every department has an on-call team for out-of-hours work, trainees and staff and associate specialist (SAS) doctors do undertake work without the presence of a consultant, and, for many departments, it is far from clear who is responsible for supervising these staff. This has been the case for too long and this report provides a compelling reason for a review of the situation, such that every department must develop a policy for the supervision of all non-consultant staff.

If a system exists within a department to ensure supervision at all times, it follows that it must be possible to identify clearly which consultant is responsible for that supervision.3 That information must be recorded somewhere, and the simplest place for this is the anaesthetic record chart.4 By recording the information there, it will stay with the most pertinent document should there be a need to ascertain the supervisor's identity in the future. Most current anaesthetic charts only prompt identification of a supervisor present during anaesthesia, but not of how indirect supervision, be it implicit in a local chain of responsibility or explicit when a consultant's advice has been sought, is provided. Arguably, this information might be found by other routes, but the experience of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the Confidential Enquiries into Maternal Deaths has shown that if sought months or years later, the audit trail is likely to be very cold, if not dead.

Returning to the published report, from the viewpoint of both the supervised and the supervisor there are other problems. Compliance with the required induction process for trainees2 5 6 is 86%, and that for staff grades/associate specialists2 5 7 is only 48%. Many of the latter were appointed before the concept of induction, but less than half of either category of those supervised reported receiving, and only 48% of departments reported giving, a written policy on accountability. Induction is a vehicle for the initial description of the lines of accountability and is not an optional extra.

Since every trainee who undertakes a list requires direct or indirect consultant supervision,8 local systems must provide this. At the time that this survey was undertaken, most departments would probably have considered that they had an acceptable system of supervision in place. In the survey, whilst the majority of trainees felt that they were able to receive assistance when required, on 2% of occasions when immediate assistance was sought from a consultant, it was not available. Using data from the College census in 2003, direct extrapolation from the sample size of the study implies that every year some 3700 calls for assistance are not immediately answered. Only a minority of the delays would threaten patient safety, but some are real risks.

The most common (and common-sense) approach to identifying the supervisor (or ‘named consultant’) is the specification on the anaesthetic rota of the nominated consultant for daytime lists. That person must be either accompanied by another anaesthetist or free of other duties. If the accompanying anaesthetist is a trainee, he or she must be of sufficient experience to be able to manage the operating list alone if the consultant is called away. Unfortunately, this ‘gold standard’ does not apply in a significant minority of hospitals, but it should. The reasons that it does not are either attitudinal or organizational. Many consultants accept the responsibility that accompanies delegation of lists to trainees, either by knowing which ‘trainee’ lists they are supervising or by accepting responsibility for patients seen only by trainees. Others believe that the responsibility lies with the clinical director or lead clinician, and are only willing to supervise trainees accompanying them on their own lists. This puts an intolerable burden on the clinical director or lead clinician that in our view must be shared by consultant colleagues. The organizational problems are different. Some hospitals have no formal method of identifying a responsible consultant, and others, while having one, have an impaired delivery of this service because the consultant is engaged on other duties and is not immediately available.

Of particular concern is that, although not reported in the paper as published, the original data commissioned by the College revealed that only 47% of labour ward sessions had direct consultant supervision. If those without such direct supervision include those with no method of identifying or releasing a nominated consultant, there is a genuine risk to mothers' lives which sits ill with the recent report of the Confidential Enquiry into Maternal and Child Health.9

So what has been done and what needs to be done? The findings of the audit have been already been sent to the local audit coordinators, and reported to the Annual College Tutors' Meeting. The Association of Anaesthetists has issued a statement on the Named Consultant,3 and the Joint Committee on Good Practice has been asked to include in its review of the anaesthetic record sheet a method of prompting the recording of the nominated consultant.10 However, apart from such recording of the identification of the named consultant, the standards already exist. They just need to be observed. New staff must undergo induction that spells out how the local department works and the chain of responsibility, with the key points put in writing. Consultants need to ‘sign up’ to how they can discharge their obligations to supervise.

While most departments of anaesthesia will be pleased to see how well they compare with the findings reported, others will not, and will have to take action to put things right. The responsibility is not just for local clinical governance, where we share with managers their primary responsibility for the safety of patients, but is also a matter of professional responsibility.

References

1 McHugh G, Thoms GMM. Supervision and responsibility: The Royal College of Anaesthetists National Audit. Br J Anaesth 2005; 95: 124–9[Abstract/Free Full Text]

2 Royal College of Anaesthetists. Guidelines for the Provision of Anaesthetic Services. London: Royal College of Anaesthetists, 2004. Available online at: www.rcoa.ac.uk

3 The Named Consultant. Anaesthesia News 2004; 209: 15–16

4 Joint Committee on Good Practice. Good Practice, 2nd Edn. London: Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland, 2002

5 National Health Service Litigation Authority. Clinical Negligence Scheme for Trusts. Risk Management Standards and Procedures. Manual of Guidance. London: National Health Service Litigation Authority, 1997

6 Association of Anaesthetists of Great Britain and Ireland. Risk Management London: Association of Anaesthetists of Great Britain and Ireland, 1998

7 Clinical Negligence Scheme for Trusts. Risk Management Standards and Procedures. Manual of Guidance. London: National Health Service Litigation Authority, 1999

8 Royal College of Anaesthetists. The CCST in Anaesthesia I: General Principles. A Manual for Trainees and Trainers. London: Royal College of Anaesthetists, 2003

9 Cooper GM, McClure JH. Maternal deaths from anaesthesia. An extract from Why Mothers Die 2000–2002: Confidential Enquiry into Maternal and Child Health, Chapter 9. Br J Anaesth 2005; 94: 417–23. Available online at: www.cemach.org.uk/publications/WMD2000_2002/wmd-09.htm[Abstract/Free Full Text]

10 Joint Committee on Good Practice. Departmental Portfolio. London: Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland, 2002





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