Audit

 

What is an audit?

An audit is an investigation into whether or not an activity meets explicit standards. It consists of reviewing and monitoring current practice and evaluating against agreed predefined objectives or standards. Audits are directed at the maintenance and achievement of quality in health care. In theory, they should encourage a reflective culture of reviewing current practice. An audit is a cycle of standards. It measures practice against standards and implements change. Audits are different to 'Clinical Governance', though they may form part of the activities performed by clinical governance teams. Clinical governance is the means by which an organisation ensures provision of quality clinical care by making individuals accountable for setting, maintaining and monitoring performance standards.

There is a danger that an audit ends up focusing on the process rather than the outcomes. This is not difficult to understand as process is what staff are involved in and is important to them. Often, an audit may end up focusing on comparing the procedure to published expert advice and ignore the impact upon the patients' health.

Stages of an Audit

People often refer to an audit as an 'audit cycle'. This can be displayed as one circle or a figure of eight representing two cycles of an audit. Either way, the stages are the same and consist of the following:

  1. Measure baseline
  2. Set standards
  3. Measure practice
  4. Compare against standards
  5. Identify opportunity for improvement
  6. Suggest change
  7. Implement change
  8. Evaluate change
  9. Review standards

Aims

1. To improve patient outcome

2. To have more cost-effective use of resources

3. To have an educational function for health professionals

Methods

A number of different methods can be used depending on the purpose of the audit. The key issue is that the design of audits should be scientifically and methodologically rigorous. Methods can include document searching and analysis (for example, random or systematic reviewing of patient records to uncover the numbers of patients prescribed a certain type of drug). Analysis of routine data, medical and nursing records, clinical case review or presentations in team meetings have all been used in audits. People refer to their method as their 'audit tool'. Sometimes, this tool can be a specifically designed questionnaire to capture if practice is matching predefined policy standards (for example, a questionnaire could be used to see if the information supplied by midwives to pregnant women matches the guidelines of the Trust or it could be used to see if every patient follows the advocated care pathway). Focus groups are also an appropriate method, especially to collect users' or patients' views of services, for example patient satisfaction or for patient assessed outcome. Focus groups are often used to audit the effects of health promotion campaigns. While the outcomes of health promotion are long term, focus groups nevertheless can be useful in capturing the immediate impact on the intended audience. Information from the focus groups can then be fed into the health promotion campaign and help improve the communication of its message(s) and the mediums utilised to reach the audience.

Types of Audits

Audits can be divided into medical and clinical audits. Both are related to quality assurance.

1. Medical Audit is confined to what doctors do, for example diagnosis and clinical decisions about treatment. It is the systematic critical analysis of the quality of medical care.

2. Clinical Audit is similar to a medical audit but refers to the whole team working on a speciality. It includes the clinical care done by doctors and other health professionals. It includes the collection of data or information to review diagnosis and the procedures or policies for diagnosis, clinical decision making and use of resources. This type of audit aims to improve health outcomes for patients by improving clinical outcomes. It is supported by Primary Care Trusts. There can be some problems inherent with this type of audit, namely, doctors initially suspected managerial inference and practices found it increasingly difficult to find time for what remains a voluntary and unpaid activity.

3. Quality Assurance involves systematic monitoring and evaluation of predefined and agreed service provision. It is a clinical and managerial approach. It can incorporate both medical and clinical audits and it is all about improving patient status. Quality assurance is the definition of standards, the measurement of their achievement and the mechanisms employed to improve performance.

Criteria for Conducting an Audit

  • The issue addressed should be a common, serious or important problem
  • Any changes following the audit should be of benefit to the patients or users of the services
  • Any changes following the audit should lead to a more effective and efficient service
  • The issue should be relevant to the professional practice or development
  • There is the potential for improvement
  • The end result should justify the time and effort that the audit investigators invested into the audit

Requirements of a Successful Audit

  • Effective clinical leadership
  • Audit staff and support
  • Training and education
  • Understanding and involvement
  • Organisation environment
  • Structure and system

Further reading

Bowling, A. Research Methods in Health, 2nd Edition. Open University Press, 2002.

Student BMJ. Clinical Audits Made Easy. Access online.

National Institute for Clinical Excellance. Principles for best practice in clinical audit. London, 2002.