Re-audit Plan Template: A Structured Approach to Demonstrating Improvement

Why this topic matters

Clinical audit is a cyclical process encompassing reviewing current practice against standards, implementing changes, and then re-evaluating practice to confirm improvement or identify further areas for action. Neglecting the re-audit step breaks this cycle, leaving questions about the impact of any interventions made. For healthcare professionals, particularly trainees and junior doctors, successfully completing a re-audit demonstrates a commitment to quality improvement and the ability to drive positive change in patient care.

Demonstrating sustained improvement is crucial for NHS organisations facing increasing pressures and scrutiny. Re-audits provide tangible evidence of effective interventions, support CQC compliance, and inform strategic decisions. They help ensure that efforts to improve care translate into measurable benefits for patients and more efficient services.

Practical explanation: What makes a good re-audit plan?

A strong re-audit plan builds directly on the findings and insights of the initial audit. It is not just a repeat of the first audit but a focused effort to assess the impact of specific changes. Key elements include:

• Clear link to initial audit findings: Explicitly state the original audit's deficiencies and the chosen interventions.
• Defined interventions: Precisely describe the changes implemented since the first audit. This could be a new guideline, staff training, a process redesign, or updated equipment.
• Methodological consistency: The re-audit methodology (e.g., data collection tools, sample size, exclusion criteria) should ideally mirror the original audit to allow for direct comparison. Any deviations must be justified and documented.
• Specific, measurable outcomes: What specific aspects are being measured to demonstrate improvement? These should align with the initial audit standards.
• Timeline and responsibilities: A clear schedule for data collection, analysis, and reporting, with assigned roles.
• Anticipated results and next steps: What do you expect to find, and what actions will be considered if the re-audit shows improvement, no change, or deterioration?

Common pitfalls

Even with the best intentions, re-audits can fall short. Being aware of common pitfalls can help teams avoid them:

• Lack of defined intervention: Re-auditing without having clearly implemented specific changes since the first audit makes it impossible to attribute any observed differences to purposeful action.
• Inconsistent methodology: Changing data collection methods, sampling frames, or definitions between audit cycles can render comparisons invalid or misleading.
• Insufficient time between audits: Implementing changes and allowing them to embed takes time. Re-auditing too soon may not capture the full impact of an intervention.
• Poor communication: Failing to engage staff in the change process or explain the purpose of the re-audit can lead to Resistance or incomplete data collection.
• Scope creep: Trying to address too many issues or introduce new standards into the re-audit that weren't part of the original focus can dilute its effectiveness.
• No plan for 'next steps': A re-audit should lead to further action, whether that's sustaining improvement, refining interventions, or identifying new areas for audit. Without this, the cycle is incomplete.

Step-by-step approach to planning a re-audit

This template provides a structured format, but here’s how to logically work through the planning process:

Step 1: Review the original audit

Retrieve your initial audit report. Understand its findings, recommendations, and the standards against which practice was measured. Identify the specific areas that required improvement.

Step 2: Document implemented interventions

Clearly list what changes have been put in place since the original audit. Be specific about what was done, when it was done, and who was involved. For example, 'New antimicrobial prescribing guideline launched on 01/01/2023, accompanied by mandatory trust-wide e-learning, with clinical lead sign-off at weekly ward rounds.'

Step 3: Define re-audit objectives

Based on your interventions, what do you specifically hope to achieve with this re-audit? Your objectives should directly relate to assessing the impact of your changes, e.g., 'To determine if adherence to the new antimicrobial prescribing guideline has improved from 60% (original audit) to 85% by June 2024.'

Step 4: Confirm methodology

• Standards/criteria: Re-state the exact standards used in the original audit. These should remain consistent.
• Target population/sample size: Define the patient group or records to be included. Aim for the same sample size and sampling method as the original audit for comparability, or justify any changes.
• Data collection: Use the same data collection tool/form as the original audit. Specify who will collect the data and over what period.
• Exclusion criteria: Re-state any exclusion criteria from the original audit.

Step 5: Establish timeline and resources

Set realistic start and end dates for data collection and analysis. Identify who is responsible for each task and what resources (e.g., access to patient records, statistical support) are needed.

Step 6: Plan for analysis and reporting

Outline how the data will be analysed (e.g., descriptive statistics, comparison tests). Consider how the findings will be presented to ensure clarity and impact, focusing on the comparison with the original audit findings.

Step 7: Outline next steps

Pre-emptively consider what actions you will take based on potential re-audit outcomes. If improvement is seen, how will it be sustained? If not, what further interventions or investigations are needed?

Example in clinical practice

Imagine an initial audit on documentation of VTE (Venous Thromboembolism) prophylaxis risk assessment on a busy surgical ward found only 55% compliance against a trust standard of 95%. Recommendations included mandatory refresher training for all nursing staff and a simplified electronic VTE assessment form. After three months, the team decided to re-audit.

Their re-audit plan would precisely detail the new training program (dates, attendance records), the new electronic form (launch date, user feedback), and then outline that the same 100 patient notes would be reviewed systematically to assess compliance against the same 95% standard. They would compare the new compliance rate directly to the previous 55% and consider further interventions if improvement was insufficient, or share the success widely if compliance had markedly increased.

How Lazomis can help

Lazomis provides a structured environment that can significantly streamline your re-audit process. Our QI Project Setup tool allows you to link re-audits directly to initial audit projects, ensuring continuity and easy access to historical data and documentation. The platform supports robust data collection, helping to maintain methodological consistency between audit cycles. You can input your standards, define data fields, and collect information efficiently.

Furthermore, Lazomis Dashboards and Reporting features enable you to visualise comparative data from your original and re-audit cycles, making it straightforward to demonstrate improvement and generate presentation-ready reports. This reduces time spent on manual analysis and enhances the clarity of your findings for stakeholders and governance committees. The system also supports assigning tasks and tracking progress, ensuring accountability throughout the re-audit process.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.

Re-audit Plan Template

RE-AUDIT PLAN: [Insert Project Title, e.g., Re-audit of VTE Prophylaxis Risk Assessment Documentation]

1. Original Audit Details

• Original Audit Title: [e.g., Audit of VTE Prophylaxis Risk Assessment Documentation]
• Original Audit Date/Period: [e.g., October 2023]
• Key Findings/Deficiencies: [Summarise the main issues identified by the original audit. e.g., 55% compliance with VTE risk assessment documentation against a 95% standard.]
• Original Audit Recommendations: [List the actions recommended after the original audit. e.g., Mandatory refresher training for nursing staff; Implementation of simplified electronic VTE assessment form.]

2. Interventions Implemented Since Original Audit

• Intervention 1: [Describe the intervention, date implemented, and who delivered it. e.g., Mandatory VTE prophylaxis risk assessment training for all ward nurses. Training modules delivered on 15/01/2024 and 22/01/2024 by Lead Thrombosis Nurse. All 25 staff completed.]
• Intervention 2: [Describe the intervention, date implemented, and who delivered it. e.g., New simplified electronic VTE assessment form launched on 01/02/2024. Developed by digital health team in consultation with surgical and thrombosis leads, with user guidance provided to all staff.]
• Other Interventions (if applicable): [List any other relevant changes.]

3. Re-audit Objectives

• Primary Objective: [What is the main question this re-audit aims to answer? e.g., To assess if the compliance rate of VTE prophylaxis risk assessment documentation has improved following the implementation of training and the new electronic form.]
• Secondary Objective (if applicable): [e.g., To identify any new barriers to effective VTE risk assessment documentation.]

4. Re-audit Methodology

• Audit Standards/Criteria: [List the exact standards/criteria used in the original audit. These should be identical. e.g., NICE Guideline NG89: Venous thromboembolism in over 16s: reducing the risk of VTE in hospital. Specifically, 'All adult inpatients should have a VTE risk assessment documented on admission and within 24 hours of admission.']
• Target Population: [Define the patient group or records to be included, consistent with the original audit. e.g., All adult inpatients admitted to Ward X under surgical care during the data collection period.]
• Sample Size: [State the number of cases to be reviewed. Aim for consistency with the original audit. e.g., 100 consecutive patient records.]
• Sampling Method: [How cases will be selected. e.g., Consecutive admissions from date X, or random selection using a departmental code list.]
• Data Collection Tool: [Specify the tool. Crucially, this should be the same as the original audit. e.g., Original audit data collection proforma (attached).]
• Data Collection Period: [Define the start and end dates. Ensure sufficient time has passed since interventions were implemented. e.g., 1st April 2024 – 30th April 2024.]
• Data Collector(s): [Who will collect the data? e.g., Dr. A. Smith, Junior Doctor, Ward X.]
• Exclusion Criteria: [State any cases to be excluded, consistent with the original audit. e.g., Patients admitted for less than 24 hours; patients with existing VTE on admission.]

5. Timeline and Responsibilities

• Task: | Responsible Person: | Start Date: | End Date:
• Data Collection | Dr. A. Smith | 01/04/2024 | 30/04/2024
• Data Analysis | Dr. A. Smith, QI Lead | 01/05/2024 | 14/05/2024
• Report Drafting | Dr. A. Smith | 15/05/2024 | 31/05/2024
• Report Review/Feedback | QI Lead | 01/06/2024 | 07/06/2024
• Dissemination | Dr. A. Smith | 10/06/2024 | 14/06/2024

6. Data Analysis and Reporting Plan

• Analysis Methods: [How will the data be analysed and compared? e.g., Descriptive statistics (percentages) for compliance rates, direct comparison to original audit findings. Qualitative review of free-text comments for new barriers.]
• Reporting: [How and to whom will the findings be disseminated? e.g., Presentation at monthly ward meeting, email to departmental consultants, submission to Trust Audit Committee, inclusion in Lazomis dashboard.]

7. Anticipated Results and Next Steps

• Anticipated Outcome: [What do you expect to find? e.g., Compliance rate of VTE documentation to exceed 80%, demonstrating improvement from 55%.]
• If Improvement is Seen: [What actions will be taken? e.g., Maintain current interventions, disseminate good practice, monitor compliance longitudinally, consider extending interventions to other wards.]
• If No Change/Deterioration: [What actions will be taken? e.g., Review effectiveness of interventions, identify new barriers (e.g., through staff interviews), further training, root cause analysis, develop new interventions, plan further re-audit.]

8. Governance and Approval

• Approving Body: [e.g., Departmental Audit Lead, Trust Audit Committee]
• Date of Approval: [Date]
• Signed Off By: [Name and Role]

9. Appendices (if applicable)

• Original Audit Report
• Data Collection Proforma (for re-audit)
• Copies of new guidelines/educational materials

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