‘As a quality improvement tool, audit can
demonstrate that real efforts are being made by dedicated,
hard-pressed staff to deliver high-quality professional care to all
their patients’
NICE Principles for Best Practice in Clinical
Audit 2002
‘Clinical audit is a quality improvement
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.’
NICE Principles for Best
Practice in Clinical Audit 2002
Introduction
Clinical audit has been endorsed in successive
strategic documents from the Department of Health as a
significant way in which to measure and improve quality of
clinical care. The promotion of clinical audit throughout the
NHS in England is being supported through an organisation set up to
re-invigorate clinical audit - the Healthcare Quality Improvement
Partnership (HQIP). The RCGP is actively working with HQIP to
ensure that the guidance produced can be tailored to the
requirements of GPs and the primary care teams.
HeathCare Quality Improvement Partnership
(HQIP)
The Healthcare Quality Improvement
Partnership was established in April 2008 to promote quality in
healthcare and in particular to increase the impact that clinical
audit has on healthcare quality in England and Wales. HQIP is
currently contracted by the Department of Health to deliver a
programme of activity to reinvigorate clinical audit and focus
on key strategic areas.
National Clinical Audit
Advisory Group (NCAAG)
The National Clinical Audit Advisory Group has
been established to drive the re-invigoration of clinical
audit programme and provides a national focus for discussion
and advice around clinical audit. NCAAG are also an advisory
body for the Department of Health on matters relating to clinical
audit and act as the steering group for the National Clinical Audit
and Patient Outcomes Programme(NCAPOP)
National Clinical Audit and Patient Outcome Programme
(NCAPOP)
The NCAPOP programme comprises more than 20
clinical audits that cover care provided to people with a wide
range of medical, surgical and mental health conditions and will be
extended to other areas of healthcare that are considered a
priority by the National Clinical Audit Advisory Group (NCAAG) and
the Department of Health. HQIP hosts the contract to manage and
develop the National Clinical Audit and Patient Outcomes Programme
(NCAPOP).
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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 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.’
This is the recognised definition of clinical
audit from the NICE Principles for Best Practice in Clinical Audit
(2002) and is endorsed by HQIP and available on the
Department of Health website.
HQIP have produced a guidance document which
defines the markers of good quality clinical audit – it outlines
the 4 essential stages of activity for a clinical audit and
highlights the key criteria within each stage. You can view
this guidance from the
HQIP website.
The clinical audit cycle
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How Should an Audit be Structured?
The following stages will help to structure
your audit. For hints on how these stages can be related to general
practice, please use the subheadings below to view pages with more
information.
Stage 1 –
Preparation & planning (including for re-audit)
1. Topic is priority for
organisation
2. Measures against
standards
3. Organisation enables
the clinical audit
4. Involves clinical and
non-clinical
stakeholders
5. Patients are
involved
Stage 2 –
Measuring performance
6. Written clinical audit
method
7. Target sample
appropriate to produce meaningful results
8. Data collection
process is robust
9. Data analysed and
reported to maximize impact of clinical audit
Stage 3 –
Implementing change
10. Action plan developed and
implemented
Stage 4 – Sustaining
improvement (including re-audit)
11. Clinical audit is cyclical
process that demonstrates improvement is sustained
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Why do GPs need to do Audit for Revalidation?
The RCGP Guide to the Revalidation of General
Practitioners conforms to the General Medical Council advice
that all doctors take part in systematic audit and be familiar with
the principles and practice of clinical audit. When revalidation is
fully established, a GP's Revalidation Portfolio will be expected
to contain appropriate evidence of auditing. This will normally be
2 full-cycle clinical audits during the revalidation
period. Clinical Audit 1 should be undertaken in years 1-3,
and Clinical Audit 2 in years 3-5.
The guide to revalidation presents the key
attributes of a clinical audit as:
- the relevance of the topic chosen;
- the appropriateness of the standards of patient care set;
- the reflection on current care and the appropriateness of
changes planned;
- the implementation of change for the GP's patients;
- demonstration of change by the GP.
Several GPs who work together as a team may
undertake a common clinical audit. If this clinical audit is to be
put into a GP's revalidation portfolio, that GP must have
contributed properly to the choice of topic and the standards
set. The GP must be able to identify his or her own care or
the care for which he or she is personally responsible, within the
first clinical audit and the re-audit. The GP must state what
changes he or she instituted and be able to demonstrate the
effects of those changes.
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What is the Difference Between Audit and Research?
The National Research Ethics Service makes a clear distinction
between clinical audit and research and states that, unlike
research, clinical audit does not need approval from a research
ethics committee. This document 
produced by
the NRES sets out the difference with audit and research.
CIRC also supports and is involved in GP research
activities and more information on this can be found at the
research webpages.
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What support will the RCGP give to GPs doing Clinical
Audit?
The RCGP will be supporting GPs with clinical
audit through the development of this clinical audit resource. The
RCGP has signposted a number of organisations, guidance documents,
example clinical audits and audit tools.
The RCGP aims to develop a peer review system to
support clinical audit, which will offer feedback for GPs doing
audit. The RCGP would welcome members’ contribution to this
initiative. If you have experience of clinical audit or
peer-review and would like to contribute, please contact CIRC or register as a Clinical
Adviser.
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Signposting Material for Clinical Audit
The following table highlights links to
organisations involved in clinical audit and accesses some of
their resources. Also included are links to useful handbooks and
good practice guidelines relating to clinical audit. The aim
of this resource is to provide good examples of
audit relating to primary care, in particular to the RCGP
clinical priority areas.
Over time the list of resources will be
expanded. If you feel you would like to make us aware of
any useful resources relating to clinical audit then
please contact CIRC.
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Organisations Involved with Clinical Audit
The organisations listed below are all involved with clinical
audit, and have useful resources or guidance. Please use the
links below to be directed to each organisations' external
website.
Audit
Commission
Care Quality Commission Engagement in Clinical Audits
The Cochrane Library
Department of Health - Clinical Audit
Department of Health - Diabetes
Diabetes UK
Diabetes – National audit
HQIP
Myocardial Ischaemia National Audit Project (MINAP)
Kings Fund
National Patient Safety Agency - significant event audit.
The NHS information centre
NICE audit implementation tools
Primary Care
Quality Information service Training Programme (NHS
Wales)
Primary Care
Quality Information Service Evidence Based Resource (NHS
Wales)
Royal College of General
Practitioners Essential Knowledge Updates
Royal College of Obstetrics and
Gynaecology
Royal College of
Pathologists
Royal College
of Paediatrics and Child Health
Royal
Pharmaceutical Society of Great Britain
Royal College of Physicians- Clinical standards
Royal College of Psychiatrists -
Quality Improvement, Accreditation and Audit
Royal College of Radiologists
The College of Emergency Medicine, Clinical Effectiveness
Committee
UK Renal Registry
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Clinical Audit Handbooks
The documents listed below introduce clinical audit and provide
definitions and guidance. Please use the links below to view
these documents from the external websites they are hosted on.
Criteria of best practice in clinical audit (Healthcare
Quality Improvement Partnerships, 2009)
Principles for Best Practice in Clinical Audit (National
Institute for Clinical Excellence, 2002)
A Practical Handbook for Clinical Audit (Clinical
Governance Support Team, 2005)
Clinical Audit
(British
Orthoptic Society 2002)
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Good Practice Guidelines
The links below give some examples of good practice guidelines
for clinical audit. Please use the links below to view these
resources.
Cancer in Primary Care – guide to good
practice
Cancer pain in adults –
SIGN guidance
Substance misuse
Sickle cell
Older people's services
NHS evidence
The following selected documents are within the
top 100 hits when using the search term ‘Clinical Audit’.
CG90
Depression in adults (update): audit support 
Clinical practice guidelines. The recognition and assessment of
acute pain in children: audit
Clinical practice guideline: The nursing management of patients
with venous leg ulcers: audit protocol
CG92
Venous thromboembolism - reducing the risk: audit
support
Improving the
assessment risk of violence: a clinical audit of case note
documentation.
Improving services for people with epilepsy: Department of Health
action plan in response to the National Clinical Audit of
epilepsy-related death: summary
National Audit of Oesophago-gastric Cancer
Report
TA130 Rheumatoid arthritis - adalimumab, etanercept and infliximab:
audit support
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Examples of Audits or Tools in Clinical Priority Areas
This page will contain examples of audits or tools in clinical
areas and will be centred around the Clinical Priority areas. This resource is
intended to develop over time, so please check back for updates in
other areas.
Headache
Guidance
and competences for the provision of services using practitioners
with special interests: headache
Guidelines
for all healthcare professionals in the diagnosis and management of
migraine, tension-type, cluster and medication-overuse headache,
3rd edition, 2007
Clinical guidelines for the physiotherapy management of
whiplash-associated disorder (WAD)
Head Injury Update
Emergency Care
Out of Hours Urgent Care Toolkit
Clinical
Audit in Out of Hours Medical Practice, Dr Walter
Scott August 2011
Other Clinical Areas
Cancer
Significant Event Audit: Cancer in Primary
Care
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Examples of IT Tools and Data Extraction Systems
Below are links to organisations with data extraction tools
and systems.
MIQUEST
PRIMIS (University
of Nottingham)
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Hints for audit
Stage One: Preparation and planning
Remember clinical audit is not research –
research is about obtaining new knowledge whereas clinical audit is
about measuring delivery against best practice i.e. existing
knowledge.
- Think carefully about what you would like the
clinical audit to achieve i.e. what do you want to know? What
standards are you going to audit against?
- Why is the clinical audit being done? Is it a priority for the
practice? Was it triggered by a significant event, results
from a patient satisfaction survey, from National Service
Frameworks?
- In choosing the audit topic can it be anticipated that there is
capacity or possibility to implement new changes. If not then
perhaps choose another topic to maintain motivation. However
although the costs of implementing change should be a factor to
consider this should not be at the expense of quality of care.
- What resources will be available to you to do the clinical
audit? Is there support available from the PCT, PBC analyst
etc.?
- Each clinical audit should have a lead who is responsible for
driving the project and liaising with colleagues. Who else will be
involved in the audit i.e. patient, colleagues from the PCT, acute
trust, community services, pharmacists etc.?
- A clinical audit involving multi-disciplinary teams should
clearly describe, from the onset, what the aims and objectives are
for the audit and what is expected from each team member.
Stage Two: Measuring Performance
- There are lots of evidence based
guidelines available which will provide standards for the clinical
audit project. What about systematic reviews, results from
national audits, NICE guidance, NSFs etc.?
- Think carefully about the standards
against which you would want to measure your performance. Standards
are there to ensure patients receive the best quality of
care.
- How are you going to collect the
data? Taking a multi-disciplinary approach will help you with
data collection.
- The sample set needs to be manageable but
representative. The information gathered needs to be informative
yet not overwhelming in volume.
- The data collected can be based on a
retrospective study (looking back through case records) or a
prospective one (assesses current practice).
- Registers are only as powerful as the data
input into the register. Thus collecting data from different
sources is recommended.
- IT systems in general practice run report wizards as well as
software packages such as
MIQUEST.
- However there may be a need to look at
individual case records directly. Record the date of the first data
collection.
- A template to collect the data such as an
excel spreadsheet or tables in Word documents helps in the
systematic collection of data. Piloting the data collector template
and modifying as necessary is worthwhile and saves time in the
long run. Remember that NICE produce clinical audit templates to
support gathering evidence of compliance against NICE
guidelines.
- The data set to be collected must be
manageable and have some value in terms of looking at quality of
care.
- Once the data is collected it needs to be
analysed. Simple statistical concepts such as means and standard
deviations and percentages with graphical illustration with bar
graphs may be powerful enough. Most of the data analysis is likely
to be quantitative (dealing with numerical data). However
qualitative analysis (looking at themes, views and opinions) can be
equally powerful.
Stage Three: Implementing Change
- Once the data has been collected and
analysed an action plan should be developed and implemented. What
are the implications for practice?
- The action plan should be agreed by all
relevant healthcare professionals and
patients.
- What changes need to be made in order to
meet the standards against which performance was
measured?
- Are there any barriers to change? Clinical
audit may highlight organisational and relationship barriers which
need to be addressed.
Stage Four: Sustaining Improvement
- Once the changes have been implemented
allow enough time for them to have an effect. Decide an appropriate
time to re-audit. In the same way that the data collection was done
for the first part of the audit, similarly data will need to be
recollected and analysed on the second collection i.e. the
re-audit.
- How did the re-audit compare with the
first collection? Is there an improvement in care as measured by
the standards attained?
- Writing the clinical audit report and
sharing it is an important part of the process. The report should
contain no patient identifiable information so it can be widely
shared.
- Data confidentiality is important and the
lead auditor should be the guardian of the work. There should be
adherence to the principles of the Data Protection Act
(1998).
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circ@rcgp.org.uk
020 3188 7597