Understanding clinical practice toolkit

Partnering for performance incorporates a toolkit designed to help doctors, their managers and organisations to understand and monitor the quality and effectiveness of their clinical practice.

The Understanding clinical practice toolkit was developed by senior Victorian doctors with support and guidance from the Department of Health & Human Services Clinical Engagement Advisory Group (CEAG) and other key stakeholders.

It provides detailed information on the use and capabilities of six principal tools that can be used at different stages of the credentialling cycle to develop a comprehensive picture of an individual’s clinical performance.

Formal peer review

Formal peer review is the process by which individuals of the same profession working in a similar setting critically assess their colleagues’ performance in order to reinforce areas of strength and quality in patient care, and to identify areas for improvement.

Peer review usually assesses a number of elements of a doctor’s performance, including their clinical expertise and practice, their communication, scholarship and professionalism.

In Partnering for Performance, formal peer review has two distinct purposes:

• it is a critical element of the credentialling and re-credentialling process
• it should be considered the key forum or activity for evaluating issues around a doctor’s clinical performance, where significant concerns about their performance have been raised and were not able to be managed at the unit or department level.

Adverse occurrence screening / targeted case note reviews

Adverse occurrence screening (AOS) or targeted case note reviews (TCNR) identify underlying problems with care delivery that might provide opportunities for clinical improvement. They generally involve the review of selected medical records by colleagues using screening criteria that may be associated with care-related adverse events.

AOS/TCNRs can be used to identify cases for subsequent review (for example, at a mortality and morbidity meeting). This helps reduce the uncertainty and inconsistency that can arise when selecting cases for discussion in such a forum. They may also be combined with other clinical measures, such as clinical audits, to provide a broader picture of an individual doctor’s clinical performance.

Mortality and morbidity reviews / case discussion meetings

Mortality and morbidity reviews (MMR) or case discussion meetings are routine, structured meetings for the open examination of cases that have led to the illness or death of a patient in order to collectively learn from events and to improve patient management and quality of care.

MMRs or case discussion meetings usually involve medical practitioners discussing a selected case for the purposes of clarifying its medical management and identifying opportunities for the improvement of patient safety and clinical care. MMRs are not designed to assess an individual doctor’s care, but to provide a forum or learning opportunity for system-level improvements, based on the identification and discussion of key issues.

Clinical audits

Clinical audits involve the systematic review of specific elements of clinical care against predetermined criteria, with the aim of identifying areas for improvement and then developing, implementing and evaluating strategies to achieve that improvement.

Audits generally target a specific clinical topic of interest or concern, and assess it against clinical-level data such as medical records and feedback from clinicians and consumers. When managed by senior doctors, clinical audits are generally viewed as a valuable means of informing doctors about their care delivery.

Clinical indicators

Clinical indicators are measures of the process, structure or outcomes of clinical care, which when assessed over time, provide a method of assessing the quality and safety of care at a system level. Clinical indicators are regularly used by health services and regulatory bodies to identify areas of concern that may require further review or development.

Clinical indicators can be used to assess the quality of care of specific services or in the treatment of specific diseases, as well as overarching areas such as clinical governance and patient safety. They measure rates of occurrence that can be benchmarked between services or against national averages.

Although they can help to determine service or system priorities and support quality improvement, clinical indicators are rarely specific enough to provide an insight into an individual doctor’s performance.

Patient satisfaction and complaints

While patient complaints have long been used to measure dissatisfaction in health services, formal patient satisfaction surveys are now more frequently used to understand aspects of the quality of care. Patient surveys and complaints can capture many elements of the quality of care, including:

• the art of care (caring attitude)
• accessibility and convenience
• affordability of care
• the physical environment
• continuity of care
• efficacy and outcome of care.

Patient surveys and complaint data can readily be integrated into clinical practice improvement programs. However, because of the broad-based, multidimensional nature of patient satisfaction, it is rarely possible to draw significant conclusions about an individual doctor’s performance.

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