Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery.

This definition is endorsed by the National Institute for Clinical Excellence.

 

       

Key Points

• to improve

• to enhance

• relevant to the practice

• to ensure

• to change.

 Performing self-audit is a critical part of clinical governance

 

 Review the NICE guide to Clinical Audit

 Look at the NSF's

Worksheet and flow chart for practice audit

Mastering clinical Audit

A new online course which is run by the University of Edinburgh Office of Lifelong Learning

 

 

See the extract from ABC of audit Dr David G Anderson Cleveland Vocational Training Scheme shown below (courtesy of well close):

 

Key Points	Definition
Audit vs. research	Why do it?
Educational Benefit	The Audit Cycle
Four Main features	Criteria and standards

                        

                                          

Definition

Audit is the process used by health professionals to assess, evaluate and improve care of patients in a systematic way in order to enhance their health and quality of life.

Is there a difference between auditing and research?

Yes!

Research	Audit
Discovers the right thing to do	Determines whether the right thing is being done
A series of 'one-off' projects	A cyclical series of reviews
Collects complex data	Collects routine data
Experiment rigorously defined	Review of what clinicians actually do
Often possible to generalise the findings	Not possible to generalise from the findings

Why do audit?

• It is compulsory for Summative Assessment.
• It improves quality of care as both an outcome and by the process of performing the audit.
• It is an aid to continuing medical education.
• There is a sense of personal and professional achievement. It may lead to a publication and can improve a CV.

The educational benefit from audit

• Audit allows a critical review of current information (keeping up to date).
• Audit highlights the need for specific knowledge/information, the acquisition of new skills and the development of existing ones.
• Audit improves communication skills and enables attitudes to be modified when working with other members of the Primary Care Team.
• Audit enables 'self evaluation'.
• Audit promotes learning by answering the following questions: 
  • What am I doing? 
  • How am I doing it? 
  • Why am I doing it in that way? 
  • Can I do it better or differently? 

How to carry out an Audit

The Audit cycle

The four main features of the audit cycle can be analysed to a greater depth.

1. Identify the need for change 
   This may come from personal experience. A problem may be identified from every day practice, and following this there is a feeling that something could or should have been done better. Problems can be identified in 3 basic areas of Practice work:
   • Structure: This refers to the input of care such as manpower, premises and facilities. Eg. 'Are the numbers of emergency appointments enough to cope with demand?' 
   • Process: This refers to the provision of care (looking at what is done and how it is done) Eg. 'Are all patients on ACEI having urea & electrolytes checked?' 
   • Outcome: This refers to the result of clinical intervention. Eg. 'Are patients on lipid reducing regimes achieving target cholesterol levels?'
2. Setting criteria and standards 
   This is where you can say what should be happening.
   • A Criterion is an item of care or some aspect of care that can be used to assess quality. The criterion is written as a statement. Below are three criteria one relating to an audit in structure, one an audit in process and one an audit in outcome.
     • All patients requesting an urgent appointment will be seen that day. 
     • All patients with epilepsy should be seen at least once a year. 
     • All patients on Warfarin should have their INR within the recommended limits.
   • Criteria can be defined from recent medical literature, and the best experience of clinical practice these are called 'Normative criteria'.
   • To make the criteria (statement) useful the Standard needs to be defined. A Standard describes the level of care to be achieved for any particular criteria. Eg. A standard may state: 98% of patients requesting urgent appointments will be seen the same day. 90% of patients with epilepsy should be seen at least once a year. 100% of patients on warfarin will have their INR within the recommended limits.
   • Standards must be set. The level of standard can often be controversial. There are basically 3 options:
     • A minimum standard. This describes the lowest acceptable standard of performance. Minimum standards are often used to distinguish between acceptable and unacceptable practice.
     • An ideal standard describes the care it should be possible to give under ideal conditions, with no constraints. Such a standard by definition cannot usually be attained.
     • An optimum standard lies between the minimum and the idea. Setting an optimum standard requires judgment discussion and consensus with other members of the primary care team. Optimum standards represent the standard of care most likely to be achieved under normal conditions of practice.
3. Collecting data on performance
   Identify what data needs to be collected, how and in what form it needs to be collected, and who is going to collect it. Remember only collect information that is absolutely essential.
4. Assess performance against criteria and standards
   With the information collected analysis is possible, and identification of any area of care below the predetermined standard of the criteria can be made. The results can then be used to develop an action plan ie what needs to be done, how it needs to be done, who is going to do it and when is it going to be done.
5. Identify need for change
   The audit cycle is now almost complete, but without re-evaluating the care the practice is giving it is impossible to see if recommendations have been implemented and the level of care improved.

Remember: when constructing Criteria and Standards

• Make unambiguous statements
• Keep the task focused on the audit project
• Refer to the literature indicating current practice
• Choose criteria and standards in line with current practice
• Ensure the criteria and standards are based on fact;

 

Flow chart for Your practice

 

Try to involve all members of the practice in audit.

 There are many factors that might trigger an audit as illustrated below. It is important to set a standard reviewing available best practice adapted to your own specific needs. Measure yourself against this standard, make changes if necessary and then re-evaluate.

Review a diagrammatic illustration of the audit process figure 1

See a copy of an audit sheet template below

 

AUDIT summary sheet             Date:

 

Title/Subject  What made you choose this topic for audit

Aims/Standards to measure against

Results. Where are we now?

Reflection.  Conclusions.

How could we change practice?  Complete the audit cycle. How/when will you re-evaluate?

 

Click Here to open a full version of this sheet that you can type into and save

 

Fig 1