Clinical Audit. How to make it work Clinical Audit Department Last revised July 2009. An introduction to clinical audit.
How to make it work
Clinical Audit Department
Last revised July 2009
‘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)
Effectiveness and Audit Coordinator (Commissioning)
Belmont 01432 344344 ext 3839
Clinical Governance Manager (Commissioning)
Belmont 01432 344344 ext 3845
Step 1 Select a Topic
Choose a topic or area of importance or concern
Useful questions to ask are:
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…..
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
Topic – Annual Reviews for people with Diabetes
Standard – 100%
Identify how you are going to collect the information or data to measure against your criteria & standard
Step 4 – the data collection sheet/questionnaire
Step 5 Analyse the results
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
Step 7 Implement 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 – don’t re-audit too soon!
6. Agree an action plan for how to implement change
Re-Audit – to ensure change in practice has been implemented
Close the Loop!
Patients confidentiality is achieved by ensuring that access to information is appropriately controlled.
Ways to achieve this:
For further information please refer to the Handling information leaflet – Information Governance available on the PCT intranet.
Please contact the Clinical Audit Department on 01432 344344 x 3839