Clinical Audit Introduction
The requirement for the implementation of mandatory HIQA standards for Safer Better Healthcare and the recently introduced mandatory professional competence requirements for doctors mean that clinical audit has to be taken seriously.
Clinical audit is at the heart of clinical governance.
- It provides the mechanisms for reviewing the quality of everyday care provided to patients with common conditions.
- It builds on a long history of doctors, nurses and other healthcare professionals reviewing case notes and seeking ways to serve their patients better.
- It addresses quality issues systematically and explicitly, providing reliable information;
- It can confirm the quality of clinical services and identify if there is a need for improvement.
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, process and outcomes of care are selected and systematically evaluated against specific 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 is described as the audit loop. The key component of clinical audit is that performance is reviewed (or audited) to ensure that what should be done is being done, and if not it provides a framework to enable improvements to be made.
Clinical audit is NOT research.
Research is a systematic investigation undertaken to discover facts or relationships and to reach conclusions using specifically sound methods. It aims to discover new information that will aid the management of our patients. Audit does not provide new information; it simply tells us whether or not our current clinical practice meets recognised standards.
Types of Clinical Audit
Standards-based audit – A cycle which involves defining standards, collecting data to measure current practice against those standards, and implementing any changes deemed necessary.
Patient surveys and focus groups – These are methods used to obtain users’ views about the quality of care they have received. Surveys carried out for their own sake are often meaningless, but when they are undertaken to collect data they can be extremely productive.
Critical incident monitoring – This is often used to peer review cases which have caused concern or from which there was an unexpected outcome.
Peer review – An assessment of the quality of care provided by a clinical team with a view to improving clinical care. Individual cases are discussed by peers to determine, with the benefit of hindsight, whether the best care was given. This is similar to the method described above, but might include ‘interesting’ or ‘unusual’ cases rather than problematic ones.
Structure and Culture
Necessary structures need to be provided in order for clinical audit to be supported. A culture is required in which creativity and openness are encouraged, and errors and failures are reported and investigated without fair or blame.
The Clinical Audit Process
Clinical audit can be described as a cycle or a spiral, see figure. Within the cycle there are stages that follow the systematic process of: establishing best practice; measuring against criteria; taking action to improve care; and monitoring to sustain improvement. As the process continues, each cycle aspires to a higher level of quality.
- Stage 1: Identify the problem or issue
This stage involves the selection of a topic or issue to be audited, and is likely to involve measuring adherence to healthcare processes that have been shown to produce best outcomes for patients. Areas to audit might include those where problems have been encountered in practice or where there is a clear potential for improving service delivery.
- Stage 2: Define criteria & standards
Decisions regarding the overall purpose of the audit, either as what should happen as a result of the audit, or what question you want the audit to answer, should be written as a series of statements or tasks that the audit will focus on. Collectively, these form the audit criteria. These criteria are explicit statements that define what is being measured and represent elements of care that can be measured objectively. The standards define the aspect of care to be measured, and should always be based on the best available evidence.
- Stage 3: Data collection
To ensure that the data collected are precise, and that only essential information is collected, the details of what is to be audited must be established from the outset. Sample sizes for data collection are often a compromise between the statistical validity of the results and pragmatical issues around data collection. Ethical issues must also be considered; the data collected must relate only to the objectives of the audit, and staff and patient confidentiality must be respected – identifiable information must be coded and rendered anonymous for both patients and staff.
- Stage 4: Compare performance with criteria and standards
This is the analysis stage, whereby the results of the data collection are compared with criteria and standards. The end stage of analysis is concluding how well the standards were met and, if applicable, identifying reasons why the standards weren’t met in all cases.
In theory, any case where the standard (criteria or exceptions) was not met in 100% of cases suggests a potential for improvement in care. In practice, where standard results were close to 100%, it might be agreed that any further improvement will be difficult to obtain and that other standards, with results further away from 100%, are the priority targets for action. This decision will depend on the topic area – in some ‘life or death’ type cases, it will be important to achieve 100%, in other areas a much lower result might still be considered acceptable.
- Stage 5: Implementing change
Once the results of the audit have been published and discussed, an agreement must be reached about the recommendations for change. Using an action plan to record these recommendations is good practice; this should include who has agreed to do what and by when. Each point needs to be well defined, with an individual named as responsible for it, and an agreed timescale for its completion.
- Re-audit: Sustaining Improvements
After an agreed period, the audit should be repeated. The same strategies for identifying the sample, methods and data analysis should be used to ensure comparability with the original audit. The re-audit should demonstrate that the changes have been implemented and that improvements have been made. Further changes may then be required, leading to additional re-audits.
This stage is critical to the successful outcome of an audit process – as it verifies whether the changes implemented have had an effect and to see if further improvements are required to achieve the standards of healthcare delivery identified in stage 2.
It is essential that the results of the audit are disseminated so that any recommendations for improvements in clinical practice are adopted.
Health Information and Quality Authority – National Standards for Safer Better Healthcare –
- The quality of care is continuously monitored and improved
- Service providers conduct local, targeted audits, which are in line with service requirements and priorities, and participate in national audits, and implement improvements based on the findings.
- Care achieves best possible outcomes for service users
- Service providers monitor and evaluate their clinical performance by conducting regular clinical audits in accordance with national guidelines and good practice, and implement improvements based on the findings of these audits.
- Service providers implement and act on the findings of an annual audit forward plan which is in line with service requirements and priorities. This plan is reported against, and monitored by, the clinical governance arrangements of the service, and includes local audits and participation in national audits.
- Service providers actively collect, manage and use quality information as a resource in delivering and improving the quality and safety of healthcare
- Service providers make decisions based on quality information that supports effective performance monitoring and audit
Figure: The audit cycle
Procedure for performing a clinical audit at RVEEH
The RVEEH clinical audit registration form must be completed prior to commencing an audit. This form is available from Cathy Fox, Education & Research Coordinator firstname.lastname@example.org or here:
A start and completion date for the audit must be provided. The support of the supervising consultant is also required. The clerical staff will assist in the retrieval of case files to perform the audit once it has been registered in accordance with the relevant hospital policy.