What is clinical audit?

Clinical audit is a way to find out if healthcare is being provided in-line with standards. We use it to monitor outcomes so we can identify areas for improvement, and to let us know where we are doing well.

Results

Spectacle non-tolerance

Not everyone gets on with their new spectacles. This can be due to many reasons, and is not always often not because the patient gave the wrong answers or the optometrist asked the wrong questions. A change in lens power results in a change in magnification that alters our perception of size and shape, and how the eyes need to move to counter head-rotation. Any change may also require the head position to be raised or lowered, or things to be held at a different distance than was customary. None of these problems indicate that the glasses are wrong - only that there has been a change. For most, the adaptation period will only last a few hours. Some individuals may need from several days to two weeks before they become completely comfortable. Any issues that have not significantly improved after this time should be investigated and is defined as a non-tolerance that requires a return to the optometrist.

The industry standard was based on Howell-Duffy et al. 2010. The value for Johnson & Furze was based on the proportion of re-checks per number of spectacles prescribed in 2015. Our 20 cases of non-tolerance can be broken-down as follows: dispensing related (9); prescription related (6); disease (5). Following a re-check, all cases were satisfactorily corrected, except those where vision was below expectations due to disease unrelated to spectacles.

Referral accuracy

An important role of optometrists is to identify eye problems that require medical attention. Missing advanced eye disease is negligent and is rare, but examining the eyes is very difficult and overlooking subtle problems is easily done and is very common. The task is complicated by there being a large overlap between the variations of normal with early disease. Not identifying a person who should be referred is defined as a false-negative.

Unnecessary referrals are also costly because it wastes the time of patients and expends healthcare resources that could be used to investigate someone else. Referring a person who does not need to be referred is defined as a false-positive.

The industry standard for false-positives was based on Davey et al. 2015. This study also noted a higher rate of unnecessary referrals from multiple practices (36%) versus independent practices (22%). The value for Johnson & Furze was based on feedback, when obtainable, from all referrals made in 2015. Feedback was either gathered from clinical correspondence or directly from patients.

False-negative data is difficult to obtain because when something is missed it remains unknown about unless the person happens to be authoritatively reviewed soon after, which does not happen routinely. The only published data on false-negatives is for glaucoma, and three studies have made estimates: Devarajan et al. 2011 (10%); Bourne et al. 2010 (15%); Azuara-Blanco et al. 2007 (24%); the industry standard was based on the middle value. The value for Johnson & Furze was estimated based on a comparison with the number of patients examined in 2015 who are known to have glaucoma (312), owing to previous referral and confirmation by a consultant ophthalmologist, with the number of cases predicted by published epidemiological data adjusted for our demographic (129). A lower number of known cases than expected would suggest that a diagnosis of glaucoma had been missed. We had more confirmed cases than predicted.

Overall satisfaction

This is a measure of how customers rate their experience and the likelihood of recommending a friend. It considers professional skills, product range, product quality, value for money, time-keeping, communication, and customer-service.