HEALTHCARE PROFESSIONALS

across the NHS are being encouraged

to take part in clinical audits.
In the inquiry report into the
management of children undergoing
cardiac surgery at Bristol Royal
Infirmary (Department of Health
2002) for example, chair of
the Healthcare Commission
Sir Ian Kennedy recommended
that clinical audit should be fully
supported by trusts and should
be compulsory for all healthcare
professionals.
In addition, the governments
Standards for Better Health
(DH 2004) has charged all healthcare
organisations with ensuring that
clinicians participate in regular
clinical audit.
As these documents make clear,
if clinical audit is used appropriately
and simply, it can be an effective
quality improvement tool.
But clinical audits are often
poorly carried out and consequently
have minimal effect on improving
patient care. Jamtvedt et al (2003)
for example find that the effects
of audit are generally small to
moderate.
The National Audit Office
(2007) makes clear moreover that,
although healthcare professionals
are expected to participate in clinical
audit, they often poorly understand
the methodology and techniques
involved, possibly due to a lack of
good training and support.
With the expectations of
clinical audit being so high but the
consequences of carrying them out
badly being so serious, now is a good
time to learn about the technique.
This article therefore offers a
brief history of clinical audits, with
an account of recent attempts to
update them.
It also describes how clinical audit
works and offers some practical tips
on implementing them locally.
Brief history
Some historians suggest that
the first laws promulgated by
King Hammurabi of Babylon in
1750BC, which became the first
written legal code, constitute the
first audit in history.
Florence Nightingale is usually
credited with having undertaken
the first known clinical audit while
collecting data on soldiers in battle
hospitals during the Crimean
War in an attempt to reduce their
mortality rate.
Initially known as medical audit,
clinical audit was not formalised until
the publication of the white paper,
Working for Patients (Secretaries of
State for Health: Wales, Northern
Ireland and Scotland 1989).
Although healthcare professionals
were quickly encouraged to
participate in it, it is still regarded
by many as a new approach to
quality assurance in the UK.
More recent attempts to revitalise
clinical audit have also been made.
A report by the chief medical
officer for England, Good Doctors,
Safer Patients (DH 2006),
for example, suggests that
healthcare regulators such
as the Nursing and
Midwifery Council
should consider more
closely their role in
the revalidation of
healthcare professionals.
Then, in January
this year, the DH
announced that the
National Clinical Audit
and Patients Outcomes
Programme will be run by a new
consortium, called the Healthcare
Quality Improvement Partnership
(NHS Networks 2008).
This new organisation comprises
the RCN, the Academy of Medical
Royal Colleges and the Long-Term
Conditions Alliance.
NHS medical director
Sir Bruce Keogh welcomed
the new approach, stating:
The consortium will understand
both the clinical context and
implications of the audits thereby
maximising the opportunity for real
improvement.
RCN director of nursing and
service delivery Janet Davies
said the college was delighted
to be involved in a coalition
of organisations with such a
commitment to quality healthcare.
She continued: This partnership
will bring together patient and staff
groups at every level of the NHS
to engender debate and positive
outcomes for patients, staff and
the health services as a whole.
Clinical audit: a guide
All nurses are expected to take part in clinical audits. Stephen Ashmore
and Tracy Ruthven explain how it should be done
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Before embarking on clinical audit
projects, nurses must understand
fully what they entail. If they lack
such an understanding, the quality of
their projects may suffer.
There are many definitions of
clinical audit but probably the
most widely accepted is as follows:
A quality improvement process that
seeks to improve patient care and
outcomes through systematic review
against explicit criteria and the
implementation of change (National
Institute for Health and Clinical
Excellence 2002).
In simple terms, this means that
audit involves finding out if working
methods are correct. In the clinical
arena, audit means identifying
shortfalls in levels of care.
Clinical audit shares some of
its key characteristics with clinical
research. Both are systematic
processes that involve statistical
analysis and topic selection, and both
can lead to changes in clinical and
non-clinical practice that improve
patient care.
Unsurprisingly therefore, many
healthcare professionals struggle to
understand the difference between
them. Yet there is a clear difference.
Research can be defined as an
attempt to derive generalisable, new
knowledge by addressing clearly
defined questions with systematic and
rigorous methods (Copeland 2005).
Thus, clinical research is an
investigation into what happens
if clinical services are changed, and
the results can indicate for example
which drugs or therapies work
best. By contrast, clinical audit is
an investigation into whether best
practice, as defined by clinical
research, is being implemented.
The general rule of thumb when
collecting data is, if best practice
is not already known, the data is
almost certainly intended for clinical
research, not clinical audit.
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In clinical audit, a systematic
process, known as a clinical audit
cycle or spiral is followed.
Clinical audit cycles should be
understood as project plans or
guides; if they are followed correctly,
audits should succeed. They can take
different forms, some of them more
complicated than others, but perhaps
the most practical and useful of them
is the eight-stage version from the
Clinical Audit Support Centre (2007)
(Figure 1).
Stage 1. Select audit topic
There are many ways to
determine which audit to
undertake. For example,
employers may ask employees to take
part in national audit projects or to
audit national documents such as
guidelines produced by the National
Institute for Health and Clinical
Excellence.
Those who want to undertake
local audit projects can regard them
as part of quality improvement
processes by focusing on practices
that should be improved or where
current standards of performance are
uncertain. A selection of potential
topics is shown in Table 1.
Once a topic is selected, the audits
feasibility should be assessed using a
tool such as the scoring grid shown in
Table 2 (Baker et al 1998).
Stage 2. Identify best practice
The next step is to
identify what aspects of
best practice should be
included in the audit. Local and
national guidelines, national service
frameworks and research papers can
help determine what is considered
best practice.
Stage 3. Agree criteria
and standards
Use of the terms criteria
and standards in clinical
audit is often misunderstood.
Criteria are statements that define
good practice in the aspects of care
under examination.
Figure 1. The audit cycle
Adapted from the Clinical
Audit Support Centre (2007)
1
Select
audit topic
8
Write and
disseminate
an audit
report
7
Conduct
re-audit
2
Identify
best
practice
3
Agree
criteria and
standards
4
Collect
the data
5
Analyse
the data
6
Implement
the necessary
changes
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An example of a criterion in
non-clinical audit is the Royal
Mail criterion that, within the UK,
first class letters should reach their
destination within 24 hours (Royal
Mail 2008).
Standards meanwhile are the
expected levels of success, usually
written as percentages. Thus, the
Royal Mail criterion described
above becomes the standard that
93 per cent of first class letters
should reach their destination within
24 hours.
Similarly, the NHS criterion that
written patient records should be
recorded in black ink becomes the
standard that 100 per cent of written
patient records should be recorded in
black ink.
Stage 4. Collect the data
The purpose of data
collection is to determine
whether, in the practice
undergoing audit, the agreed criteria
and standards are being achieved.
The data collected must
be relevant, accurate and
representative.
Most audit data are collected
using either manual data collection
forms or recorded using electronic
computer software such as the
Microsoft applications, Excel
and Access.
Stage 5. Analyse the data
Data analysis involves
interpreting collected
audit data to discover how
current practice compares to agreed
criteria and standards.
It identifies areas both of under-
performance, which should be
reviewed in detail to identify why
care falls below the desired levels and
how it can be improved, and of over-
performance.
Stage 6. Implement the
necessary changes
Implementing changes that
will improve poor results
is often the hardest part of any audit
project. All team members should
be involved in discussions about
what changes should take place
so that all possible solutions are
explored. These changes invariably
depend on the specific circumstances
of the audit, but often include staff
training, the introduction of better
systems of practice, or new protocols
and guidelines.
Stage 7. Conduct re-audit
Re-audit is another key part
of the audit cycle, which
should be carried out within
a year of implementing change.
Re-audit involves collecting
a second set of data to review
progress after the changes have been
implemented to identify whether
further improvement is needed.
The numbers audited should be
comparable to those from the first
data collection phase.
Stage 8. Write and
disseminate an audit report
This, the final stage of the
audit cycle, is intended to
create a record for the auditor, the
team and the organisation involved.
This report should be shared also
with colleagues who have taken part in
the work so they can see what effects
the audit has had on their practice.
Sharing audit reports widely
also helps those who want to
conduct clinical audit using the same
methodology.
Conclusion
Healthcare professionals in the UK
are expected to use clinical audit
techniques to ensure that their work
is of the highest calibre.
Recent national developments
indicate that nurses are expected
to take part in clinical audits at
national, regional and local levels,
and so must understand how to do
so successfully.
Further information can be
gathered from the sources listed
in Table 3 nm
Table 1. Potential topics for audit
Patient or general complaints
Poor patient care or compliance
Issues involving patient safety or significant events
Systems that are unused or ineffective
Poor documentation
Missing data
Areas where delays occur
National guidance
Administration of drugs
Table 2. Audit feasibility scoring grid
Does the audit address a problem that is relevant to patient care?
Is the topic a priority for the team or organisation?
Can data be collected quickly, ideally in less than a month?
Is there confidence that the data will be reliable and accurate?
Could changes recommended as a result of the audit be implemented?
Scoring
In answering the questions, award two points for a Yes, one point for a Not Sure and no points
for a No. Audits that score five or less are unlikely to succeed, those that score six or seven are worth
considering, and those that score eight or more will usually succeed
Adapted from Baker et al (1998)
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22 nuraing management Vol 15 No 1 April 2008
Table 3. Useful websites and resources
The RCN offers ideas on topics for audit at www.rcn.org.uk
For advice on how to conduct clinical audits, email: qip.hq@rcn.org.uk
The Clinical Audit Support Centre offers a range of accredited clinical audit
training packages at www.clinicalauditsupport.com
The NHS Library offers details of previous audit projects and examples of best
practice at www.library.nhs.uk
References
Baker R, Fraser RC, Lakhani M (1998)
Evidence Based Audit in General Practice.
Butterworth-Heinemann, Oxford.
Clinical Audit Support Centre
(2007) What Is Clinical Audit? www.
clinicalauditsupport.com/what_is_clinical_
audit.html (Last accessed March 17 2008).
Copeland G (2005) A Practical Handbook
for Clinical Audit. NHS Clinical
Governance Support Team. www.
cgsupport.nhs.uk/downloads/Practical_
Clinical_Audit_Handbook_v1_1.pdf
(Last accessed March 10 2008).
Department of Health (2002) Learning
from Bristol. www.dh.gov.uk/en/
Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_
4002859 (Last accessed March 10 2008).
Department of Health (2004) Standards
for Better Health. www.dh.gov.uk/en/
Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_
4086665 (Last accessed March 10 2008).
Department of Health
(2006) Good Doctors, Safer
Patients. www.dh.gov.uk/en/
Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_
4137232 (Last accessed March 10 2008).
Jamtvedt G, Young JM, Kristoffersen DT,
OBrien MA, Oxman AD (2003) Audit and
feedback: effects on professional practice
and healthcare outcomes. Cochrane
Database of Systematic Reviews. 1.
National Audit Office (2007) Improving
Quality and Safety Progress in
Implementing Clinical Governance
in Primary Care: Lessons for the new
primary care trusts. The Stationery
Office, London.
NHS Networks (2008) New Arrangements
for Clinical Audit. www.networks.nhs.
uk/news.php?nid=2051 (Last accessed
March 10 2008).
National Institute for Health and Clinical
Excellence (2002) Principles for Best
Practice in Clinical Audit. Radcliffe
Medical Press, Abingdon.
Royal Mail (2008) Delivery Options: UK.
www.royalmail.com/portal/rm/jump1?
catId=400023&mediaId=400028&keyname
=ssm (Last accessed March 12 2008)
Secretaries of State for Health: Wales,
Northern Ireland and Scotland (1989)
Working for Patients. The Stationery
Office, London. i
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1. Start small
Clinical audit projects often fail
because staff try to collect too much
information. They should be viewed
as snapshots of current practice
and workload should be kept to
a minimum.
2. Involve team members
Audit is most effective when it
is carried out by teams. All staff
should be asked to suggest suitable
topics and told about results.
One team member should
co-ordinate each audit but other
team members should be involved.
3. Distinguish between research
and clinical audit
Remember that research is
undertaken to find out what
best practice should be; audit is
undertaken to find out whether
best practice is taking place.
4. Learn from others
Completed projects, which can
be found by carrying out simple
internet searches or by discussing
them with peers, can often be
adapted for new ones.
5. Select audit topics that relate
to current work
Nurses collect information in
many formats, often routinely,
and opportunities to link audits
to such work can arise.
6. Gather support
Local support for clinical audit
varies but some trusts have
audit teams.
7. Plan audits properly
Simple audit calendars, which are
used to map out audit activities
over the course of a year for
example, are useful.
8. Pilot audits
A small number of data collection
forms should be tested to make
sure that they provide all the
information that is required.
9. Re-audit is vital
Without undertaking re-audit, there
is no way of knowing if the changes
made have improved patient care
or service delivery.
10. Get the most out
of clinical audit
Although audit is essentially
about identifying weaknesses and
improving patient care, it can also
be used for example to improve
teamwork or communication.
Ten tips for successful audits
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