The Audit Process

Tahera Chaudry

March 2009

Clinical audit

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

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

The audit process

Stage 1: Identify the problem/issue

Selection of a topic or issue to be audited

Likely to involve measuring adherence to healthcare processes that have been shown to produce best outcomes for patients

Audit topics may be recommended by national bodies, such as NICE or the Healthcare Commission

Stage 1: Identify the problem/issue (2) Selection of an audit topic is influenced by factors including:

where national standards and guidelines exist; where there is conclusive evidence about effective clinical practice (ie. evidence based medicine)

areas where problems have been encountered in practice what patients & public have recommended that be looked at where there is a clear potential for improving service delivery areas of high volume, high risk or high cost, in which

improvements can be made

Stage 2: Define criteria & standards Series of statements or tasks to reflect the 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

Collectively, these form the audit criteria explicit statements that define what is being measured and

represent elements of care that can be measured objectively

Stage 2: Define criteria & standards (2) A criterion is a measurable outcome of care, aspect of

practice or capacity For example, ‘parents / carers are involved in negotiating or

planning their child’s care’

A standard is the threshold of the expected compliance for each criterion (usually expressed as a percentage)

For the above example an appropriate standard would be: ‘There is evidence of parent / carer in care planning in 90% of cases’.

Stage 3: Data collection To ensure data collected are precise, and that only essential

information is collected, certain details of what is to be audited must be established from the outset. These include:

The user group to be included, with any exceptions noted The healthcare professionals involved in the users' care The period over which the criteria apply

Sample sizes for data collection are often a compromise between the statistical validity of the results and pragmatic issues around data collection.

Consideration needs to be given to What data will be collected Where the data will be found Who will do the data collection

Stage 3: Data collection (2) Ethical issues considered

data collected must relate only to the objectives of the audit

staff and patient confidentiality must be respected - identifiable information must not be used

any potentially sensitive topics should be discussed with the local Research Ethics Committee

Stage 4: Compare performance with criteria and standards Analysis stage Results of the data collection are compared with criteria

and standards The end stage of analysis is

concluding how well the standards were met identifying reasons why the standards weren't met in all cases these reasons might be agreed to be acceptable, i.e.

could be added to the exception criteria for the standard in future or will suggest a focus for improvement measures

Stage 4: Compare performance with criteria and standards (2) 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

Stage 5: Implementing change An agreement must be reached about the recommendations for

change Action plan to record these recommendations is good practice Each point:

well defined an individual named as responsible for it agreed timescale for its completion

Action plan development may involve refinement of the audit tool particularly if measures used are found to be inappropriate or incorrectly assessed

In other instances new process or outcome measures may be needed or involve linkages to other departments or individuals

Re-audit: Sustaining improvements Audit repeated after an agreed period Use same strategies for identifying the sample,

methods and data analysis to ensure comparability with the original 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

Re-audit: Sustaining improvements (2) Critical to the successful outcome of an audit process -

it verifies whether the changes implemented have had an effect to see if further improvements are required to achieve the

standards of healthcare delivery identified in stage 2

Results of good audit disseminated locally via the Strategic Health Authorities and nationally where

possible published in professional journals, such as the BMJ, especially

if the work or the methodology is generalisable

Summary: The audit process