Clinical Audit

How to make it work

Clinical Audit Department

Last revised July 2009
An introduction to clinical audit
Clinical Audit is a quality 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
Principles for Best Practice in Clinical Audit
the National Institute for Clinical Excellence (2002)
Why undertake clinical audit?
To ensure the best possible care for patients is
provided
To ensure clinical practice is evidence-based
Audit is an integral part of Clinical Governance
Assist with the implementation of national initiatives
(NSFs, NICE)
To improve working between multi-disciplinary
groups
Essential Elements of Clinical Audit
It should be patient focused

It should have a direct impact on patient care

Audit assists to improve patients experience of NHS

It can highlight an area of concern

It should be based on evidence based practice

Helps to ensure an efficient use of resources
What can be audited?
Structure The resources and personnel
available, e.g. skill mix of staff, patient access
to see GP

Process Amount and type of activities of
clinical care, e.g. annual review for diabetes

Outcome Result of an intervention, e.g.
pain relief, patient satisfaction
Clinical Audit Cycle

1. Select
topic
7. Implement
change
8. Re-audit
2. Agree
standards of
best practice
3. Define
methodology
4. Pilot
and data
collection
5. Analysis and
Reporting
6. Make
recommendations
Action Planning
Audit
If you require help at any stage

Gordon Lyth
Effectiveness and Audit Coordinator (Commissioning)
Belmont 01432 344344 ext 3839

Susan Little
Clinical Governance Manager (Commissioning)
Belmont 01432 344344 ext 3845

Stages in completing the audit
Step 1 Select a Topic
Choose a topic or area of importance or concern
Useful questions to ask are:
Is it measurable?
Is it evidence based? Complete a literature search
Is improvement achievable?
Does the project have clinical/relevant support?
Who is going to undertake the audit?

Be SMART!
Specific
Measurable
Achievable
Realistic
Timely
Stages in completing the audit
Step 1 continued
Define your objectives for the audit
Give a clear outline / purpose of what you expect to
achieve from the audit, this will assist with step 3.
The following verbs may be useful:
To improve.. To enhance
To ensure.. To change..
Stages in completing the audit
Step 2
Define your criteria and then set your standard
Criteria Defined & measurable statements about
healthcare which describe the quality and
can be used to assess it
Standard The proportion of times the criteria can be
fulfilled to ensure the quality of care and is
measured as a percentage
Stages in completing the audit
Example
Topic Annual Reviews for people with Diabetes
Criteria:
Patients will have a blood test taken for their NbA1C
and the result is recorded in their medical notes
Patients will have their blood pressure recorded
Standard 100%

Stages in completing the audit
Step 3
Identify how you are going to collect the information or
data to measure against your criteria & standard

Retrospective focuses on the evidence of the care
or service that has been provided in the past
Prospective focuses on the care being provided in
the future
Sources of data patient record, computer system,
survey, focus groups, direct observation.

Stages in completing the audit
Step 4 the data collection sheet/questionnaire
Pilot - the data collection sheet
This will ensure the DCS/questionnaire is workable
and highlight any areas that may need adapting. It
will also help to make sure you are collecting the data
you want to collect!

Collect your data

Collate the results organise your data
Stages in completing the audit
Step 5 Analyse the results
Compare the results with the initial criteria and
standards and examine the reasons for any deviation
Write a report

Writing a report
What to include:

1. Title page 9. Audit Type
2. Contents Page 10. Methodology
3. Executive Summary 11. Caveat
4. Background/Rationale 12. Findings
5. Aims & Objectives 13. Observations
6. Standards/Guidelines/ 14. Presentation/Discussion
Evidence Base 15. Recommendations
7. Sample 16. Learning Points
8. Data Source 17. References

Template Available on Intranet
Stages in completing the audit
Step 6 Make Recommendations

Recommendations for practice how the outcome of
the audit will change practice

Give feedback of the results to colleagues and
ensure an action plan to implement any changes is
developed alongside colleagues ownership.

Stages in completing the audit
Step 7 Implement Change

Share the information with colleagues
Share the information with people who can influence
change
Publish outcomes

Implementing Change
1. Involve all concerned in project
2. Ensure consensus to the changes avoid conflict
3. Identify any resources / training needed
4. Ensure everybody understands why change is
necessary helps build teamwork
5. Effective change takes time dont re-audit too soon!
6. Agree an action plan for how to implement change

Stages in completing the audit
Step 8

Re-Audit to ensure change in practice has been
implemented

Close the Loop!

Clinical Audit Cycle

1. Select
topic
7. Implement
change
8. Re-audit
2. Agree
standards of
best practice
3. Define
methodology
4. Pilot
and data
collection
5. Analysis and
Reporting
6. Make
recommendations
Action Planning
Audit
Confidentiality
Patients confidentiality is achieved by ensuring that
access to information is appropriately controlled.
Ways to achieve this:
Ensure compliance with the six Caldicott principles
Ensure compliance with the Data Protection Act
(1998)
For further information please refer to the Handling
information leaflet Information Governance
available on the PCT intranet.
Annual Audit Plan
Create an Annual Audit Plan

Being pro-active

Involves colleagues

Demonstrates good practice

Any questions?






Please contact the Clinical Audit Department
on 01432 344344 x 3839