Examples

Examples of audits actually carried out by CAM practitioners, with the results, were published by the RCCM in a research pack in 1999: ‘Improving patient care in complementary medicine: using clinical audit’ Although subsequently available on their website, it may no longer be there: contact ARRC for a copy.  
Presented below are several theoretical examples, chosen across topics that may be relevant for acupuncturists, and which illustrate the application of the methods described above and issues that may arise from this.

Example 1. Practitioner punctuality

Let’s say that a practitioner is aware of the fact that (s)he tends to over-run the treatments sessions and be late for the next patient.
Specific criterion to measure: how many minutes late is the practitioner in relation to the due start time.
There is no officially designated standard for this though possibly there is prior information about it from other settings (e.g. GPs). The aim may never to be late by even one minute but this is usually impractical. Your decision on standards will be based largely on common sense and your own experience. For example, you could specify that 90% of appointments should be no more than 5 minutes late.

Good points about this audit:

  • Easy to measure/record the data on the criterion
  • The objective is largely under your control, not dependent on others

Recording your punctuality for a month should provide ample data. Let’s say that you meet the standards in 80% of cases. This falls below the 90% level, so theoretically you should take action to improve the situation. In the absence of existing standards you may decide at this point that in fact 80% is OK, but backsliding on your initial target should not be done without good reason. You may want to get answers to some subsidiary questions before deciding on any actions:

  • What do the patients feel about your time-keeping?
  • How do you compare with colleagues in this respect?
  • What is causing you to be late?

Hence there could be more data collection, e.g. a questionnaire for patients, ideas from self-reflection.
If, on the other hand, your initial results showed being at least 15 minutes late in 80% of cases then the need for action would be very clear.

Example 2. How good are your patient records?

This is a favourite area with those who promote audit (e.g. Rees 1997) with many aspects of record-taking that could be used as good practice criteria. Some of these, such as writing legibly, including the patient’s full name and consultation dates, are certainly necessary and could be legal requirements. The recording of salient characteristics of the patient presentation, diagnosis and treatment given, are perhaps more interesting for practitioners and vital for monitoring and evaluating practice.
BAcC SPA standard S1.4 states ‘Practitioners keep appropriate records of their practice and treatment.’ It covers the legal and health care aspects of record keeping and also information about the diagnosis and treatment plan, but it does not specify any precise requirements.

There is some published data on the extent to which practitioners record the Chinese medicine diagnosis: 61% of the records examined did this (Wadlow and Peringer 1996). These were the combined records of 13 practitioners, who may well have varied a lot amongst themselves. Bettering the 61% figure might be a legitimate goal for the profession overall but it’s not a useful standard for an individual acupuncturist. If you think it’s valuable to record diagnosis then why not aim for 100% (perhaps 95% is more realistic); if not, then why bother to audit it?
For auditing any aspect of your records you could start by retrospectively analysing a sample of your case notes. If you have changed what you do over the years then select the more recent ones to look at. Then use these data to guide your standards.`

Example 3.  How many treatments do patients have?

Analysing your back records to count how many patients came once, twice, three times etc easily provides a practice profile that’s informative on patient satisfaction and financial viability.  Here is one person’s data (Huber 2012):

No. times attendedProportion of patients (%)
1 34
2-4 29
5-10 21
11-20 12
21-50 2
>50 2

A third of patients coming only once may seem unacceptable, but if your practice contains a lot of one-off embryo transfer treatments then it is a different matter. You need to take account of all such relevant factors when setting your standards. This is a good area to audit and can lead on to various actions and further explorations:

  • contact the one-offs and ask why they stopped
  • use a satisfaction questionnaire for a sample of your patients
  • ask a colleague to sit in on some sessions or audio-tape them
  • look at the expectations of new patients and the information you provide to them.

Example 4. Are patients getting better?

There is a growing body of acupuncture outcomes data, especially with MYMOP. You could, for example, set a standard of one unit MYMOP change (the cut-off that’s often taken to indicate clinical significance) to be achieved by at least 50% of patients. This sort of audit is fraught with difficulties, not least, how do you go about improving practice if you get poor results? Patient outcomes depend on many factors, including the unknown and the unalterable, so the likelihood of success may be low.
However, there may be value in comparing the outcomes for different groups of patients, for example different diagnoses. If your back pain patients are doing much worse that those with neck pain then perhaps you should do some more learning about the former and/or try a different approach. If you’re having little success with people with blood stasis then perhaps you should consider referring them to a herbalist. Better knowledge of your past record also allows you to give more reliable information to new patients, but that’s another audit entirely.

Example 5. Lifestyle advice

Giving patient lifestyle advice is an important part of medical practice, not least in traditional East Asian medicine, where the advice may be adjusted according to the traditional diagnosis and hence be considered integral to the specific effect of the treatment. Some examples of questions in this area:

  • What proportion of patients get lifestyle advice from you?
  • Is the advice generic or individually tailored: is it matched to the traditional diagnosis?
  • What range of lifestyle aspects are covered?
  • How is the advice given (see Paterson et al, 2012, for more information)
  • How is it followed up? What level of compliance is there and how is it encouraged?

There is scope here for a lifetime of audits but let’s look more closely at the firs, and probably the most straightforward of these questions.  It’s unlikely that many acupuncturists (systematically) record whether and what advice they give, so you’ll need to decide what to record and incorporate it into your routine note-taking. The main difficulty with this audit may be defining what’s meant by a patient getting lifestyle advice from you: does it include passing comments ‘some more exercise would be a good idea’ or does there have to be a more definite encouragement with more specific advice, or even a categorical request that the patient carries out a particular task? If you’re going to audio-tape your sessions and analyse the conversation then any of these would be possible but focusing on the more definite end of the spectrum would make it much easier. The definition still needs some thought, but after this you could simply  make a note in each treatment session as to whether advice was offered and what was its nature. Adding up the ‘yes’ and ‘no’ markers would give you a quantitative answer to the question and you can then proceed with the usual following audit stages.