PEPs - Clinical Quality and Evidence

Module 3 - Clinical Audit

How to do an audit

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Clinical audit can conveniently be looked at in the context of a national initiative or a local one.

The essential characteristics of national clinical audit are:

* Agreed standards

* Quantitative (i.e. involves measurement)

* Comparison of providers (e.g. hospitals; general practices) or purchasers (e.g.  commissioners)

* Focus on one or more of inputs, processes and outcomes

     - input and process audit require evidence-based criteria of good quality;

     - outcome audit may be based on criteria but is usually based on comparison of providers'/purchasers' performance

     - outcome measures may be obtained from clinicians (impairment, complications) and/or from patients (symptoms, disability, and quality of life)

Local clinical audit may differ from national audits in two ways. First, it may not involve comparison with other providers (sometimes referred to as 'benchmarking').  but focus  on comparison with accepted standards  over time, looking at an internal trajectory of improvement.Second, many local initiatives referred to as 'audit' are not confined to quality assessment but also encompass quality improvement (usually through education or reorganisation interventions). In other words, they are an amalgam of assessment and improvement.

Clinical audit can be described as a cycle or a spiral.

Within the cycle there are stages that follow a systematic process of:

  • getting the right people [stakeholders] together
  • establishing best practice,
  • agreeing measurable standards
  • measuring care against criteria,
  • taking action to improve care, and
  • monitoring to sustain improvement.

The spiral suggests that as the process continues, each cycle aspires to a higher level of quality.

Irrespective of what type of audit is carried out the audit  report must contain an action plan to address any deficiencies found. This is an essential component of audit without which no improvements in practice can be expected. The action plan must describe the actions to be taken in SMART (specific, measurable, achievable, and realistic) format.  Tasks must be allocated to individuals with time frames built in.

Audit is intended to be a process for making improvements to patient care and not used for the purpose of criticising the performance of colleagues. It is important to get the right people together at the beginning of the project to agree what ‘best practice’ looks like. Failure to do that can result in key people becoming disengaged from a process that they feel is ‘being done to them’. This may lead to problems in agreeing and implementing the action plan. For instance if an important finding was that money needed to be spent to improve a certain part of a service then it is difficult to involve a manager or commissioner late in the proceedings. Much better that they are involved at the beginning.

Action plans need to be monitored to ensure that actions are being completed in a timely fashion and all actions are complete  and have time to embed prior to the re-audit being undertaken.

The purpose of the re-audit is to demonstrate an improvement in achieving the standard as a result of the actions undertaken. If improvement cannot be demonstrated or the improvement is insufficient to meet the expected target then alternative actions need to be considered and a further action plan implemented.

On occasions it may be that only one or two standards out of a larger number are causing problems. In this case it is perfectly acceptable to focus the re-audit on those standards until a successful outcome is achieved.

Teacher's Comment

It is important to remember that even if your audit shows adherence to the standard 80% of the time, this means that 1 patient in 5 is not being given optimum treatment or care.

Intermediate level clinical audit training for clinicians (April 2012) (1 - 2 Hours)

This online educational resource was produced for HQIP by the Royal College of Paediatrics and Child Health (RCPCH).

This package is comprised of four complimentary sessions:

1 - Thinking about doing clinical audit

2 - Identifying and collecting data

3 - Analysing and interpreting data

4 - Feedback and changing practice.

NICE: evidence into practice - how to use audit to improve patient care (1 hour)

Please visit The University of Manchester Library for instructions on how to access BMJ modules both on-campus and off-campus.

On completion of this learning package you will:

  • Have a working knowledge of evaluating existing practice against agreed national standards
  • Have a working knowledge of using healthcare audit to change and improve practice
  • Be able also to use patient encounters to promote smoking cessation
  • Be able to discuss social and/or preventive aspects of care including health education and promotion.

Attachment: 5-HQIP-CA-PD-026-Guide-to-Involving-Junior-Doctors-in-Clinical-Audit-19-April-2010.pdf

Guide to involving junior doctors in clinical audit - Healthcare Quality Improvement Partnership (HQIP)