|11. What is the Evidence for the Role of Audits to Improve the Quality of Obstetric Care|
In criterion-based audit, agreed standards of care based on explicit criteria are agreed by those involved in the care (Crombie et al. 1997, Graham et al. 2000, Bullough & Graham 2000). These standards do not only involve the definition of criteria of good management, but also an agreement of the extent to which these criteria ought to be met (i.e. the target). For example, in a study in Scotland one of the criteria of good management of induced abortion was that the womans rhesus status should be ascertained and rhesus prophylaxis given after abortion is indicated (Penney et al. 1994). Performance was considered good (i.e. attaining the target) if more than 90% of cases fulfilled this criterion. This is clearly distinct from the confidential enquiries where recommendations for improvement are made on the basis of the assessment of substandard care but no explicit objectives for change are set. Similarly, other review processes such as the individual case reviews often do not specify clear-cut agreed standards of care. The main hypothesis with criterion-based audits is that the knowledge on (not) meeting the agreed levels of care will lead to specific changes in clinical practice.
Criterion-based audit involves a review process whereby clinicians first agree on a number of explicit and realistic criteria of good quality, adapting external guidelines to take into account the local resource context. Rather than being comprehensive, the list of criteria has to be kept short and simple to apply. Criteria are selected based on their relevance to the audited topic, the strength of the research evidence in their support, their ease of measurement using hospital case notes, and the capacity of the facility in terms of human and other resources. To assess current against standard practice an external audit assistant reviews a large number of case notes for their conformity with the set criteria, and the findings are fed back to the providers. Using the proportions of cases in which the relevant criteria are met as a starting point for discussion, improvements in care are recommended and realistic targets set. Changes in care are suggested and the audit cycle is closed by implementing the changes and re-evaluating practice. Carefully designed criterion-based audit may provide one of the most efficient methods of audit (Crombie et al. 1997). The approach is relatively simple and the use of trained non-clinical staff for data gathering enables a large number of representative cases to be reviewed. The local staffs involvement in reflecting on their current practice and setting standards is believed to be an effective mechanism for bringing about improvements in care. Even the detailed process of development of criteria may be beneficial, focusing attention on the topic and increasing the sense of ownership of the audit among the clinicians involved. Potential limitations of this approach include the sole reliance on case notes which have to be of sufficient quality, the need for external expertise (for screening case notes and statistical analysis), a tendency to focus mostly on clinical factors and possibly the high cost.