National Clinical Audit Workshop 2023

On 8th June 2023, the College of Physicians Malaysia (CoPM) in collaboration with the Royal College of Physicians (RCP) of London, organized the second National Clinical Audit Workshop, at the Academy of Medicine of Malaysia, Taman Teknologi Mranti, Bukit Jalil. This workshop was expanded and conducted in two days with full physical attendance by the participants at the College of Physicians, Malaysia, after taking into consideration feedback from the first event last year. 

Clinical audit is a key principle underpinning clinical governance. It is a quality improvement process that seeks to improve patient care and outcomes through a systematic review of care against explicit criteria and the implementation of change. It starts with a mindful strategy looking at the performance of own practices against the standard for benchmarking. Along this, it is essential to highlight any process that provides a framework to identify pitfalls and enable the implementation of change with sustainability. Findings from clinical audits guide to improve the standard and quality of clinical care. This process, or “cycle,” is designed to be perpetually repeated to forever improve standards, thereby transforming the cycle into an upward spiral.

This workshop aimed to provide insight for healthcare professionals about the importance and step by step in conducting clinical audit for their daily practice, with hands-on group works to enhance their learning curves. We wish that this workshop will become an annual event to allow capacity building to reach a critical mass to instill the spirit of clinical audit for quality improvement in the nation. The spirit of quality improvement is at the heart of every healthcare professional. One of the goals of this workshop is to institutionalize and internalize quality in the health system. We cannot improve what we cannot measure, hence selecting measurable criteria and standards for clinical audit is important.

The organizing chairperson was Professor Dr Tan Maw Pin, Consultant Geriatrician, Universiti Malaya and Honorary General Secretary, College of Physicians Malaysia. This event was well attended by 36 participants, consisting of various specialties, from medical students, pharmacists and doctors, and levels of clinical experience, both from academia and government sectors. Participants came from as far as Kedah, Kelantan, Terrengganu, Sabah and Sarawak. 

The event was endorsed with a motivating welcome speech from the Director General of Health, Malaysia, Datuk Dr Muhammad Radzi bin Abu Hassan. He reiterated that clinical audit is an indispensable tool to help us determine how well our care delivery adheres to available guidelines and expected standards of care. He emphasized that this is carried out within a blame-free and transparent culture. Deficiencies identified through audit should be addressed positively to drive service improvement efforts. The practice of medicine should go beyond medical knowledge. The modern doctor needs to also possess skills that will help them constantly evaluate their care delivery as well as improve their clinical practice. He wished to see many more clinical audit workshops and completed audits throughout the country in the future.

The programme started with ice breaking session among all participants to get to know each other. Dr Terence Ong Ing Wei, Consultant Geriatrician from Universiti Malaya, started the first lecture on “Introduction to Clinical Audit”. He inspired the crowd by setting the scene from the historical and contemporary perspectives on the values of clinical audit in clinical care. He delineated the differences between research, audit and quality improvement (RAQI). Besides, he shared a sneak peek for future Internal Medicine Postgraduate Training in Malaysia where RAQI project becomes a requirement for candidates undertaking Master of Medicine or parallel pathway.

Next, Dr Ng Rong Xiang, Internist and Infectious Diseases Physician from Universiti Malaya presented the second lecture on “The Audit Cycle”. He succinctly introduced different parts of the audit cycle, namely the PDSA cycle (Plan, Do, Study and Act), how to select a topic and decide what to audit, how to select and determine the standards, such as organizational, process or outcome standards, and implementing changes to improve the standards followed by re-audit.

After a short break, our facilitators led by Dr Hor Chee Peng, conducted the group works on critical appraisal of published clinical audit projects, identifying the strengths and limitations of each example. Active engagement from all groups with group presentations made the session fun for learning.

In the afternoon session, Professor Dr Edmund Ong Liang Chai, Senior Consultant Infectious Diseases Physician and Honorary Professor from Newcastle University Medicine Malaysia and RCP’s International Global Advisor proceeded with the topic of “Preparing an Audit Proposal”. The key elements included identifying team members in an audit project and preparing a written proposal He illustrated successful examples using the British National HIV Testing Programme and Chronic Obstructive Pulmonary Care Programme, how both programmes identified and engaged key stakeholders in the audit process, disseminated the findings and implemented the recommendations to improve care sustainably.

Professor Dr Tan Maw Pin then shared her lecture on “Structuring an Audit Proposal with a detailed structural framework in the written proposal, highlighting deficits in current practice, objective of the audit, proposing standard of the audit/QI project and the governance structure in the practice. Approval to conduct clinical audit can be sought from local institutional authority and can be exempted from ethics clearance from the Medical Research Ethics Committee, Ministry of Health, Malaysia. Following this, the participants were enrolled into six different groups to structure an audit proposal, which they would present the next day for a competition. Each group was led by a facilitator. 

Day 1 of the workshop ended with our honoured guest speaker, Dr Jane Youde, Senior Consultant Geriatrician and former Clinical Director for the RCP National Clinical Audit and Accreditation Programme, joining us virtually from Derby, UK. She amazed us with her dedication and career-long journey in audit to improve care for older persons. She has been involved in the care of older persons with falls and syncope for more than 20 years and has seen first-hand how the RCP national audit for hip fractures has led to quality programmes which reduced the morbidity and mortality from hip fractures. The RCP has hosted various national audit programmes in the UK, including the National Lung Cancer Audit (NLCA), National Asthma and COPD Programme (NACAP), and the Falls and Fracture Fragility Programme (FFFAP), in which she has been involved in some. Dr Jane Youde emphasized the power of audit and introduction to quality improvement in the United Kingdom. This should be integral to all aspects of clinical care for all patients and should inspire more audit and improvement projects to be undertaken not just by the medical team but the multidisciplinary team.

Day 2 of the workshop started with “Data Collection” by Dr Hor Chee Peng, a clinician from Kepala Batas Hospital and Clinical Research Centre, Seberang Jaya Hospital, Penang. He shared on audit methodology from sampling to design of simple data collection forms, collecting the data (paper forms versus apps such as Excel, Google forms, REDCap) followed by reflections on the audit. Professor Dr Edmund Ong then talked about “Data Analysis” to guide the participants on descriptive and comparative analyses, followed by observing deviation from standard and interpreting the data. Dr Irene Looi, Consultant Neurologist and Head of the Clinical Research Centre, Seberang Jaya Hospital, shared the example of the National Stroke Registry and the application of the registry findings as part of audit outputs to improve stroke care for the country. There were hurdles to overcome which requires multidisciplinary collaboration and relentless effort to sustain the national programme.

The next agenda was an audit presentation by Dr Sharmilan Gangatharan from the Department of Emergency and Trauma, Bukit Mertajam Hospital. Other team members, Dr Khor Chin Chuan and Dr Illiana Syahmun Binti Mohd Razally were present together virtually. His team won the best audit proposal for the workshop in 2022. Their project titled “Clinical Audit on Adherence to Acute Stroke Activation and Thrombolysis Protocol Target Time in Emergency and Trauma Department of Bukit Mertajam Hospital” was completed after the workshop, and presented at the National QA Convention end of last year. The project was applauded by the participants for their great effort and stakeholders' involvement across different disciplines.

Following the short tea break, an new and interesting component introduced for this workshop was Closing the Audit Loop Forum by the panel facilitators, moderated by Professor Dr Tan Maw Pin. Examples of successful projects with closing the loop were discussed along with the challenges and uncertainties encountered from individual experience. It takes perseverance and tactful strategies to convince stakeholders to implement changes for good and to make them sustainable.

After the lunch break, the group works resumed. The intense discussion and active participation from every member in each group demonstrated their strong interest in clinical audit. Each of the six groups presented their audit proposal to Dr Jane Youde, who judged virtually from Derby. They received constructive and useful feedback to move forward with their respective projects. The best audit proposal this year was won by Mr Jason Tan who presented the proposal on “Clinical Audit on Medication Discrepancies in Prescriptions from Medical Outpatient Department, Sungai Bakap Hospital”. The group with nominated members were invited to attend the upcoming Annual Scientific Congress of the College of Physicians Malaysia, in November, in Kuching, Sarawak, to receive the prize.

The workshop ended with a question-and-answer session and reflection of the day by our organizing chairperson, Professor Dr Tan Maw Pin. Many expressed their great interest in echo training in their respective institutions. Heartfelt gratitude to the secretariat of College of Physicians Malaysia, Ms Siti Adilah binti Abu Bakar, Ms Farhana binti Ahmad Affandi and Mr Muhammad Afiq Mustakim bin Sharudin, who have made this workshop a great success this year! 

We sincerely look forward to participants developing their ability to lead key clinical audit projects and apply implementation science practice wherever is practical. We aim to organize similar events annually, at a larger scale in years to come. Please get in touch with the College of Physicians Malaysia if you would like to know more.