PEPs - Clinical Quality and Evidence

Module 3 - Clinical Audit

Setting the scene

Image by dianor smada on Flickr


The first clinical audits are attributed to Florence Nightingale who during the Crimean war noted that there were very unsanitary conditions in the hospital treating wounded soldiers and as a consequent a very high mortality rate. She applied strict standards of hygiene, keeping careful records, demonstrating an important drop in this mortality. Her emphasis on records, uniformity and reflection was the earliest record of audit and measurement of outcomes ¹ .

Codman in Boston was an evangelical advocate of clinicians reviewing their own practice, coining the term “end result idea” ² . He followed patient’s case histories identifying errors. He, however, was regarded as an eccentric and his approach was not widely taken up at this time. This lay dormant  for many years and has only recently been taken up in the United Kingdom, being promoted by both the Department of Health, starting with the White Paper, “Working for patients”, in 1989 ³ , and the General Medical Council in its publication “Good Medical Practice” ⁴ . The National Institute of Health and Care Excellence (NICE), together with the Commission for Health Improvement (CHI, forerunner of the Healthcare Commission and most latterly, the Care Quality Commission) produced the handbook for clinical audit, “Principals for Best Practice in Clinical Audit”, in 2002 (see attached document below).

Clinical audit can, on the one hand, be seen as a stand alone process which assures us, as clinicians, that any particular patient is having best evidence based practice treatment irrespective of the situation they find themselves in. There are many ways in doing this and these will be covered later. Suffice it to say that no matter what the situation and no matter what the level of evidence it should be possible to develop such assurance. This is important for the patient, primarily, but also for the individual clinician, the governance structure in which the clinician works and to those who pay for the service (the commissioners).

On the other hand clinical audit is a quality improvement (QI) process. The emphasis on implementing changes to achieve improvements has significant implications. The Tavistock ethical principles ⁵ for everybody involved in health care included the principle of improvement, which states that improving health care is a serious and continuing responsibility.

The emphasis on quality improvement should shift the way clinical audit is carried out. In a QI approach to clinical audit, repeated data collection is used to test different change interventions, including redesigning processes and systems, in order to improve the performance of a clinical service in comparison to measures of good practice. Clinical audit as a QI process should involve members of a team working together to introduce best practices and make them routine, using quantitative (and in some instances qualitative) feedback on the effects of changes on processes and outcomes. QI implies a more holistic approach to improving the quality of patient care, can involve the patient in defining quality and is more than the sum of discrete audited parts of a service.

It is important to note that there are other techniques to improve services and a wider view of audit would include such techniques. These have been brought together by the National Institute for Innovation and Improvement ⁶ under the guise of Quality and Service Improvement Tools.  These include, for example, using information in more innovative ways such as the development of statisical process control (SPC) ⁷ and improvement techniques such as the PDSA (plan, do, study, act) cycle ⁸ .

  1. Nightingale's 'Coxcombs'
  2. Donabedian A. The end results of health care: Ernest Codman's contribution to quality assessment and beyond. MilbankQ. 1989;67(2):233-56; discussion 257-67
  3. Department of Health. Working for patients. NHS White Paper. New diagnosis--new prescription. Health Serv J. 1989 Feb 2;99(5136):134-7
  4. Good Medical Practice - General Medical Council
  5. Smith R, Hiatt H, Berwick D. Shared ethical principles for everybody in health care: a working draft from the Tavistock Group. BMJ 1999;318:248–51
  6. Quality and Service Improvement Tools - NHS Institute for Innovation and Improvement
  7. Statistical Process Control (SPC) - NHS Institute for Innovation and Improvement
  8. Plan, Do, Study, Act (PDSA) - NHS Institute for Innovation and Improvement