Clinical audits must improve to benefit patients, providers, and doctors

Authors: Priyan Maleuwe Tantrige 

Publication date:  16 Jul 2014


Priyan Tantrige looks at the rationale behind the use of clinical audit and its role in medical training and considers how audits could be better used to improve training and patient care

Clinical audit has the potential to benefit patients, healthcare providers, and clinicians, but in the present set-up the net result of clinical audits may be to the detriment of junior doctors. Changing the way audits are implemented and used could therefore bring huge benefits.

All doctors in training must complete at least one clinical audit each year, and bonus points are awarded for completing an audit cycle. The medical colleges strongly support clinician participation in audit,[1] and the General Medical Council requires doctors to produce evidence of participation in audit towards revalidation.[2] The medical training deaneries require completion of an audit assessment for the annual review of competency progression.[3]

Despite these requirements, doctors are not routinely allocated an audit on starting a rotation, and the audit lead for a department is unlikely to have a prioritised list of pending audits that require completion for either the patients’ or the doctor’s benefit. Rather, the doctor is encouraged to identify an area of clinical practice that warrants improvement. He or she must then select a set of guidelines that should be adhered to; register the project with the audit department; collect and analyse the data; and identify the sink points, develop and implement solutions, and complete the cycle by showing that the service has been improved. No time for this activity is included in the doctor’s rota.

Why clinical audit is deemed essential

Every NHS provider in England has a legal obligation and financial incentive to audit its performance. The Health Act 2009 requires that healthcare providers in England submit quality accounts containing prescribed information relevant to the quality of any NHS services that the body provides.[4] The Health and Social Care Act 2012 sets out the process for how the NHS Commissioning Board or the secretary of state may commission the National Institute for Health and Care Excellence (NICE) to develop these quality standards.[5]

The NHS Confederation, the membership body for organisations that commission and provide NHS services, requests that all providers publish quality accounts annually.[6] The largest part of the quality accounts document is the section describing how the healthcare provider measures how well it is doing and continuously improves the services it provides. The method of assessment is the clinical audit, and the quality indicator may be national, regional, or local.

The Healthcare Quality Improvement Partnership lists the national audits that NHS trusts are requested either to complete or to provide reasons for not having completed.[7] The Commissioning for Quality and Innovation payment framework determines the regionally set targets for payment.[8] Trusts also set themselves targets for improvement in areas specific to the services that they offer or the levels of quality that they wish to achieve. The data are then presented to demonstrate performance against the national average and regional and local targets, and new targets are set with plans to achieve them.

Even though every NHS provider in England has a legal obligation and financial incentive to audit its performance, there is no direct legal requirement or immediate financial benefit for doctors to participate in clinical audit. However, the educational benefits of participation have meant that directors of medical education have retained clinical audit in the core curriculum with a view towards future health service development.

How audit could improve

Despite legal requirements on providers and training requirements on doctors to conduct audits, there is evidence that the current deployment of junior doctors into the audit cycle is ineffective.[9] [10] Furthermore, most audits deal with a known diagnosis and not the presenting complaint or the technical tasks that the junior doctors manage in their daily practice, and where they are the most likely to face litigation.[11]

One way that junior doctors can be judiciously employed in the audit cycle is in the development of local guidelines based on their experiences of the clinical environment, their feedback on the causes of system failure, and their suggestions for improvement. Using clinical audit in this way would empower doctors to provide a service they would be proud to deliver and would want for themselves. It would also provide the opportunity to analyse a broad range of guidelines, share ideas, and engage problem solving skills. The medical colleges and NICE strive to facilitate this by providing audit tools and templates to expedite the process and yield comparable datasets.[12] The deaneries assist trainees by recognising alternative methods of quality improvement as part of assessment.[13] [14] [15]. However, individual NHS trusts have not embraced the value of these resources and there is ample scope for development.

Another way to improve the implementation of clinical audit would be to ensure that, since it is a formal training and General Medical Council requirement for doctors, it is also part of junior doctors’ rotas. In addition, local agreements could be put in place that include allocation of protected time, study leave, or remuneration for completion of audits included in trust quality accounts.

The implementation of audits could also be improved by making better use of the monthly audit meetings that many hospital departments hold and which junior doctors attend. These meetings could be used as forums to propose service improvement priorities, allocate projects, provide updates on ongoing projects, and brainstorm recommendations to results of completed projects. Quality improvement work could be shared across the whole department, with tasks such as data collection being allocated to clerical staff, who could discuss any problems with clinicians. The process would be self funded through greater trust income from higher quality accounts and potentially lower litigation costs from doctors spending more time in clinical training.

I thank Harold Ellis, clinical anatomist, Department of Biomedical Sciences, King’s College London, for proofreading the original manuscript, and Sandi Guram, solicitor, for review of the Health Act 2009 and Health and Social Care Act 2012.

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

References

  1. Academy of Medical Royal Colleges. Details for clinical audit and revalidation. [Link] .
  2. General Medical Council. Supporting information for appraisal and revalidation. [Link] .
  3. Joint Royal Colleges of Physicians Training Board. Workplace based assessment. [Link] .
  4. Health Act 2009, chapter 2. [Link] .
  5. Health and Social Care Act 2012, s234. [Link] .
  6. NHS Confederation. [Link] .
  7. Health Quality Improvement Partnership. National clinical audits for inclusion in quality accounts. [Link] .
  8. NHS Institute for Innovation and Improvement. Commissioning for quality and innovation payment framework. [Link] .
  9. Stanton E. An audit of audits. London Deanery, 2009.
  10. John C, Mathew DE, Gnanalingham MG. An audit of paediatric audits. Arch Dis Child  2004;89:1128-9.
  11. Medical Defence Union. [Link] .
  12. National Institute for Health and Care Excellence. [Link] .
  13. Hillman T, Roueche A. Quality improvement. BMJ Careers  2011; [Link] .
  14. Dharamshi R, Hillman T. Going beyond audit. BMJ Careers  2011; [Link] .
  15. BMJ Quality. [Link] .

Priyan Maleuwe Tantrige radiology year 1 specialist trainee Department of Radiology, King’s College Hospital, London SE5 9RS, UK

 pmaleuwe@doctors.org.uk

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