What is Clinical Audit? A Practical Guide for UK Clinicians

Introduction

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. The core principle is that clinical practice should be evidence-based and reflect best practice, and that regular review helps ensure this remains the case. It is distinct from research, service evaluation, and quality improvement activities, though they share common goals and methodologies.

Why this topic matters

Clinical audit is integral to clinical governance, professional development, and maintaining high standards of care across the NHS. For junior doctors and trainees, it is often a mandatory requirement for revalidation and career progression, demonstrating a commitment to improving services. For established clinicians and QI leads, it provides a structured framework to identify areas for improvement, implement change, and measure the impact of those changes.

Effective clinical audits can:

• Improve patient safety and outcomes: By identifying and addressing discrepancies between current practice and best practice.
• Enhance service efficiency: Streamlining processes and reducing waste.
• Ensure compliance: With national guidelines, standards (e.g., NICE, Royal Colleges), and commissioning requirements.
• Promote professional development: By fostering critical appraisal skills, project management, and collaborative working.
• Inform policy and practice: Generating local data that can contribute to wider understanding and guideline development.

Practical explanation: The Audit Cycle

Clinical audit is often described as a cyclical process, commonly referred to as the 'audit cycle'. This iterative approach allows for continuous improvement and reassessment.

The Audit Cycle Stages

1. Identify the topic (Plan): Select an area of clinical practice to audit. This should be relevant to your service, have potential for improvement, and ideally link to national guidelines or local priorities. Consider areas with variation in practice, high risk, high volume, or high cost.

2. Define criteria and standards (Plan): Establish clear, measurable criteria against which current practice will be assessed. Criteria are specific statements of good practice, and standards are the measurable levels of achievement that should be attained for each criterion (e.g., '100% of patients with X condition should have Y investigation within 24 hours'). These are usually derived from national guidelines (e.g., NICE), professional body recommendations, or local protocols.

3. Collect data (Do): Systematically gather information about current practice. This must be done ethically, respecting patient confidentiality and adhering to local information governance policies. Data sources might include patient notes, electronic patient records, databases, or surveys. Ensure the sample size is appropriate and representative.

4. Compare performance with standards (Study): Analyse the collected data and compare your current practice against the pre-defined standards. Identify any gaps or shortfalls. This stage often involves statistical analysis, even if simple descriptive statistics.

5. Implement change (Act): Based on the findings, develop and implement an action plan to address any deficiencies. This might involve updating protocols, delivering training, improving communication pathways, or re-designing processes. Involve relevant stakeholders in developing these actions.

6. Re-audit (Iterate): After a suitable period, re-audit the same area using the same criteria and methodology to assess whether the implemented changes have led to the desired improvements. This closes the loop and is crucial for demonstrating the impact of your work.

Common pitfalls

Even with a clear cycle, certain challenges frequently arise in clinical audit projects:

• Lack of clear objectives: Starting an audit without well-defined questions or measurable standards.
• Poor data collection methods: Inconsistent data collection, inappropriate sample sizes, or issues with data accuracy and completeness.
• Ambiguous standards: Using standards that are not specific, measurable, achievable, relevant, and time-bound (SMART).
• Failure to implement change: Identifying issues but not developing or acting on an action plan.
• Skipping the re-audit: Not closing the loop to verify if changes have been effective, making the initial audit less impactful.
• Information governance breaches: Not securing appropriate approvals or handling patient data inappropriately.
• Working in isolation: Failing to engage key stakeholders, leading to resistance to change or impractical solutions.

Step-by-step approach to conducting a clinical audit

1. Project Initiation

• Identify a topic: Choose an area where you suspect there is room for improvement, or where national guidance suggests. Discuss with your supervisor or colleagues.
• Consult locally: Speak with your clinical audit department or governance lead early. They can advise on local processes, approvals (e.g., ethical review exemption for audit), and available resources.
• Formulate a question: What specifically are you trying to find out or improve?

2. Planning and Preparation

• Define criteria and standards: Use published guidelines (NICE, Royal Colleges) or local protocols. Be precise.
• Methodology: Determine your data sources, sample size, and data collection tools (e.g., a proforma). Ensure you have access to the data needed.
• Info Governance (IG): Obtain necessary approvals for data collection and processing as advised by your local audit department. This often means completing a project registration form and adhering to local data protection policies.
• Timeline: Set realistic deadlines for each stage.

3. Data Collection

• Systematic approach: Collect data consistently from all identified sources. Ensure anonymisation or pseudonymisation where appropriate.
• Quality control: Regularly check for data accuracy and completeness.

4. Analysis and Comparison

• Clean data: Prepare your data for analysis (e.g., using a spreadsheet).
• Measure against standards: Calculate percentages or other metrics to show current performance versus your set standards.
• Identify gaps: Clearly articulate where performance falls short and by how much.

5. Action Planning

• Disseminate findings: Present your results to relevant stakeholders (e.g., department meeting, governance forum).
• Collaborate on actions: Work with colleagues and managers to develop specific, actionable recommendations. Consider barriers to change.
• Assign responsibilities: Who will do what, and by when?

6. Re-audit and Sustained Improvement

• Implement changes: Ensure the agreed actions are put into practice.
• Plan the re-audit: Schedule a timeframe for the re-audit (e.g., 6-12 months later) to allow changes to embed.
• Evaluate impact: Conduct the re-audit and compare results to the initial audit. Did the changes lead to an improvement?
• Further action/monitoring: If standards are met, consider ongoing monitoring. If not, further actions or a new audit cycle may be needed.

Example in clinical practice: Management of Sepsis in an Admission Unit

Background: National guidelines (e.g., NICE, Sepsis Trust) recommend early identification and management of sepsis with a 'Sepsis Six' bundle within one hour of recognition.

Audit Cycle in Practice:

1. Identify topic: Compliance with Sepsis Six bundle completion for patients admitted to the Acute Medical Unit (AMU).
2. Criteria and standards: All patients identified with sepsis on AMU should have documentation of Sepsis Six completion within one hour of recognition (Standard: 90%).
3. Data collection: Retrospective review of 50 patient records admitted to AMU with a diagnosis of sepsis over 3 months. Data points include time of sepsis recognition, time of Sepsis Six components commenced/completed.
4. Compare performance: Analysis reveals only 65% of patients had complete Sepsis Six within one hour, with fluid resuscitation and lactate measurement being the most common omissions.
5. Implement change:
   • Introduce weekly teaching sessions for junior doctors and nurses on sepsis recognition and Sepsis Six completion.
   • Place prominent Sepsis Six posters in AMU clinical areas.
   • Work with IT to update the electronic patient record with clearer prompts for Sepsis Six documentation.
   • Designate a 'Sepsis Champion' nurse for each shift.
6. Re-audit: After 6 months, conduct a re-audit of 50 new sepsis patients. The re-audit shows compliance has increased to 88%, demonstrating significant improvement, though not yet meeting the 90% standard. This suggests further refinement of interventions or ongoing monitoring is needed.

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

How Lazomis can help

Lazomis offers structured tools that can significantly streamline the clinical audit process. Our templates guide you through defining your project, setting clear criteria, and outlining data collection strategies. The platform's secure data entry features can help ensure data accuracy and compliance with information governance principles. Lazomis dashboards can then assist in visualising your results, making it easier to compare performance against standards and identify areas for action planning. For re-audits, Lazomis simplifies tracking progress and demonstrating the impact of your improvement efforts over time, ensuring your projects are robust and contribute effectively to patient care.