Clinical Audit

An audit is a process that aims to improve the quality of patient care by examining current practice and modifying it where necessary. This is done by assessing how patients are managed in comparison to local or national standards. A good audit will identify any problems in patient care and lead to effective changes that result in sustained quality improvement.

What is an Audit Cycle?

What standards do you use?

Standards of care can be found using national or local guidelines such as NICE guidelines or a departmental Wiesegram. The Royal College of Emergency Medicine also publishes care standards for certain conditions on its website.

What if there aren't any guidelines?

Not all clinical conditions have specific guidelines that will be relevant to patient care in the Emergency Department. There are two options in this instance. The first is to define local standards of care based on ‘gut feeling’, which can be difficult. The second is to complete the audit as a service evaluation. This means that there may be no defined standards. An example of a service evaluation could be, ‘Does having an individual patient care plan in patients who present to the Emergency Department frequently reduce the frequency of them attending?’. A service evaluation is a type of research and can be used to set future audit standards.

Are there any problems with Clinical Audit?

The short answer is yes. Clinical audit is very good at revealing where care may be substandard. It doesn’t give you an insight into why this is the case. This can mean that it can be difficult to know how best to implement change that will have a positive effect on patient care in the long term.

Clinical audit tends to take longer than you think it’s going to. Often trainees who perform the first part of the audit cycle move on to other jobs and never follow up on their results.

How do I run an Audit?

Find a suitable topic

Ideally, you should choose an audit from the list of departmental audits that are currently up for grabs. Some of these may be re-audits that allow us to close the audit cycle. You may have a topic that you are interesting in because it is relevant to your chosen career or because you have had a specific patient experience that has made you question the quality of care delivered. You should discuss these ideas with your supervisor or the department’s audit lead to make sure that the department would be willing and able to support your project.

The Royal College of Emergency Medicine publishes quality standards and guidelines that lend themselves easily to audit and it also conducts three audits per year on a national level that you can get involved with.

Plan your audit

Once you’ve chosen your topic, you need to think about which patients you want to examine. Think about the diagnosis they may have been coded with, what age group is relevant and what time frame you want to look at. Generally speaking, you should audit a minimum of 30 patients. It is possible to audit both retrospectively and prospectively.

When it comes to comparing the patient’s care against the set standards, it’s best to audit using only a few standards. For example, the NICE head injury guidelines have standards of care related to every step of the patient’s journey. Your project needs to be achievable, so try applying the most relevant standards to your patient group, for example the criteria for performing a CT head scan within one hour. You should express what percentage of patients should meet the standards and whether it is acceptable for there to be any exceptions.

Once you have an idea of how you are going to go about doing your audit, you should complete an audit planner. The supervisor of your project will either be a consultant with a specific interest in your project or your educational or clinical supervisor. Show your audit planner to your supervisor and then submit it to the departmental audit lead for approval. This will ensure that your project gets registered with the trust audit team.

Design your pro forma

Once you have submitted your planner, you must design your data collection pro forma. This can be done directly using an Excel spreadsheet or you can do a paper version and then transfer the data onto Excel at a later date. Only collect data that is directly relevant to your audit to prevent data overload. When you have your case notes, it is worth piloting your pro forma with a sample of 5-10 notes first to ensure that you are capturing the data you want.

Obtain your sample

The admin team can obtain a list of the ED notes you require by using a programme called business objects that interrogates EDIS. It is important that you provide the admin team with very specific search criteria to ensure that you get the correct cohort for your audit. You need to be specific regarding the coded diagnosis, age range and time range. The admin team will only search for audits that have been approved by the department’s audit lead.

Once you have your list of patients, the ED admin team can pull your notes for you. The admin team are very busy, so notes will only be pulled for approved audits. Medical notes cannot leave the department and so will be stored in the ED admin suite. The team can give you access to the notes and can book a meeting room for you to be able to work in peace. It is acceptable for registrars to audit notes in the registrar room.

Analyse your data

Once you have your data, you must compare your results with the predefined standards in your audit planner. The audit team can help if you are struggling with this. If your data shows that standards are not being met then you need to consider the reasons for this. You also need to consider how best to improve care.

Make changes to improve care

Just when you think you’ve nearly reached the finish line, you encounter the hardest part of the audit process! If your audit reveals that standards haven’t been met, it’s important to consider why this might be. Are there issues with process, capacity, culture, equipment, education or training for example?

Discuss your results with your supervisor to get their opinion. They may be able to recommend the next steps to take before deciding what changes need to be implemented in order to improve care. Remember that it’s important to engage with and get buy-in from those people who will be responsible for making the changes. Also remember that a hard fix tends to be more successful than a soft fix. An example of this from every day life would be speed bumps being more successful than speed limit signs at reducing child death from road traffic accidents.

The college of Emergency Medicine also provides useful tools and resources to help you improve the quality of patient care.

Present your data

Your audit must be presented at one of the Quality and Safety meetings, organised by the nurse lead for Clinical Governance. These meetings are intended as a shared learning experience and are open to all clinical ED staff. There is a PowerPoint presentation on Insite that can help you structure your presentation. If you’re not used to presenting at meetings, run your talk past your supervisor who can give you some hints and tips.

Complete an audit summary form

This must include your results and more importantly, what actions are going to be taken to improve standards of care if these have not been met. This needs to be sent to the department’s audit lead, who will make sure that your audited is registered as complete within the trust.

Re-audit

As part of the audit cycle, any changes that have been introduced need to be re-audited regularly in order to assess whether they have been successful. Don’t forget that quality improvement is only worth doing if it leads to sustained change.