The Clinical Audit Cycle Explained

What is Clinical Audit?

According to the National Institute for Health and Care Excellence (NICE), an audit is described as:

a quality improvement process that  seeks to improve patient care and outcomes through a systematic review against explicit criteria and  the implementation of change.

Essentially, clinical audits are methods of systematically examining, reflecting and implementing change, generally in the clinical environment, to improve patient care. They are an essential pillar of clinical governance.

The Audit Cycle described the six key steps of any clinical audit, which are describes in further detail below:

1. Identifying the issue
2. Setting the standard
3. Collecting data
4. Analysing the data
5. Implementing change
6. Re-audit

Step 1 – Identifying the issue

First we need to identify an issue to audit. These are typically evident in your daily work e.g. patient waiting times or complications following treatment. These are usually issues that we want to look at improving in order to, ultimately, improve patient care.

Step 2 – Setting the standard

Next we need to determine the gold standard we want to compare our data to. This is typically determined in one of two ways:

1. Pre-existing guidelines, evidence or research – There may already be existing literature that you can reference, such as the FGDP guidelines relating to the number of radiographs that have to be an acceptable quality. There may be literature published on clinical procedures or complications, for example a peer-reviewed paper may suggest a complication rate for a procedure at 20%. These figures can then be used as our reference point and standard for the audit.
2. Creation of the standard – Alternatively, we may create an idealistic standard in our minds if there isn’t an existing one to compare to. For example, we may decide that we want 100% of our patients seen on time. These standards are usually driven by a vision we have.

Step 3 – Collecting the data

Once the standard has been determined, we then want to collect the data. There are a few basic things we need to determine at this point:

• What time period are we going to look at? It could be a few weeks, a few months etc
• How much data do we want to collect? Do we want 100 records, 200 etc
• Are we doing the audit retrospectively or prospectively?

In addition, a data collection form is extremely useful to use in an audit. This will cover all the key bits of data you need so it’s easy to log and then eventually to analyse the data you have collected.

Step 4 – Analysing the data

Once we have collected all the data, we then need to compare and analyse the data in comparison to the set standard.

This will then allow us to see if we are exceeding the standard, meeting it or falling short of the standard. If we are falling short, we then need to start considering why. This will then allow us to implement change to help meet the standard.

Team meetings are useful ways to help find reasons why we are failing to meet the standard. A team meeting will also help get everyone involved in the process to meet the standard.

Step 5 – Implementing change

When we have decided on some methods to meet the standard, we want to implement this change in our environment. This may involve changing protocols, techniques or equipment. We need to allow for this change to have an impact before we consider Step 6.

Step 6 – Re-audit

This is the crucial sixth step of an audit which helps close the loop. Without a re-audit, we will never know whether our changes have made any difference and whether we have actually been successful in meeting our standard.

At the re-audit step, we essentially go through all the steps of the audit again to see whether we now meet the standard.

Example of a Clinical Audit

An example of an audit that I have done is looking at the diagnostic quality of biopsies in my department. If I go through each step to breakdown the example.

1. Identify the issue

I noticed that multiple biopsies were being reported as non-diagnostic. This was potentially harming patient care as it meant that we couldn’t confirm a diagnosis and therefore, we couldn’t provide effective treatment. It also meant that patients were undergoing repeat procedures

2. Set the standard

I decided to set my own standard that 100% of biopsies should be diagnostic. I also decided to look at other features of biopsies, e.g. the size, and compare these to the requirements by our local histopathology department.

3. Collect the data

I decided to retrospectively collect 50 patient records and collected data, as below, in a data capture form.

4. Analysing the data

I then compared the data to my standard and drew conclusions, as below. I then presented this in our team meeting and we discussed methods to reduce poor quality biopsies.

5+6. Implementing change and re-audit

We implemented various forms of change and approximately 6 months later, I re-audited the data.

What can we Audit?

Some common examples of audits that could be done in practice:

• Consent processes
• Radiography audit comparing to FGDP guidelines
• Wisdom tooth extraction compared to NICE guidelines
• Procedure complication rates

Why carry out Clinical Audit?

Amongst many reason, the 2 key reasons for auditing include:

• Improving patient care – without carrying out audits, we wouldn’t identify potential issues with treatment and care. Through auditing, we are able to identify these and improve outcomes for patients
• They are a crucial part of training programmes e.g. specialty training

Summary

• Clinical audits are a crucial aspect of clinical governance and aim to improve patient care.
• Clinical audits are divided in to six key steps
• One of the most important parts of an audit is to re-audit to assess change

Recommended Reading

• Principles for Best Practice in Clinical Audit
• The Clinical Audit Handbook