Clinical Audit

NICE defines clinical audit as 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". I feel this might be a bit misleading. The process is quite unlike a
systemic review. While a systemic review is meant to divine a larger, fundamental truth by
correlating data from a myriad of widespread sources, a clinical audit searches for more
personal, relative figures by doing a detailed search in a small area, such as a single hospital
or department. Its also more practical than a systemic review. While a systemic review tells
us what is the best course of action in ideal conditions, a clinical audit tells us how to deliver
the best care to our patients within our ability.
Clinical audits, much like normal audits, make sure everything is running on track. However,
they are a bit more complicated than normal ones since any 2 patients with the same disease
may require wildly differing treatments. Also unlike a normal audit, problems are expected.
Indeed they are the whole point. To identify the problems currently plaguing your work, so
that they may be fixed or improved upon. Clinical audits are divided into 5 steps;
Identification of the problem, the setting of criteria and standards, collection of data,
comparison of data with the criteria and standards set and finally the implementation of
change.
Identification entails the selection of the topic to be audited. They usually measure adherence
to tried and tested healthcare processes. The topics are selected by considering affected by
national guidelines, recurrent problems in the practice, outside recommendations and high
cost, risk and volume.
Criteria and standards define the purpose of the audit, whether it is the physical outcome of
the audit or the information that needs to be gained from doing it. A criterion is what is being
measured, e.g. care, respect, capacity, etc. A standard is the threshold of compliance for each
criterion.
Data collection is self explanatory and should include the group to be included(with
exceptions noted), the healthcare professionals involved and the period over which the
criteria are measured. Data sample sizes are far smaller and less precision is required than
normal.
Next, the data is compared to the criteria and standards to identify how well the standards
were met and any reasons why they weren't met. If these reasons are agreeable, they might
simply be added to the exception criteria next time. The standards need not always be met
100%. In cases where close to 100% is achieved and further improvement might be very
difficult, it might be acceptable to settle for less than 100%. In certain areas, particularly life
and death cases, less than 100% may not be acceptable, whereas in areas such as minor
complications, lower percentages may be acceptable.
Finally, the results of the audit are discussed and an action plan detailing what must be
achieved by when is drawn up. This may include a refinement of audit tools and processes, as

well as new outcome measures to correct for inappropriately assessed measures and linkages
to other departments. In the latter case, a joint audit might be beneficial to avoid simply
shifting the blame.
To properly utilise clinical audits, they must be repeated after an appropriate period of time
has passed to allow the implemented changes to have a visible effect. And they must be done
in a way such as to verify if the implemented changes have had any effect and to identify if
any further changes are required to meet the standards and criteria, which also may change
due to new developments.
After watching the PGH clinical audit competition, I felt that some of the departments might
not have properly understood the way a clinical audit is to be carried out. I think that, while
clinical audits have to be tailored and specifically planed for each situation given their
extremely specific nature, at least rough guidelines and instructions should be standardized
and more training in the performing of clinical audits be given to all parties who might be
involved. There was an advisor with an open door policy, but sometimes it's hard to go out of
your way to ask about something you just aren't that sure about or for minor things which
may eventually pile up.
While clinical audits are meant to be internal, I think some manner of outside regulation of
data collection, at least within a hospital level, should be considered. While clinical audits are
simply meant for improvement rather than acting as a hard quota, inaccurate data or flawed
collection methods are distinct possibilities, especially since many will be attempting to do
their own job at the same time or have had little prior training in such things or even both at
the same time. One of the presentations on customer satisfaction was strangely positive.
Excessively so for a government hospital. While it is possible that the staff was providing
near perfect services, it's much more likely that the participants didn't fully understand the
questionnaire they were given, or it's nature and purpose. It was also very likely that they
didn't know the level of service that was actually supposed to be provided and assumed that
what they were getting was correct, barring catastrophic mistakes.
Flaws aside, many of the clinical audits showed an improvement in the delivery of care and
had solid plans to improve upon it further. The competition seems to be an annual event
where a nearly all the departments which had carried out clinical audits are reviewed, which
makes me wonder about clinical audits that need to be done more than once a year or do not
need to be done so often. Also, presenting the review as a 'competition' might give many the
wrong idea and sway people into presenting more 'favourable' audits as opposed to more
important ones, topics where the department involved might greatly benefit from outside help
and advice.