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I just coming off. So. Ok. Uh So good evening. My name is Mohammed Hashim. I'm, I'm a consultant uh foot and ankle surgeon at uh UK Northwest London from the Health Trust. Um and I have a very long history with medical education, um quality improvement projects, audits and research. Um I'm the audit and research date in my trust and I've conducted many, many projects for uh the last few years. It's a, it's a fantastic idea to be involved with audit and research and quality improvement is the way of development, is the way of assessment, is the way of auditing and the way to know if you are doing well, if you are doing bad, if you're sticking to trust and um standards. And the so in a simple way, um audit, quality improvement and research all aim for you to uh improve your service to the patient. We all aim for a very qualified service to our patients. And to reach this, you need to know is, is what you are doing up to the standards or you're doing something different than the standards and guidelines. And if you're doing something, not following the guidelines or uh the standards, what shall you do to get this back to standards and guidelines and how to improve your service? So, the first one is a clinical audit and to understand the audit, you need to understand that um most of our clinical practice and, and all uh subspecialties, medical subspecialties is going according to guidelines. Uh there is a lot of guidelines around the world and uh some of them are very old, some of them then um are just recent guidelines, but there is very good established guidelines on top of them. It's post guidelines and the nice guidelines from UK uh the American Academy guidelines from um States and the Australian guidelines from Australia and the Canadian College guidelines from Canadian um uh Medical Society. These guidelines is basically based on a very extensive research, very robust, uh well done, wellformed research which came with a very um strong evidence which support certain practice as a standard practice. And um these guidelines meant exactly to standardize your practice and make your practice uh very safe, very efficient and very qualified. And when you, you, you speak about clinical audit, so we speak about comparing what you're doing to the standard or the the the guidelines. So basically, you must have a standard, you must have a guidelines and you are comparing what you're doing to these guidelines or these to these standards and this is the idea of clinical audit. So audit, you just reassessing your practice and looking into this practice. Is it following the guidelines and standards or not very simple procedure? You can run it everywhere in the world. Even in very, very developing countries with need, it doesn't need any funding, it doesn't need any financial support, it doesn't need any technical support. It needs you to understand the idea and once you understand the idea, it's very easy for you to conduct it. So, a audits in Egypt, a audits in Oman, I found audits in uh UK, I found audits in UK in different stages of my career and in different places, clinical audit, you shall do it in your home. So you should, you normally do this in your, in your normal day without understanding this is an audit. So basically, if you, um if I speak about your normal day, your normal schedule. So if you start your day in six at 6 a.m. getting breakfast on time, going to school or going to um medical school or going to um uh work and then from work, you um get lunch at 12, then continue normally uh after lunch break and then you go back home on at five, then five, you spend some time reading or doing something and then you have some family time. This is nearly a standard day and you are day by day looking into making your day as a standard day. And if it's not, you try from time to time to just audit yourself and see what I'm doing, what I'm doing wrong. Oh, what, what, uh, do I sleep up to a very late time in the morning? Do I don't go to work on time? Do I have a problem with the traffic? Do I have a problem with my meal times? So, actually you're auditing yourself all the day without understanding that this is an audit, same idea in the clinical practice. So I'm operating on certain patient by a certain way. And um I have to ask myself what I'm doing, is it according to the, the nice, the guidelines and the standards of practice or not? So you, it's a process to measure the current clinical practice against established standard. This idea has to be very clear and why I do that firstly, to evaluate the quality of the care I'm giving to know if my my care to the patient is up to the standard or not try for myself to adhere to the standard and best practice. So if I'm not doing, if my practice is not compliant with um with the standards or the guidelines, I'm a, I'm aiming to improve my standard, my care to go up to the standard or the um guidelines, then to identify the areas of improvement and easily, while you're doing an audit, you're basically looking into certain points to compare it to the standard of the guidelines. But actually, you get a lot of associating points which you can improve and make it better. So, uh it's very common that people understand all the things as a form of like sober vision or a form of, of uh uh uh watching what you are doing. It's not that it's, it's aiming to quality improvement. So it's aiming to improve my work. It's not aiming for blaming anyone, it's not aiming to um uh uh but anyone in a, in a, in a trouble, it's not against anyone. It's, it's only, it's only positive. So I'm doing that just to standardize my practice to improve my care, to understand what is the area of weaknesses, where is the area of ST so how can I make the, the the the stance points more strong and the weak point uh improving to be strong. So we are not auditing for any negative reason. It's all positive reasons to run an audit. You have an audit cycle. So you have firstly uh to understand um what you are doing and identify that the practice you are doing is not up to the standard. Then you identify the standard, you need to find the guidelines for the for the point you are going to audit, then you need to collect the data about what you are doing, you know about your current practice and then compare this to the standards. And then once you compare it to the standard, this will reflect, are you compliant to the guidelines or not. If you compliant to the guidelines, that's perfect. And you need to carry on doing this. If you are not compliant with the guidelines, you need to stop and find where is the problem plan, an action to change this and implement this change. Then once you do that, you need to go and re audit to ensure that you have improved what's needs improvement. So the key steps of the audit cycle is to identify the audit topic. So I know I need to know what part of my practice I need to audit. Number two, I need to know what the standard, what's the criteria I'm going to benchmark against or what, what the criteria I'm assisting against. Then I need to collect the data about my current practice. So I gather all the data about the point I'm auditing. Then I need to analyze this data to know uh is what I'm doing is compliant or not. And if it's compliant, it's ok. If it's not, I need to know why not. Then once I know why I'm not compliant, I start plan to change that, implement this change. And then once I do that I can re audit and to ensure that this audit cycle has end into change. So I have done what I aimed for. The aim of any clinical audit is to improve patient care. This is the our aim in everything we do is to to give our patient the most um qualified efficient service to ensure that your clinical practice is up to the standard. Uh accountability means you encourage the healthcare professional to meet the established guidelines, data driven decision. So all what all the decision you will take is based on the data already you have in your hand. So I'm not following the the guidelines in VT prophylaxis. Um My problem is I'm not giving this to patient to the patients on time and I'm not, I'm not using the mechanical VT prophylaxis. I need to improve this. So I'll implement this action. So you have that in your hand and your decision will be based on this data then to be cost efficient. So basically, you are aiming to optimize your practice and optimization of practice improves the patient care and at the same time, deserve and save your resources. So example, for one of the audits we have run. So audits is very easy, very quick. Uh We do more than 60 audit um a year um teams who are working at every point you need just to identify that you have a problem in one of the points and start to audit to ensure that you're doing what, what should you do or not. So one of the simple one we have done and has a very impact on the, on, on the practice in our trust in our, our hospital. We have audited our um practice in the mechanical PT. So basically every patient go to the hospital. According to the nice guidelines, any surgical patient go to the hospital according to the nice guidelines, should have vte assessment, venous thromboembolism and venous thromboembolism uh prophylaxis mechanically, which could be a could be um uh uh flu Thrones, any form of mechanical vte prophylaxis. This is the guidelines. Then I start to notice that not every patient in my ward, especially if I've done a a hip operation to this patient has had a VT mechanical VT prophylaxis. So we went there, we collect data. We see if every patient, every surgical patient admitted to the hospital has had uh VT mechanical VTA prophylaxis or not. Then we came to know that we are not compliant with the guidelines because most of our patients doesn't have a mechanical VTE on the operated uh hip side because basically the stuff, the nurse stuff and the nursing staff were, were worried about the operated hip. They don't want to touch the operated hip, they're worried about dislocating it. So they don't do any mechanical VTE on the operated side, which is not according to the guidelines because the nice guidelines say that every surgical patient going for an operation, admitted to the hospital should have a mechanical vte prophylaxis. So they don't do that as they are wanted to make any problem for the operated hip. So we we weren't compliant. So the first cycle of this audit, um we've done a booster to inform them that we are not compliant and we should do be compliant because the guidelines say that every patient should have a mechanical vte. We, we run some decisions, some education decision to the nursing staff on the borders. Then uh we make a sticker to be able to in every patient notes. At that time, we were running just um paperwork notes, not, not um computer system as we do now. So we bought a sticker over every patient notes to remember them that this patient had a mechanical VTE or not. And they have to take the books. If the patient has a mechanical VTE and if they don't take the books, then they understand they have to know that there is a problem in the, in the notes and the patient has to have a mechanical PTE. Then we went again. After three months, we reassessed the situation and we found that we start to be compliant with the nine guidelines that use of mechanical VTA reflexes on operated side has improved. They now use mechanical VTA on most of the patients, but we still not 100% compliant. That's why we went for the second cycle. We applied. The change at that time was uh to have this VT reflexes from the emergency department. So the patient, once the patient comes to the emergency department from the root, he should have a mechanical PT prophylaxis. So he, when he goes to the world, he definitely have and, and the same from the operative theater. And with that, we have seen an emails, we have um spoken about this in a lot of meetings. So the, the, the practice start to improve and we end after the second cycle that we ha we are 100% compliant to the nice guidelines. All our patient has a mechanical VT prophylaxis uh done for them. So our mo all our patients are safe before this audit, we have two cases died because of um VT events. So DVT or PE or something like that. And after the audit, after this um uh two cycles audit, uh this has decreased a lot and uh we become compliant with the nice guidelines. So mechanical VT E our standard was the nice guidelines. We checked what we are doing compared to the nice guidelines and we found that we are not compliant. Wel the change which is a poster and education, education decision to the nursing staff. Then we audited in six months in three months and another cycle in six months. And we found that we have at the first, at the first cycle, we improved about 70%. And by the second cycle, we are 100% compliant with the nice guidelines. So before I go to the quality improvement, um is the point is the idea of all clear or do you have any questions? Uh uh yeah, it is, it's recorded you uh uh guys. So any, any non Arabic, could you just let me know in the chat because the guys are asking for it to be in Arabic and I don't, I don't want anyone to be um inconvenient. Was Arabic? Are we all Arabs? These are non Arabic speakers just to both in the chart that he um needed le and fully in English. I think we have some non Arabs. This meaning non means OK, So a lot of people, no Arabic. So usually if I have, I have to go on Arabic and uh yeah, I'll be very slow and I'll try to be very clear. But till, till, till this point, anyone has a question about the audit idea about the audit cycle or everyone understand this world. OK, I'll, I'll suppose it, everyone understands it good. So the second one is the quality improvement project and the difference between the audit and quality improvement is quality improvement. You don't need to have a standard. So both of them aim to improve the patient care. Both of them aim to a qualified service. Both of them aim to uh save your resources. But the difference between audit and quality improvement project is audit. You must have a standard, you are not checking your practice. Uh Absolutely, you check your practice against guidelines against standard. So with the audit, you must have a standard. But with the quality improvement, you don't need to have a standard. So in the quality improvement. You just go through a systematic approach to improve the health care services. You will try to identify your problems, implement solutions and try to evaluate the impact of these solutions. So basically audit, you're just combining what you do to the standard. We don't care what you're doing. If this is right or wrong, we, we care that it is according to the standard. But with the quality improvement now with quality improvement, you run through what you're doing. You need to check if what you are do. If you are doing this is satisfactory, achieving what you aim for or not. And if not Hawaii is not achieving and then you start to improve it. The purpose again is to enhance the service delivery, improve your clinical outcomes and foster a culture of continuous improvement. So the aim for the quality improvement to continue improving and whatever you are doing, you try to do it better, you try to do it better, you try to do it better. So every time you try to go check what you are doing, try to find how to do it better, how to do it, more efficient, how to do it more easier than you do in the quality improvement. The cycle is you assess what you are doing. Analyze what you find in the assessment come with the changes you want to do to improve your service, implement these changes and then you're done. So the key steps is to identify. So go through what you are doing systematically. So if I want, for example, if I want to do AQ uh we are doing a quality improvement now about documentation in the emergency department. So basically, we look into the documentation in the emergency department for all the emergent orthopedic cases. And we checked the documentation and we found that not all the documentation is is clear, some of the juniors just write 23 words. Some of the juniors write 56 pages of of writing some of them uh comment on every point, some of them do not comment on every point. So the documentation is not coherent is not systematic and sometimes it's not clear. So we went and try to standardize the documentation in our trust. So we make a smart phrase for everyone. So a smart phrase is, is a way to is is is like an like like a format or template. So everyone see an emergent or medication in the emergency. He use one of the templates and fit in this template what we call for. So for basically, I give you so and and any one of you can apply this anywhere. So if, if you want to standardize the documentation about a point, you go uh to this point and um see what, how is your documentation. So uh every is I in the emergency department document in a different way. And we found that the documentation isn't, isn't the best. Sometimes you couldn't understand what, what he did or he or she did, right? Sometimes it's not all the data there. Sometimes um we feel uh we feel like like like uh uh uh you couldn't understand what is the problem. So what we do, we make a template. Like what should he if, if he see a patient with compartment syndrome, what shall we write? History, examination, investigation plan. And we make a standard template and every gen in the emergency department when he see a compartment syndrome case, he use a template. We bought he just fill in the template. And so all the documentation for the emergency cases in the emergency department from orthopedic site will be standardized in a one way of documentation. And this has improved a lot, the documentation, the understanding and after that the management of the patient. Very simple, we didn't look in a standard. We we we look into making our documentation very clear, very easy, understandable, have all the information. So we went into the emergency department documentation from our genius as assist the problem set an objective to improve this and make our documentation, standardized design a plan to apply this which is a template and we agreed on the template and then start to implement this template and ask all the juniors to use it to make the documentation for the emergency cases and orthopedics very clear. Then we went again, reassess and ensure that already all the juniors are using the template we we bought and the documentation has already improved. And based on that, we reevaluate and again, after three months, we did reevaluate again. And we come to say that we have improved our documentation in the emergency department. Now we have a standardized orthopedic documentation for all the emergent orthopedic cases in the emergency department. Another example. So we run a quality improvement project about did not attend in the clinic. So if the patient is booked for a clinic and he doesn't attend the clinic, we call it DNA patient, a patient who did not attend the clinic. And at some point, we we we noticed that is a lot of DNA patient in the clinics and the number is increasing that we normally see, we normally see about 5 to 6% of the clinic patient not do not attend. So if you have like a 50 patient in the clinic, you may find that uh two or three of them did not attend. At some point, we feel we felt that the DNA is increasing. So from 50 patient, 78 did not attend. So we went into this point, evaluate why these patients do not attend, assist the clinic, which they don't attend and collect that about them. Is it the first time? Have they have, have they didn't attend before? Um uh In which clinic, is it a fracture or elective clinic? And um this patient is uh is a new patient or a follow up patient. And after collecting all this, we called the patient over phone, asking them why they did not attend tracing what are the causes of, of, of not attending? Ask them if they have a communication from our side or not and ask them how they want us to communicate them efficiently for not for them not to do that again and attend all the clinics. And we came to know that we have a problem with the communication. So the patient doesn't receive the text messages or the calls, we give them to remem to remind them with the uh appointment. We ha we we found that we have a problem with um the transportation. So they book an ambulance to get them to the hospital and then sometimes the ambulance doesn't go. So we work in both of them. We spoke to the booking office. We, we, we, we implemented um an application on the mobile called my friend the app for the patient to remember the patient with the appointment, we spoke to the transportation office to make an easy booking for the transportation for them. And based on that, the rate of DNA in the clinic has improved. And now the patient who do not attend the clinic are less than 2%. So the main difference between the audit and Q I is the audit is, is measuring your practice against the standard not about your practice alone. We don't look into, are you doing well or you're doing that we look into, are you following the standards of the guidelines or not? But the Q I not is a continuous improvement. We uh uh uh process, you go, you check what you are doing, you ensure that you are doing. Is it perfect or not? And it's not perfect why it's not and blend to make it perfect. So NHS as uh uh one of the best health services in the world, they have clear guidelines for other than Q IB. They have a lot of institutional which are working on this only the Care Quality Commission commission, which is the CCC, the National Institute of Health and Care Excellence. Nice guideline. Nice which of all the guidelines, the quality accounts and every trust and every department has quality and all the which works with all the department and the team to do a continuous auditing uh projects, continuous quality involvement projects to ensure that we are doing a safe, efficient, effective will be best qualify service to our patients. So the best practice is to involve the whole team. So it it doesn't, it doesn't go just to seniors or juniors. No, you have to audit the whole team, you have to have a structured approach. So um how to register your audit, you have an audit and the quality team which look into the, the, the the project, ensure that this project hasn't been done uh done before. So we sure that this project will add something to the service. Then we guide the people how to do that. We give them the help, we ensure that the implement that change they come out and the monitor the progress. And definitely we try them to share the results with all the concerned department to just the world and everyone to offer the the patient a qualified service. The next part of the talk is about the clinical research and the clinical research is a totally different idea. Yes, it is a quality improvement project. Yes, it's a quality project. Yes, it aims to the same aim which is improving the patient services, improving uh uh the quality of the service serves the resources and um the efforts. But the clinical research is basically to implement something in you. So with the clinical research, you're trying to find a new way of treatment, a new way of investigation, a new way of doing things. So inventing or introducing something in you, this is the clinical research, clinic care research could be observational. So you just look at what the people doing retrospective or prospective to ensure to see how is the practice. So basically, I'm looking into all the patient who had lung cancer to understand what is the relation between smoking and lung cancer. So I come and look into all the patient who had lung cancer and check who are a smoker from them. And from this, I come with an assumption or result saying that smoking is associated with lung cancer. So next time, if I'm a lung cancer clinic, I will counsel my patient that we found that all the patients with lung cancer are a smoker. So smoking is closely associated with lung cancer. So we have to stop smoking a very simple example. So observational means you just look into what you found and try to come with an assumption or, or, or a message uh intervention and no, you try to prevent something in you. So, so you use like a new technique, a new surgery, a new drug and you see how is your new surgery or new drug or new way of management will make an effect? Would it be ok? Would it be bad? Would it give good results? Would it be safe? Would it be dangerous? So, intervention is how you implement something in you new treatment, new investigation, whatever and you fi you, you try to find is the, the thing, the, the, the new treatment or the new um um intervention you implemented is doing well or not. So that you know, now that all, all the decision making is based on what we call evidence based medicine. There is no, any more expert decision, there is no, any more um uh um just uh simple trials in, in, in, in vitro all now has to be based on all the clinical practice, all the decision making, all the operations, all the intervention, all the drugs should be based on an evi evidence based medicine. An evidence based medicine goes from is, is, is a, is a, is as you see, it's a pyramid, it come from the on the ground B which is the lowest evidence with the lowest quality evidence, which are expert opinion and like you're doing your world round and you go with what the senior or the consultant says or the uh professor says, if even we don't know what is the evidence behind that, that is the poorest way of, of practicing because it depends on one only decision which is always mistake. Or you depend on nonhuman studies like individual studies, the level above this or the better evidence is based on observation study. So you don't intervene, you don't put anything in you, you don't invest anything in you, you just observe what's happening either prospective. So prospective means to from now onward or retrospective from now backward. So either you look in the back or you look in the front but you at the end of the day, you're still just observing and you document what you observe and you come with your observations that living above this and the evidence is the intervention studies to run a randomized controlled trial or run AAA clinical trial. So basically you try to implement a new drug or a new treatment or a new surgical technique. And you try to see if this is uh safe and effective or not. The highest level of evidence is meta analysis and systematic review. Because bas basically systematic review and meta analysis, they assist a lot of intervention studies together to come with a conclusion. So with a systematic review or a meta analysis, you come to a good quality projects or studies, you collect all the data from all of them and you come with a message from all of them. And this message is based on a lot of intervention studies. So it is always a strong and a good message. So observation is a is descriptive or analytic. So discre you, you basically have a look at what's happening and you describe what you see like if you do a case series, like basically every patient come to me with an ankle fracture, I fix them with a blatant screw. Then after a year of doing this, I ask one to look into all the cases of done an over reduction of the ankle and to come to me to um show me the X rays ensure that all ha has all of them are united or not and any of these patients has a problem or not. Uh what I did just observation, I didn't do anything and the case series will come to say, oh yeah, you have operated 100 vision of an fracture with fixation, all of them are doing well. We have been united, all of them are functioning. OK. So I can ii probably a bit by saying that fixing ankle fracture with grade and screw is a safe and effective method of management of ankle fracture. Based on my case series. This is what is the, what what's mean by descriptive analytic means. I'll have a look what's happening and then I analyze this. So to analyze this, you have three types of, of, of, of studies. Corri study means you do a study on a large number of patients at the same time. So like I like we did did in COVID. So in COVID, we did a cross section study like, oh we have vaccinated everyone. So you look into all the patients vaccinated to see if the vaccine has a problem or not cohort study. So basically in the cohort study, you have a result and you go and assess the input. So as the example of lung cancer, so cohort cohort study, cohort means global patient. So if I want to run a cohort study about lung carcinoma, so I will go to a cohort of patients who has a lung carcinoma already and then go back and look is what is, how, how, how, how the smoking was there or how um certain type of treatment? How is it, is it more in female? Is more in male? Is it more in, in, in, in rural areas? It's more in cities. Is it more in developed countries? It's more in developing countries. So I do an analytic study but it's still observational. I just go to a cohort patient which has lung carcinoma patient. And I go back and look into the causes which cause the lung carcinoma. See how is the lung carcinoma is more common? Is it common in male or female? Is it common in this age, a certain age? And uh this is how I do a cohort study. The other way of cohort study is the case control for the case control. You basically look into the smokers to see how many of them will get a lung cancer. So the difference between the cohort and the case control, the cohort start start from the result and look on into the causes. But the case control, it starts with the causes and look and look how will be the results. I hope you got that. So both of them are observation study. Both of them would analyze this observation. The difference between the cross section means I do a study now on a number of patients. Now I don't look in the back or look in the forward. I just go now see all the patients vaccinated with COVID vaccine. See if any of them get a heart attack or not. This is a cross section study and this is mainly come with a prevalence with incidence of diseases. Case control study. Basically, I go to the smoker people and follow them up to see if every smoker will get a lung cancer or not. And if not, who gets who not cohort study the other way around. I start with the people who already have a lung cancer and I go back to check if they have, if they were a smoker or not. And I can from co study say that patient who are smokers are more prevalent to have a lung carcinoma. But in the qui control, what I will say, I will say that 80% of the smokers will get a lung cancer. I hope this difference is clear. So as you see, it's just observational, you don't do any intervention, you just watch, sit and watch and what you can see. Either you just mention what you have seen as a case series or you analyze what you have seen, which is observational cohort, case control or section studies. The other hand of it is the is the interventional studies. So you have to intervene something, you have to do something. So you randomly assigned patient into two group, group with the treatment number A and group with the treatment number B. So like if we're trying to treat um pain with Vitamin C, so I will go to a patient with uh make it much easier. So if we if you want to look into uh yeah, if vit Vitamin C will take the regional pain away or not, you go to, you get the patient with regional pain, you assign them to two ran randomly into two groups, group number A which will receive Vitamin C and group number B or, or group B which will not receive that, not receive Vitamin C and then you follow them up for a certain period of time. And then you come to say, has the patient with Vitamin C has been improvement in the patient who didn't have Vitamin C. And based on that, I can see that Vitamin C would reduce the original pain. Again. I have patient patient with regional pain. I have patient make it easy. I have patient with ankle fracture who had a fixation. So all my patients are ankle fracture patient who had fixation with beta screw, I will assign them into two groups. Group number A and group number B, group number A. I will ask them to both, wait to walk on foot, which is operated in two weeks. Group bi will ask them not to walk on the foot, which is operated for six weeks. Group B is my control group because that is the normal, the normal, most of the ba most, most of the surgeon doesn't ask their patient to walk before six weeks. Then I will keep them for a long time. So a year, a year or two and then I will check who are the patient who has failure of fixation? Who are the patients who are more in pain or are the patient who are not doing well in each group? And I will compare both groups. So imagine I find that the patient who are walking two in two weeks are doing the same regarding the X ray regarding the fixation, regarding the vein as the one who are non weight bearing for six weeks. So I will come with a conclusion to say no, all our patient can walk from two weeks because walking from two weeks doesn't have any problems compared to walking after six weeks. So no need to keep the patient for four weeks, nonweightbearing. So all our patient can weight bear based on our study patients. As you see, group of patients have the same characteristic. I randomized them, put them into two groups, a blind intervention in one group from them and the other group doesn't have the intervention for as a control group and then to come to assess the outcome and see if the outcome is more in the, in, in the tested group than the control group. So my um so my treatment has done a job if not. So my treatment hasn't done a job. And as you see, it's, it's uh basically the trials, the clinical trials is the way how we change the practice that, the way how we change the knowledge. So we start if, if you go any one of you, according to the specialties, even in the medical school, the ideas and the operations and the treatments we are, we are teaching you now. Wasn't there 100 years ago? So every, every 56 years, the the knowledge is evolving, the knowledge is changing. Uh what I have, what I have been taught in the, in the, in the medical school is totally different than what you you've been taught now. Why? Because of the clinical trials, clinical trials, they change the practice every day. We start by, if all the ait tend to rupture, we operate all of them. Then the clinical trial came to no no to to say no patient can continue to be treated non operatively. Then the clinic, new clinical trials came to say no, the patient can be treated non operatively. But with functional rehabilitation and the clinical trials came to say no, now you can operate on this patient, you can do a non operative on this patient. So the the knowledge is evolving, the the science is evolving based on a clinical trial. So if you want to run a clinical trial, which is a very high level of research and if you work as a research fellow, if you blend, if you like researching, if you like it's changing the future and you want to set up a clinical study, it's very, very easy, it's not difficult. But the difference is that clinical trial, we need uh a lot of people to be involved with. They will need some funding, they need some money. So you can do it through one of the um clinical research centers. You have to identify a problem. You don't do clinical research for clinical research, you do clinical research to solve a problem or to improve a service you are doing. So you have to identify the service who needs improvement or the problem. You have, you have to put a question for yourself which is we call the B question B co means BB means patient. You identify the patient you are looking into, I means intervention, C means comparator of control and o means outcome. So you have a problem. I have a problem about uh shall I ask my patient with ankle fracture to walk in, in week two or not? I bought a question to ask and say is weight bearing in two weeks after anti fracture fixation is effective and safe as weight bearing after six weeks or not. This is my question. Then you have to do a literature review. You have to go and search over the internet to see if anyone has searched about this question before. And what is the result? Because if you have an answer to this question in the previous research, there is no point to re redo the research. Then you study, you design your study, you, you do the way of randomization. You choose, what's your, what is your treatment group? What's your co comparison group? And for how long you will follow them up and what is your outcomes you want to measure and how will you publish these results? Then you have to get the approval because you're dealing with patient information and vision. You're doing basically you're doing some exper on experimental, on the patient. So you have to have that the the necessary approvals. You start conducting your study, you come with a conclusion and then you publish your results for all the people to follow you. The role of clinical research is to improve your patient care differently because we're introducing new therapies, introducing new strategies, introducing a new operations. It informs the healthcare policy because basically it makes from the clinical trials, we make the guidelines, we make the policy decisions and you innovate because with the clinic trial is the only way to apply new, new things in the in the science and see are they safe and effective or not? Like a lot of studies? Now clinic trial is now running about the A I, you see if the A I is a safe option to use in the clinical practice or not and how will we benefit from it? So to sum up for you, um there is three quality projects, audit, clinical audit, quality improvement project or Q I or web and clinical research. Three of them aims to improve the quality, the audit improves the quality by making you compliant with the standards or guidelines. The quality improvement makes you um uh uh uh improve your process and patient outcome. And clinical research is advancing the medical knowledge and introducing new ideas and uh and treatments. Focus of the clinical audit is to compare your practice to a, a standard guidelines. Focus of the Q I is to find your area of sts and area of weaknesses. Focus of the clinical research is to ensure that you have an efficient treatment with new technology with new treatment options. The method is clinical audit. You collect the data about your current practice and compare it to the guidelines like your IB use you, you, you assist your practice, analyze it and come with the area of ST and weaknesses. The clinical research either you observe or you I intervene or experiment. Outcomes of technical audit is improving in the practice based on evidence or guidelines or standards. Outcome of Q I is to enhance the care, efficiency and safety. Outcome of the clinical research is new treatment, new innovations, new knowledge, the challenges you will face with everyone. There's nothing without the challenges without problems, without difficulties. The difficulty with the clinical all is time consuming. Sometime after you come with a change and you ask the staff to do it, you find some resistance because the adapt to you to do this for years and you're coming out to say to them, no, your practice is not following the standards of the guidelines and you have to change it. So sometimes you face some resistance. The challenges for the quality is difficult in maintaining the improvement because I check. Now my practice, I found some area of weaknesses, I improve them. Now, then I disappear. If I don't follow my my improvement at some point, it will go back to the weak point again. So you have to keep doing it. And definitely you have limited resources, limited timing and limited uh funding for that clinical research. The main problem is approval because uh we're dealing with a human body, we do experiment or intervention newly in a human body. Imagine yourself uh ask it to be involved in a study and they will try a new treatment or a new surgical technique on you. You will not be happy. That's why the most difficult way to clinical research is to get an E approval is a consideration, recruitment and trying to get patient and convince the patient to be involved in the trial isn't an easy job there. A lot of administrative, a lot of financial, financial and a lot of support is needed for the research to be conducted to conclude the clinical audit uh quality improvement projects and clinical research are vital for advancing the care and ensuring a high standard uh standards of the NHS. Final source is they have to start is hand to hand. You have to try to promote as much as you can of your patient safety. Uh health systems depend completely on audit, quality improvement and research to improve the service, to save the resources and to offer a qualified safe service. And thank you so much. So time for questions, I'll stop. Share. Good. We have a good number of questions. That's great. Ok, so Ahmed Mohammed is asking firstly, how how can I get an evidence for an audit I have done. So basically, um if you have a full clinical audit team, uh it can easily get it as a certificate. They normally after you finish your audit, submit your audit results, they give you a certificate. If not, you, you need to find a senior, you need to find a consultant. You have done the audit under his um supervision and he can give you a certificate that you have conducted this audit. You come with this change and you re audited what you did and this is the results. So the way to get an evidence on your audit, either from an audit team, if you have an audit team in your institution or through um a senior who signed it for you, Mustafa is asking some uh so in some hospitals in developing countries without they will establish protocols, which guidelines do you follow. So basically, Mustafa is, is you have, as I told you, there's a lot of guidelines everywhere the most and uh the will form established. One is nice guidelines. Um The, the British nice guidelines and for orthopedics is called post. According to British Orthopedic Association, um uh um standards care for quality and for trauma and orthopedics. You have the American Academy standards and you definitely will find your seniors in every hospital in the developing countries are following wave way of this. So for example, the diabetologist everywhere in the world, the endocrinologist, everywhere in the world. If you, if you are medical, they follow the Canadian, they follow Mayo clinic guidelines, they follow um um health uh National Health um institute guidelines from the UK. So see what your seniors in the hospital you are working in using as the guidelines or standard, try to audit the practice in your hospital compared to the ni to the the guidelines or the standard they are using. And from where from here, the audit will come. Um Mo she is asking how can we find so few simple practice guidelines on orthopedic a specific patient? So basically go uh right post bo Ast British Orthopedic Association, standards of care for orthopedics and Thumma and you will get all the guidelines for all the aspects of orthopedic practice and same for American Academy, a AO American Academy of Orthopedic Surgery. And you will find very simple practical guidelines on orthopedic specific patients. Can we have a hint about what it means the audit? So audit basically is a comparison. So audit means you go, you compare what you are doing to a standard to a a guidelines to a standard of care. As I told you, very simple exam, you in your normal life, you always audit yourself, how you audit yourself. Um, you're doing a diet so you should have, uh, 100 100,500 Koc calories or something like that. Uh, like 40 50 g of carbohydrate or protein or whatever. And you eat a lot and then you come and calculate what you did eat compared to what you should eat or what is the normal requirements of an adult? And then you say, oh, I, I've eaten a lot. I've got a lot of calories. I should reduce that. This is an audit. Very simple. What did you do? You re you compared what you did or what's your practice or what's the way you have done compared to the standard, how you should done. So you compare what you do to what you should do and this is comes to say to you, are you following the standards or not? Simple way your calories should be like 1000 calories a day after you eat? You go and calculate how many calories did you take? If you take a lot of calories, you reduce it. If you take these calories, you increase it. So basically you're comparing the calories you are taking to the calories you should take. And this is exactly an audit. Same for any clinical practice. Oh uh When comparing two interventions on two groups and comparing the outcomes, what did the study called? So basically what you are comparing, you're comparing the outcomes. So this is a case control study. So you as an example, you've given, you're given an example of a distal tibia treated with bleating or nailing. So what you are doing, you go to all the patients with distal tibia treated by nail and all the patients treated by plate. This is group number A, this is group number B, you follow them up for uh 10 years and you come to say, oh union rate in the group treated by plate was that union rate in the out my outcome is union rate. Union rate was like 80% in the people with uh fix it with me, 70% in the baby, fix it with plate. So this is a case control study. You're comparing a a AAA group to a control group and you come to say, oh the results is blade or the N is better than the blade because it achieves more union how and where to register clinical trial. So clinical trials is according to is different from country to country. So like uh in Egypt, I'm not sure in India to be honest, I think it's with association. So I'm a member of um uh Bombay orthopedic Society. So I think Bombay orthopedic society, they uh register clinical trials. I'm not sure what's your institute uh in Egypt, you have to register it with uh with the Ministry of Health in UK, you have um uh national uh health system you mentioned in, in the NHS in, in I hr is a system to register all your clinical research. Has a website you go and, and, and, and um register your clinical plan and you start do it. It is tough to register. Definitely, it's not tough, it takes a longer time because you have to give a lot of evidence for, for them to be sure that you're doing it ethically. You um you respect the dignity of the patient, you respect the patient information, patient um has been informed about the study. They understand that they are, they will be um exposed to a different treatment. They understand that their data will be going out as, as a establishment or whatever. So it's not tough, but it's difficult to take an e to, to get an ethical approval and it takes a long, a long time. Does audit need an ethical approval? Uh Local ethical approval. Ahmed means local ethical approval means uh you just get your audit team, your consultant or whoever to say that? Oh OK. This is going with the, this is going with, with the E SIX, going with the E six means you are not searching something. Uh I'll give you an example if you want to go and um to audit um something about sexual behavior, this will not be acceptable because uh this is uh an area of privacy. So I if I'm your consultant, I will not, I will not say I will not agree on this audit to be to, to be done because this is, doesn't follow the e uh some audits is going to compare ation based on um religion, based on uh ethnicity, based on language. So all these audits are ethically not approved. I'm giving you just a a AAA difficult uh uh easy example like something which will never happen. But approval for audit needs to be just a local approval either from your audit team, clinical audit team in the trust or the department or from your consultant. Like I'm, I'm the audit lead, I'm the audit in my trust. So I approve all the audits run in my department based on what I can see. Uh audit is reasonable, it speaks about, it doesn't cause any problem, doesn't mix any uh any uh conflict, doesn't go with any racism or bullying or problems like that. So it's just a local ago in quality improvement. How can I know if I am in the correct ba or the wrong one? So you there is in the q quality improvement, there is no correct or, or there is no correct and wrong, there is no right or wrong. It's basically how you aim to see your practice. So I aim to see that my, no one of us will, will, will will that we need to see a patient coming to the ed seen as quickly as possible, have the first aid immediately and from the first aid immediately uh goes to the service which will help him and from the service which will help him will have the operation or whatever treatment immediately. If I go and find that my vision is delay in the ad for eight hours, I'll have to go assist and see why the vision is great in the um am I, am I short on the stuff? II have a problem with communication. So there is no right or wrong. The point is and you don't and you don't need to be comparing yourself to a standard. You compare yourself to the perfect, you're trying to have a perfect service, perfect service means you're doing all you can to get the service to the best. So your aim for a quality improvement is to get your your service to the perfect. So you don't compare to a standard. There is no correct or bus or wrong path, the the right bus, the correct bus is the perfection. You need to reach a perfection and throw your way to reach a perfection. You need to assess what are you doing? What is the problem? How to reach the perfection? This is a quality improvement project. Can we publish an audit? Definitely, definitely. Or most of the research you see based basically on an audit. So the research idea starts from an audit. So when you audit like I give you an example. So the documentation, the quality improvement documentation, the one II spoke to you about now we are publishing it, we are publishing it the same. Yeah. Uh to see the results, we came from the improving documentation making templates to our juniors is that and we show the people how to do this in their trust to improve the documentation to make a standard or documentation. Same for the audit of DNA, we will be publishing our results of the DNA audit to, to say to the other people that people who are do do not attend the clinic, mostly do not attend because of that. And when we done that this has improved and patients are not um uh DNA s again. So if you want to improve the attendance of the patient in your clinic, follow these rules because we have done an audit which did show us that this is a way to reduce the DNA. So if you can follow this, you will reduce your DNA. So definitely an audit can be published and the audit is basically is the base of most of the research. No, sure. But it don't worry man, it's, it's same, same, same here and there. Uh May we receive a certificate of attendance? Definitely will do so once I finish, uh you will get an email for a feedback and once you fill the feedback, he will send you an uh a certificate. Thanks a lot. You're welcome and see you in the next, in the up coming year. We'll see you in the Congress next, next week. Um All of these guys, we, we done, we on time. I hope it was useful and you now have a clear idea what's idea, what's audit, quality improvement and research uh recorder will be on the in M all and will be on my channel on youtube. Um I'm happy to receive any of your questions. Um Later on this is my uh email address and um E and phone number and you are more than welcome to send me any question you want. Um Any one of you is interested in research. I can get him involved or her involved with the research and um yeah, have a good evening and night and see you in uh another education and event all the best and yeah, wish you all the best. Bye.