Introducing routine clinical audit in public hospitals to

Introducing routine clinical audit in public hospitals to improve quality of care: potential and pitfalls. The case of Casablanca public health hospitals in Morocco Pierre Blaise*, Amina Sahel‡, Marc-Eric Gruénais**, Vincent De Brouwere* *Institute of Tropical Medicine (ITM), Antwerp (Belgium); ‡Directorate of hospitals and ambulatory care, Ministry of Health, Rabat (Morocco); **Institute of Research For Development (IRD), Marseille (France) Correspondence: pblaise@itg. be Intervention: Implementation of criterion based clinical audit in 4 public hospitals of Casablanca to improve quality of clinical care Project structure: Technical support team introduces and supports clinical audits: Sociological research team documents social process: Provides training Supports data entry & analysis Creates supportive discussion space Feeds-back the qualitative analysis of discourses Mouley Youssef Hospital teams Baouafi Hospital Physicians Director Maternity Surgery Paediatrics Nurses Midwives Al-Hassani Hospital Maternity Surgery University Hospital Oncology Paediatrics Research outline The research objective Inform the process of routine implementation of clinical audit for both promoters and implementers Two research questions What are the constraints and the potential for the routine implementation of clinical audit ? How do the system and its actors react to the routine implementation of clinical audit ? Method: In-depth interviews with clinicians and hospital directors, first to support the process through a platform for teams to unveil and discuss perception about the implementation process while doing it, second to collect longitudinally the actors’ perception in order to document the process, followed by a qualitative content analysis on the transcripts of the in-depth interviews, coding the discourse for pre-identified (framework method) and emerging themes. Key Results 1. Practical lessons for implementation: Supporting the process trough discussion groups is perceived as very useful by the teams However, a web of constraints questions the strategy of rapid scaling up: First, clinical audit alone has limited potential to implement improvement initiatives, it must be embedded in a wider quality system. Second, dedicated resources, allocated time, trained personnel and technical support must be available 2. Issues worth for further research: Doctors and pens, a difficult relation ! Is refusal to write, a legitimate claim for professional autonomy or an unacceptable form of protection undermining accountability ? The patients-professionals’ conflicting relation, a battlefield to investigate ! The remarkable variability across professional groups in the appropriation of audit, an observation worth to explore. Interpretation and conclusion The “theoretical” assumptions for clinical audits to “work” : - Professionals are accountable : they perceive a dysfunction affecting their patients as their problem - Professionals are reflexive: they question their own practice to identify problems - Professionals are willing and able to change and improve clinical practice: When confronting problems, they take initiative and look for available solutions 3. The difficult appropriation of clinical audits: The cause of problems are externalised: professionals rarely question their own practice Audits are perceived as one more management problem to solve rather than a solution to clinical management problems. Audits are instrumented as a lever to claim additional resources rather than a lever to improve the efficient use of available resources The actual conditions may not be favourable for clinical audit to “work” in public hospitals in Morocco: - Accountability to patients is limited: Beside compassion for the sick, no genuine patient –centeredness - Willingness to exert reflexivity is limited: The blame for dysfunction is pushed to ‘others’ (central, administration, patients, lack of resources) - Capacity to change is limited: the bureaucratic system leaves little room for professionals to introduce changes Poster session, 23 th International Conference of the International Society for Quality in Health Care (ISQua) London 2006 Research supported by the Belgian Directorate-General for Development Cooperation