A Brief Introduction to the Clinical Audit Cycle

INTRODUCTION
This guide provides a brief introduction to the principles of undertaking a clinical audit project at UHBristol.
Each aspect of the clinical audit cycle is covered in more detail as part of the complete range of ‘How To’
guides as available on the clinical audit website:
 What is Clinical Audit?
 How To: Choose & Prioritise Topics.
 How To: Set an Audit Aim, Objectives & Standards.
 How To: Set an Audit Sample & Plan Your Data Collection.
 How To: Analyse & Present Data.
 How To: Share Your Findings – Clinical Audit Report & Presentation.
 How To: Implement Change Successfully.
 How To: Engage Patients, Service Users & Carers in Clinical Audit.
 How To: Apply Ethics to Clinical Audit.

WHAT IS CLINICAL AUDIT

“Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through
systematic review of care against explicit criteria…Where indicated, changes are implemented…and further
monitoring is used to confirm improvement in healthcare delivery”
Principles for Best Practice in Clinical Audit (2002, NICE/CHI)

The main stages of the clinical audit process are:

1) Selecting a topic.
Choose
2) Agreeing standards of best practice (audit criteria).
topic
3) Collecting data. Agree /
4) Analysing data against standards. review
5) Feeding back results. standards
6) Discussing possible changes.
Implement Collect data
7) Implementing agreed changes. change if on current
needed practice
8) Allowing time for changes to embed, before re-auditing.
9) Collecting a second set of data. Compare
10) Analysing the re-audit data. data with
11) Feeding back the re-audit results. standards
12) Discussing whether practice has improved.

This process is called the Audit Cycle and is summarised in the diagram above.

UNDERTAKING A CLINICAL AUDIT PROJECT AT UHBRISTOL

Clinical audit at UHBristol is supported by Divisional Clinical Audit Facilitators, centrally located within Trust
Headquarters. Before undertaking a clinical audit project, you should discuss your proposed project with
the relevant Facilitator and complete the clinical audit project proposal paperwork (available on the clinical
audit website - website and contact details are listed at the end of this guide).

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 A Brief Introduction to Clinical Audit

1. CHOOSE A CLINICAL AUDIT TOPIC

Your topic should be chosen systematically. Clinical audit projects take time and resources so the topic that
you choose to address should be of potential benefit to the service as a whole.

Clinical audit projects are best focussed on the processes - e.g. investigations, treatments, or procedures -
which have been shown to result in the best patient outcomes if followed.

Possible sources for your clinical audit project include the:

 National Institute of Clinical Excellence (NICE), National Service Frameworks (NSFs), National
Confidential Enquiries, Patient Safety Initiatives, or Royal Colleges / national professional bodies.
 Publication of conclusive new evidence about clinically effective healthcare; local or regional treatment
guidelines, protocols or frameworks; user views or complaints; adverse incident/near miss reporting
(aka clinical/critical incident reporting); or identified local priorities or concerns, e.g. areas of high
volume, risk or cost.

If you would like to carry out a clinical audit project but are unsure about appropriate topics your divisional
Clinical Audit Facilitator will be able to help you to identify key subjects in your clinical area.

2. FORM A PROJECT TEAM

Clinical audit projects are generally described as being either unidisciplinary (i.e. involving only one staff
group) or multidisciplinary (i.e. involving more than one discipline or profession). It is important that a
clinical audit project assesses patient care as provided by the whole clinical team, in order to identify how
care can be improved. Therefore if your project has implications for a profession or discipline other than
your own, whether within or outside the clinical area you work in, it is important to ensure that they are
represented on the project team.

If your clinical audit project is looking at the patient journey across different care sectors, i.e. ‘interface’
audit, try to include staff representatives from these other care sectors in your project team. An example of
an interface audit would be looking at the process of referral into the hospital from primary care.

Consider including a patient, service user and/ or carer representative(s) on your project team or gaining
their views on what they would like to see from the service. Engagement is important as healthcare is a
partnership between clinicians and their patients/ service users. Whilst we strive to provide the best quality
of care as we see it, patients/ service users might want something different. Direct engagement is best e.g.
through participation of identified individuals on project steering groups or divisional/specialty audit
committees. However, indirect engagement is another possibility, e.g. through the completion of a survey,
usually administered at the end of an episode of care.

It is important that your project is supported by colleagues who have the authority and commitment to see
that any necessary changes indicated by the audit results are put into practice.

3. SET THE AIM, OBJECTIVES AND STANDARDS

To define the aim of your clinical audit project consider Audit Topic
what it is that you hope to achieve, i.e. the overall
purpose of the project. The aim can be written as either a Aim
statement that about what you want to happen as a result
of the audit or as a question that you want your audit to Objective Objective
answer. Statements should be phrased positively, to
ensure that the audit brings about improvements in Standard Standard Standard
practice.

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Your aim is then broken down into a series of smaller objectives. Objectives are the steps that you need
to take in order to assess whether or not you have achieved your aim. Your objectives can be written as
either specific tasks to be undertaken or as the different aspects of quality that your project will address,
e.g. appropriateness = right treatment for right patient; timeliness = treatment given at right time; or
effectiveness = treatment given in right way or with desired effect

S pecific Standards should be SMART and are more specific than objectives. They are
quantifiable statements detailing the specific aspects of patient care and
easurable
management that you intend to measure current practice against. Standards
greed should always be based on the strongest, most up-to-date evidence of what
constitutes best practice. If standards are available in the form of guidelines, you
elevant
should base your audit on the most widely applicable guidelines available, e.g.
heoretically sound national rather than regional or local guidelines.

If guidelines/ protocols do not exist or existing ones are out of date, you will need to undertake a literature
search to identify best practice. Assistance with this can be provided by the Library and Information Service,
whose contact details are listed at the end of this guide. It is important that there is agreement with your
standards locally before you start. You will find it hard to improve practice if there is disagreement as to
what constitutes best practice.

4. ETHICS & ENGAGEMENT

Unlike research, clinical audit projects do not need to be submitted to a Research Ethics Committee (REC)
for ethical approval. This is one of the key reasons why you must ensure that your project is clinical audit
rather than research. If you think that there are ethical issues with your project you must discuss these with
your divisional Clinical Audit Facilitator.

Clinical audit should always be conducted within an ethical framework. This means abiding by the principles
of the Data Protection Act; e.g. by ensuring patient and staff confidentiality and by ensuring that data is
collected and stored appropriately.

If you are including a patient survey as part of your project it must be submitted to the Questionnaire,
Interview and Survey (QIS) Group for approval. Contact details for the QIS group are listed at the end of this
guide.

5. SELECT AN AUDIT SAMPLE

The sample population will be dependent upon your topic. Occasionally an aspect of treatment or care that
applies to all patients is audited. However, the majority of clinical audit tends to assess the care of a defined
group of patients who share certain characteristics. Typically, the fact that they have the same medical
condition, have received the same form of treatment or were seen within a certain time frame.

It is not always practical to audit all patients within your population, therefore you will need to select an
appropriate sample size. The sample should be large enough so that senior clinicians/managers are willing to
implement changes based on your findings. A ‘snapshot’ is often sufficient (roughly 20-50 cases) for process-
based audit.

It is important that your sample contains current/recent patients. Clinical audit is about improvement. You
cannot change the past but you can change the future.

6. PLAN AND CARRY OUT DATA COLLECTION

Data should only be collected if it is necessary to enable you to measure current practice against your audit
criteria (standards). Any extra data means more time spent on your project without any additional benefit
and is contrary to the principles of the Data Protection Act.

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If data is routinely recorded either in the patient’s notes or electronically it is possible to carry out a
retrospective audit, i.e. assessing past episodes of patient care. If the data is not routinely recorded
prospective data collection is required, i.e. assessing the patient care at the time it is given. Data can be
collected using an audit form (proforma) or entered directly onto a computer.

Before you collect the data for your entire sample it is important to pilot your data collection ‘tool’ (form/
spreadsheet/database). The purpose of the pilot is to try out your tool on a small sample to make sure that
it works, especially if someone else is going to be collecting the data for you. The pilot may reveal that some
of your instructions on how to complete the tool or the questions asked are ambiguous, that the tool is
difficult to complete or that you are simply not getting the information you wanted.

7. ANALYSE THE DATA Number of patients

Your data analysis should establish which standards are who meet standard
being met and which are not. If a standard is not being met 100
x
you need to identify why and how practice can be improved
to ensure that the standard is met in the future. You may Number of Number of
also consider if there were other, acceptable reasons for the patients to patients who
whom standard
– meet any listed
standard not being met, i.e. an exception not considered
applies exceptions
during the planning stage.

8. PRESENT THE FINDINGS

The findings of your project should be discussed by the project team and presented to colleagues. If full
compliance with the standards was not achieved an action plan should be developed to address any issues.

Once completed projects should be presented both verbally and written up as a report. Both should address
how well the standards are being met and highlight any problems that need to be addressed. The
presentation gets the message of your audit across to key staff and should generate discussion and
agreement about changes to practice in light of the audit results.

Your final report (template available on the clinical audit website, address provided at the end of this guide)
acts as the official record of what you have done and contains more detail than the presentation. It should
include an Action Plan if improvements are required and all the information needed to plan a re-audit.

9. IMPLEMENT CHANGES AND RE-AUDIT

If an audit shows that current practice needs to be improved, making changes is important. The public has
the right to expect that practitioners will provide care that is consistent with recognised good practice.

Not all changes will be improvements. Do not make changes for change’s sake. At an appropriate time,
repeat the audit (re-audit) to ensure that changes have been implemented and that practice has improved.

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 A Brief Introduction to Clinical Audit

A FLOW CHART SUMMARISING THE CLINICAL AUDIT PROCESS AT UHBRISTOL

Discuss and agree project with divisional Clinical Audit Facilitator

Audit topic
Form a project team
Set the aim, objectives and standards
Consider ethics and engagement
Select an audit sample
Plan your data collection and data collection form

Agree project with all areas and staff affected and gain senior clinician support

Complete the UHBristol clinical audit proposal paperwork

Submit proposal to relevant Clinical Audit Convenor/Facilitator for approval

Carry out data collection

Analyse the data

Share your findings: 1. Presentation 2. Report and action plan

Implement changes and re-audit

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CONTACT DETAILS / USEFUL INFORMATION

CLINICAL AUDIT
 The UHBristol Clinical Audit website is available via http://www.uhbristol.nhs.uk/for-
clinicians/clinicalaudit/
 Contact details for UHBristol Clinical Audit Facilitators are available via
http://www.uhbristol.nhs.uk/for-clinicians/clinicalaudit/contacts/
 The full range of UHBristol Clinic Audit ‘How To’ guides are available via
http://www.uhbristol.nhs.uk/for-clinicians/clinicalaudit/how-to-guides/
 Copies of UHBristol Clinical Audit Proposal Form, Presentation Template, Report Template, Summary
Form, and Action Form are available via http://www.uhbristol.nhs.uk/for-
clinicians/clinicalaudit/carrying-out-projects-at-uh-bristol/
 The UHBristol Clinical Audit & Effectiveness Central Office can be contacted on 0117 342 3614 or e-
mail: stuart.metcalfe@uhbristol.nhs.uk
 Clinical Audit Training Workshops can be booked through the Clinical Audit & Effectiveness Central
Office as above.

CLINICAL EFFECTIVENESS
 For advice on Clinical Effectiveness (NICE, NCEPOD, PROMS, guidelines) matters contact Stuart
Metcalfe, Clinical Audit & Effectiveness Manager, 0117 342 3614 or e-mail:
stuart.metcalfe@uhbristol.nhs.uk

PATIENT EXPERIENCE
 For advice on carrying out surveys, interviews and questionnaires please contact Paul Lewis, Patient
Experience Lead (Surveys & Evaluations), 0117 342 3638 or e-mail: paul.lewis@UHBristol.nhs.uk
 For advice on conducting qualitative and Patient Public Involvement Activities (focus groups,
community engagement, co-design, workshops) please contact Tony Watkin, Patient Experience Lead
(Engagement & Involvement), 0117 342 3729 or e-mail: tony.watkin@UHBristol.nhs.uk
 All surveys that are being carried out for service evaluation or audit purposes should be discussed with
Paul Lewis in the first instance. Patient experience surveys will also usually need to be approved by the
Trust's Questionnaire, Interview and Survey (QIS) Group. Proposals should be submitted to Paul Lewis
using the QIS proposal form. The proposal form and covering letter template is available via
http://www.uhbristol.nhs.uk/for-clinicians/patient-surveys,-interviews-and-focus-groups/

RESEARCH
For advice on research projects contact the Research & Innovation Department on 0117 342 0233 or e-mail:
research@UHBristol.nhs.uk
Further information can be found via http://www.uhbristol.nhs.uk/research-innovation/contact-us/

LITERATURE REVIEWS/EVIDENCE
For advice on literature reviews, NHS Evidence, article/book requests and critical appraisal contact the
Library and Information Service on 0117 342 0105 or e-mail: Library@UHBristol.nhs.uk

SAMPLE SIZES
 The Sample Size Calculator is available via: http://www.uhbristol.nhs.uk/for-
clinicians/clinicalaudit/how-to-guides/

QUALITY IMPROVEMENT
Further information about clinical audit and wider quality improvement is available via the Healthcare
Quality Improvement Partnership (HQIP) - http://www.hqip.org.uk/

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