Clinical audit: a guide

Clinical audit: a guide All nurses are expected to take part in clinical audits. Stephen Ashmore and Tracy Ruthven explain how it should be done HEALTHCARE PROFESSIONALS across the NHS are being encouraged to take part in clinical audits. In the inquiry report into the management of children undergoing cardiac surgery at Bristol Royal Infirmary (Department of Health 2002) for example, chair of the Healthcare Commission Sir Ian Kennedy recommended that clinical audit should be fully supported by trusts and should be compulsory for all healthcare professionals. In addition, the government s Standards for Better Health (DH 2004) has charged all healthcare organisations with ensuring that clinicians participate in regular clinical audit. As these documents make clear, if clinical audit is used appropriately and simply, it can be an effective quality improvement tool. But clinical audits are often poorly carried out and consequently have minimal effect on improving patient care. Jamtvedt et al (2003) for example find that the effects of audit are generally small to moderate. The National Audit Office (2007) makes clear moreover that, although healthcare professionals are expected to participate in clinical audit, they often poorly understand the methodology and techniques involved, possibly due to a lack of good training and support. With the expectations of clinical audit being so high but the consequences of carrying them out badly being so serious, now is a good time to learn about the technique. This article therefore offers a brief history of clinical audits, with an account of recent attempts to update them. It also describes how clinical audit works and offers some practical tips on implementing them locally. Brief history Some historians suggest that the first laws promulgated by King Hammurabi of Babylon in 1750BC, which became the first written legal code, constitute the first audit in history. Florence Nightingale is usually credited with having undertaken the first known clinical audit while collecting data on soldiers in battle hospitals during the Crimean War in an attempt to reduce their mortality rate. Initially known as medical audit, clinical audit was not formalised until the publication of the white paper, Working for Patients (Secretaries of State for Health: Wales, Northern Ireland and Scotland 1989). Although healthcare professionals were quickly encouraged to participate in it, it is still regarded by many as a new approach to quality assurance in the UK. More recent attempts to revitalise clinical audit have also been made. A report by the chief medical officer for England, Good Doctors, Safer Patients (DH 2006), for example, suggests that healthcare regulators such as the Nursing and Midwifery Council should consider more closely their role in the revalidation of healthcare professionals. Then, in January this year, the DH announced that the National Clinical Audit and Patient s Outcomes Programme will be run by a new consortium, called the Healthcare Quality Improvement Partnership (NHS Networks 2008). This new organisation comprises the RCN, the Academy of Medical Royal Colleges and the Long-Term Conditions Alliance. NHS medical director Sir Bruce Keogh welcomed the new approach, stating: The consortium will understand both the clinical context and implications of the audits thereby maximising the opportunity for real improvement. RCN director of nursing and service delivery Janet Davies said the college was delighted to be involved in a coalition of organisations with such a commitment to quality healthcare. She continued: This partnership will bring together patient and staff groups at every level of the NHS to engender debate and positive outcomes for patients, staff and the health services as a whole. 18 Vol 15 No 1 April 2008 NM1501 18-22 ftr083.indd 18 20/3/08 2:57:27 pm

Before embarking on clinical audit projects, nurses must understand fully what they entail. If they lack such an understanding, the quality of their projects may suffer. There are many definitions of clinical audit but probably the most widely accepted is as follows: A quality improvement process that seeks to improve patient care and outcomes through systematic review against explicit criteria and the implementation of change (National Institute for Health and Clinical Excellence 2002). In simple terms, this means that audit involves finding out if working methods are correct. In the clinical arena, audit means identifying shortfalls in levels of care. Clinical audit shares some of its key characteristics with clinical research. Both are systematic processes that involve statistical analysis and topic selection, and both can lead to changes in clinical and non-clinical practice that improve patient care. Unsurprisingly therefore, many healthcare professionals struggle to understand the difference between them. Yet there is a clear difference. Research can be defined as an attempt to derive generalisable, new knowledge by addressing clearly defined questions with systematic and rigorous methods (Copeland 2005). Thus, clinical research is an investigation into what happens if clinical services are changed, and the results can indicate for example which drugs or therapies work best. By contrast, clinical audit is an investigation into whether best practice, as defined by clinical research, is being implemented. The general rule of thumb when collecting data is, if best practice is not already known, the data is almost certainly intended for clinical research, not clinical audit. KROPFKD J>K>DBJBKQ Vol 15 No 1 April 2008 NM1501 18-22 ftr083.indd 19 SuperStock CB>QROB 19 20/3/08 2:58:23 pm

Figure 1. The audit cycle 8 Write and disseminate an audit report 1Select audit topic 2Identify best practice 7Conduct re-audit 3Agree criteria and standards 6 Implement the necessary changes 5Analyse the data 4Collect the data Adapted from the Clinical Audit Support Centre (2007) In clinical audit, a systematic process, known as a clinical audit cycle or spiral is followed. Clinical audit cycles should be understood as project plans or guides; if they are followed correctly, audits should succeed. They can take different forms, some of them more complicated than others, but perhaps the most practical and useful of them is the eight-stage version from the Clinical Audit Support Centre (2007) (Figure 1). Stage 1. Select audit topic There are many ways to determine which audit to undertake. For example, employers may ask employees to take part in national audit projects or to audit national documents such as guidelines produced by the National Institute for Health and Clinical Excellence. Those who want to undertake local audit projects can regard them as part of quality improvement processes by focusing on practices that should be improved or where current standards of performance are uncertain. A selection of potential topics is shown in Table 1. Once a topic is selected, the audit s feasibility should be assessed using a tool such as the scoring grid shown in Table 2 (Baker et al 1998). Stage 2. Identify best practice The next step is to identify what aspects of best practice should be included in the audit. Local and national guidelines, national service frameworks and research papers can help determine what is considered best practice. Stage 3. Agree criteria and standards Use of the terms criteria and standards in clinical audit is often misunderstood. Criteria are statements that define good practice in the aspects of care under examination. 20 Vol 15 No 1 April 2008 NM1501 18-22 ftr083.indd 20 20/3/08 2:58:25 pm

Table 1. Potential topics for audit Patient or general complaints Poor patient care or compliance Issues involving patient safety or significant events Systems that are unused or ineffective Poor documentation Missing data Areas where delays occur National guidance Administration of drugs An example of a criterion in non-clinical audit is the Royal Mail criterion that, within the UK, first class letters should reach their destination within 24 hours (Royal Mail 2008). Standards meanwhile are the expected levels of success, usually written as percentages. Thus, the Royal Mail criterion described above becomes the standard that 93 per cent of first class letters should reach their destination within 24 hours. Similarly, the NHS criterion that written patient records should be recorded in black ink becomes the standard that 100 per cent of written patient records should be recorded in black ink. Stage 4. Collect the data The purpose of data collection is to determine whether, in the practice undergoing audit, the agreed criteria and standards are being achieved. The data collected must be relevant, accurate and representative. Most audit data are collected using either manual data collection forms or recorded using electronic computer software such as the Microsoft applications, Excel and Access. Stage 5. Analyse the data Data analysis involves interpreting collected audit data to discover how current practice compares to agreed criteria and standards. It identifies areas both of underperformance, which should be reviewed in detail to identify why care falls below the desired levels and how it can be improved, and of overperformance. Stage 6. Implement the necessary changes Implementing changes that will improve poor results is often the hardest part of any audit project. All team members should be involved in discussions about what changes should take place so that all possible solutions are explored. These changes invariably depend on the specific circumstances of the audit, but often include staff training, the introduction of better systems of practice, or new protocols and guidelines. Stage 7. Conduct re-audit Re-audit is another key part of the audit cycle, which should be carried out within a year of implementing change. Re-audit involves collecting a second set of data to review Table 2. Audit feasibility scoring grid Does the audit address a problem that is relevant to patient care? Is the topic a priority for the team or organisation? Can data be collected quickly, ideally in less than a month? Is there confidence that the data will be reliable and accurate? Could changes recommended as a result of the audit be implemented? Scoring progress after the changes have been implemented to identify whether further improvement is needed. The numbers audited should be comparable to those from the first data collection phase. Stage 8. Write and disseminate an audit report This, the final stage of the audit cycle, is intended to create a record for the auditor, the team and the organisation involved. This report should be shared also with colleagues who have taken part in the work so they can see what effects the audit has had on their practice. Sharing audit reports widely also helps those who want to conduct clinical audit using the same methodology. Conclusion Healthcare professionals in the UK are expected to use clinical audit techniques to ensure that their work is of the highest calibre. Recent national developments indicate that nurses are expected to take part in clinical audits at national, regional and local levels, and so must understand how to do so successfully. Further information can be gathered from the sources listed in Table 3 In answering the questions, award two points for a Yes, one point for a Not Sure and no points for a No. Audits that score five or less are unlikely to succeed, those that score six or seven are worth considering, and those that score eight or more will usually succeed Adapted from Baker et al (1998) Vol 15 No 1 April 2008 21 NM1501 18-22 ftr083.indd 21 20/3/08 2:58:30 pm

istock Ten tips for successful audits 1. Start small Clinical audit projects often fail because staff try to collect too much information. They should be viewed as snapshots of current practice and workload should be kept to a minimum. 2. Involve team members Audit is most effective when it is carried out by teams. All staff should be asked to suggest suitable topics and told about results. One team member should co-ordinate each audit but other team members should be involved. 3. Distinguish between research and clinical audit Remember that research is undertaken to find out what best practice should be; audit is undertaken to find out whether best practice is taking place. 4. Learn from others Completed projects, which can be found by carrying out simple internet searches or by discussing them with peers, can often be adapted for new ones. 5. Select audit topics that relate to current work Nurses collect information in many formats, often routinely, and opportunities to link audits to such work can arise. Table 3. Useful websites and resources The RCN offers ideas on topics for audit at www.rcn.org.uk For advice on how to conduct clinical audits, email: qip.hq@rcn.org.uk The Clinical Audit Support Centre offers a range of accredited clinical audit training packages at www.clinicalauditsupport.com The NHS Library offers details of previous audit projects and examples of best practice at www.library.nhs.uk 6. Gather support Local support for clinical audit varies but some trusts have audit teams. 7. Plan audits properly Simple audit calendars, which are used to map out audit activities over the course of a year for example, are useful. 8. Pilot audits A small number of data collection forms should be tested to make sure that they provide all the information that is required. 9. Re-audit is vital Without undertaking re-audit, there is no way of knowing if the changes made have improved patient care or service delivery. 10. Get the most out of clinical audit Although audit is essentially about identifying weaknesses and improving patient care, it can also be used for example to improve teamwork or communication. References Baker R, Fraser RC, Lakhani M (1998) Evidence Based Audit in General Practice. Butterworth-Heinemann, Oxford. Clinical Audit Support Centre (2007) What Is Clinical Audit? www. clinicalauditsupport.com/what_is_clinical_ audit.html (Last accessed March 17 2008). Copeland G (2005) A Practical Handbook for Clinical Audit. NHS Clinical Governance Support Team. www. cgsupport.nhs.uk/downloads/practical_ Clinical_Audit_Handbook_v1_1.pdf (Last accessed March 10 2008). Department of Health (2002) Learning from Bristol. www.dh.gov.uk/en/ 4002859 (Last accessed March 10 2008). Department of Health (2004) Standards for Better Health. www.dh.gov.uk/en/ 4086665 (Last accessed March 10 2008). Department of Health (2006) Good Doctors, Safer Patients. www.dh.gov.uk/en/ 4137232 (Last accessed March 10 2008). Jamtvedt G, Young JM, Kristoffersen DT, O Brien MA, Oxman AD (2003) Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews. 1. National Audit Office (2007) Improving Quality and Safety Progress in Implementing Clinical Governance in Primary Care: Lessons for the new primary care trusts. The Stationery Office, London. NHS Networks (2008) New Arrangements for Clinical Audit. www.networks.nhs. uk/news.php?nid=2051 (Last accessed March 10 2008). National Institute for Health and Clinical Excellence (2002) Principles for Best Practice in Clinical Audit. Radcliffe Medical Press, Abingdon. Royal Mail (2008) Delivery Options: UK. www.royalmail.com/portal/rm/jump1? catid=400023&mediaid=400028&keyname =ssm (Last accessed March 12 2008) Secretaries of State for Health: Wales, Northern Ireland and Scotland (1989) Working for Patients. The Stationery Office, London. 22 Vol 15 No 1 April 2008 NM1501 18-22 ftr083.indd 22 20/3/08 2:58:40 pm