Clinical audit: why bother?
Authors: Robert Ghosh
Publication date: 10 Jun 2009
Robert Ghosh, chairman of Homerton University Hospital’s Clinical Audit and Effectiveness Committee, talks you through the pleasures and pitfalls of auditing
Most people would agree that the term “audit” applies (wrongly) to a large range of activities. The definition offered by the Concise Oxford Dictionary is the “official examination of accounts or account book.” Many universities, for example, have an audit feast at the end of deanery accounting, at which audit ale would be drunk.
In 1956, medical audit started to become apparent. In 1989, the secretary of state for health, Kenneth Clarke, suggested the “systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient.” This definition ran in tandem with the Working for Patients white paper, which heralded the creation of the internal market. In the new corporate world, quality had to be measured.
A reasonable contemporary definition of the clinical audit process may be “clinical quality assurance achieved by comparison of one’s own practice with a recognised standard, subsequent identification of any deficits in practice, recognition of the causes of these deficits, and rectification education strategies.” This process, or “cycle,” is designed to be perpetually repeated in order to forever improve standards, thereby transforming the cycle into an upward spiral.
Triggers for embarking on a project will vary. The clinician may simply be aware of a standard and ask the question whether his or her department delivers. There could be a perception that there is a problem with quality; this feeling may have been reinforced by an adverse incident or a complaint. Conversely, an audit project might be performed in order to confirm the impression that standards are indeed being met. Another possibility is that a new benchmark may have been made available to clinicians; however, it should be remembered that in these circumstances an audit project should only take place if there is academic consensus that the standard is appropriate. Operational triggers may exist; these are described in the following section.
The process should be led by health professionals, and be confidential to them. Luckily, by adopting inclusive participation strategies in health care, we (clinical and non-clinical personnel) all qualify as potential clinical auditors and lead auditors. Blame culture should remain alienated from the clinical audit process.
I believe that some clinicians take a back seat with regard to clinical audit. It is not clear why this may be so, though occasional remarks made to me in confidence include, “Lacks intellectual challenge of original research,” “boring,” “I feel threatened by findings which I don’t agree with,” and, at least in my experience, the list goes on.
Attractions and pressures for performing clinical audit
Many clinicians enthusiastically perform clinical audit simply with the worthy aim of improving clinical excellence. In the face of additional pressures for doing audit (highlighted below), this enthusiasm should be commended and protected.
Clinical audit is usually itemised in the appraisal of consultants. Junior doctors will often either have a requirement (from the deanery) or a desire to partake in an audit project. My experience of involvement with non-medical staff has been that they find the experience enjoyable and career enhancing. In my opinion, it should not be a requirement for any one individual to commence or finish an audit project in order to fulfil their appraisal or validation requirement; evidence of involvement in a project should suffice. Projects might, therefore, have multiple auditors (kept to a sensible number) and a lead auditor. This set-up should enhance teamwork and obviate the perennial problems of junior doctors hastily concocting suboptimal projects before rotating out of the trust. I believe this strategy will generate fewer, though higher quality, audits.
Now more than ever, clinical and operational standards are repetitively externally measured. Government arm’s length bodies may seek to determine whether local clinical standards measure up to so-called national guidelines (for example, from the National Institute for Health and Clinical Excellence). In addition, operational standards and “targets” (for example, from the Care Quality Commission) might suggest or demand internal auditing. It is likely, therefore, that trusts will increasingly seek specific audit projects from relevant staff.
Some individuals might be sceptical about the philosophy of trusts initiating audit projects. Quality and standards for each and every specialty are measured in various ways, however, encompassing the whole array of old fashioned clinical values, national standards, and government targets.
Committee or board dealing with clinical audit
The group dealing with clinical audit should meet regularly (for example, monthly or quarterly), and should exist to support the trust in its aspiration to produce high quality audit projects. The chair can be any clinician enthusiastic about the cause, and this individual should be supported by a designated manager. In addition, there should be directorate-division-specialty representation both clinically and managerially. The topics traditionally discussed may include new projects, strategies, and funding.
Forums for participation and the process
Although the philosophy of audit should allow the furthering of clinical excellence by the presentation of data at any appropriate forum, it is in the interests of the trust to keep a register of all ongoing audit projects in order to facilitate the availability of data and provide a forum for presentation and re-presentation. In my opinion, this aim is best achieved at dedicated clinical audit days.
Trust intranet pages dedicated to clinical audit should help facilitate applications.
When a clinical audit project is identified, the following process may be adopted by the clinical audit committee or board.
(1) Registration of project and agreement of criteria for comparison. The lead auditor should be named. There should be an entry referring to the size of the impact, the trigger, and the desired performance, and a credible (named) source. The presentation date and venue will be decided at this stage. An audit reference number should be issued.
(2) Data are made available. The lead auditor should describe the methodology of inclusion and exclusion criteria and lost data. This technique should mirror the rigour of data handling in research projects.
(3) Data analysis and interpretation. Statistical methodology should be made clear.
(4) Presentation of the project, with recommendations for implementation.
(5) Trust certification of completed audit should be provided to all participants.
(6) Incorporation of the findings from the project into a protocol should be considered.
(7) Registration for re-auditing, as per (1) above.
This list is only a rough guide. Ideally, there should not be an extraordinary gap between (2) and (4); in such circumstances projects should be removed from registration to avoid a stagnant collection of unfinished projects.
Issues for education in order to implement findings
Post-audit, the implementation of change should include the usual what, how, who, when questions. If a protocol already exists, is there a novel way to implement it? Tried and variably trusted techniques are:
Feedback, with or without comments.
Combination of the above.
Unfortunately, clinical audit projects do not find themselves in peer reviewed journals or on posters in conventions as often as they should. Instead, trust audit activities may be advertised on the internet or in a glossy magazine.
Clinical audit is a universally applicable tool, and its development in health care has accelerated over the past few years. This process should be used to promote quality and clinical effectiveness in flexible and expansive ways. Clinicians in trusts may wish to attempt to improve liaisons with their audit committee in order to push the boundaries and create new ideas for projects. It is my hope that dedicated “audit days” will be the norm in trusts and hospitals across the country.
Competing interests: Dr Ghosh is the editor of the forthcoming book Clinical Audit for Doctors.
Robert Ghosh chairman
Clinical Audit and Effectiveness Committee, Homerton University Hospital, London E9 6SR