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Clinical Audit. How to make it work Clinical Audit Department Last revised July 2009. An introduction to clinical audit.

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clinical audit

Clinical Audit

How to make it work

Clinical Audit Department

Last revised July 2009

an introduction to clinical audit
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
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
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
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
Clinical Audit Cycle




if you require help at any stage
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
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






stages in completing the audit1
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 audit2
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 audit3
Stages in completing the audit


Topic – Annual Reviews for people with Diabetes


  • 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 audit4
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 audit5
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 audit6
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
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 audit7
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 audit8
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
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 – don’t re-audit too soon!

6. Agree an action plan for how to implement change

stages in completing the audit9
Stages in completing the audit

Step 8

Re-Audit – to ensure change in practice has been implemented

Close the Loop!

clinical audit cycle1
Clinical Audit Cycle





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
Annual Audit Plan
  • Create an Annual Audit Plan
  • Being pro-active
  • Involves colleagues
  • Demonstrates good practice
any questions
Any questions?

Please contact the Clinical Audit Department on 01432 344344 x 3839