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Clinical audit : Clinical audit : Clinical audit : Clinical audit : Clinical audit :
w hat it is and w hat it isn w hat it is and w hat it isn w hat it is and w hat it isn w hat it is and w hat it isn w hat it is and w hat it isn t t t t t
W WW WWHA HA HA HA HAT TT TT IS IS IS IS IS CLINICAL CLINICAL CLINICAL CLINICAL CLINICAL A AA AAUDIT UDIT UDIT UDIT UDIT? ?? ??
Cli ni cal audi t i nvolves systemati cally looki ng at the procedures used for di agnosi s,
care and treatment, examining how associated resources are used and investigating
the effect care has on the outcome and quali ty of li fe for the pati ent (Department of
Health, 1993).
Audit is a word which has acquired different meanings over time in relation to health care
quali ty. The above defi ni ti on, provi ded by the Department of Health, emphasi ses the fact
that clinical audit can be used to examine all aspects of patient care from assessment through
to outcomes.
In brief, clinical audit provides a method for systematically
reflecting on and reviewing practice
In the literature about clinical audit methods, the following terms are often mentioned: criteria-
based audits; adverse occurrence screening; critical incident audits; peer reviews; and case
note analysi s. These are used i nconsi stently by di fferent authors and tend to add to the
general confusion about the clinical audit process. We would recommend ignoring this labyrinth
of terminology since there is only one clinical audit method the clinical audit cycle. This method
involves completing a number of stages and activities as described in chapter 2, Undertaking a
clinical audit project .
There is only one clinical audit method the clinical audit cycle
W WW WWHY HY HY HY HY IS IS IS IS IS CLINICAL CLINICAL CLINICAL CLINICAL CLINICAL A AA AAUDIT UDIT UDIT UDIT UDIT IM PORT IM PORT IM PORT IM PORT IM PORTANT ANT ANT ANT ANT? ?? ??
There are a number of reasons why clinical audit is an important activity. The main reason is that
it helps to improve the quality of the service being offered to users. Without some form of
clinical audit, it is very difficult to know whether you are practising effectively and even more
difficult to demonstrate this to others. The benefits of clinical audit are that it:
identifies and promotes good practice and can lead to improvements in service delivery
and outcomes for users
can provide the information you need to show others that your service is effective (and
cost-effective) and thus ensure its development
provides opportunities for training and education
helps to ensure better use of resources and, therefore, increased efficiency
can improve working relationships, communication and liaison between staff, staff and
service users, and between agencies.
The overarching aim of clinical audit is to improve service user
outcomes by improving professional practice and the general
quality of services delivered
4
W WW WWHA HA HA HA HAT TT TT AREAS AREAS AREAS AREAS AREAS CAN CAN CAN CAN CAN Y YY YYOU OU OU OU OU A AA AAUDIT UDIT UDIT UDIT UDIT ? ? ? ? ?
There are numerous topics which are suitable and relevant for clinical audit. Several ways of
subdividing clinical audit topic areas have been devised. A useful framework has been provided
by Donabedian (1966) who classified topics under three headings:
Structure Structure Structure Structure Structure The availability and organisation of resources and personnel.
P PP PProcess rocess rocess rocess rocess The activities undertaken, that is, what is done with the services resources.
O utcome O utcome O utcome O utcome O utcome The effect of the activities on the health/well-being of the service user, that is,
changes for the individual which can be attributed to the clinical intervention
they received.
H HH HHOW OW OW OW OW M UCH M UCH M UCH M UCH M UCH TIM E TIM E TIM E TIM E TIM E IS IS IS IS IS REQUIRED REQUIRED REQUIRED REQUIRED REQUIRED T TT TTO OO OO DO DO DO DO DO A AA AA CLINICAL CLINICAL CLINICAL CLINICAL CLINICAL A AA AAUDIT UDIT UDIT UDIT UDIT
PROJ ECT PROJ ECT PROJ ECT PROJ ECT PROJ ECT? ?? ??
For some clinical audit projects, data collection, analysis and action plans can be carried out in
an hour or two. Similarly these audit stages can take one or more years to complete. What is
important is to design a clinical audit project which will produce meaningful data and which can
be finished within the budget and time available. The most time-consuming element of any
clinical audit project is the implementation of required changes. It is suggested that projects be
kept simple and cover areas in which changes can be achieved.
Clinical audit can be both simple and quick
W WW WWHO HO HO HO HO SHOULD SHOULD SHOULD SHOULD SHOULD BE BE BE BE BE INV INV INV INV INVOL OL OL OL OLVED VED VED VED VED IN IN IN IN IN THE THE THE THE THE CLINICAL CLINICAL CLINICAL CLINICAL CLINICAL A AA AAUDIT UDIT UDIT UDIT UDIT PROJ ECT PROJ ECT PROJ ECT PROJ ECT PROJ ECT? ?? ??
A clinical audit project is more likely to be successful and beneficial to service users if all of the
key stakeholders are involved from the outset. These may include:
clinical and non-clinical staff providing the service
service users
people whose support may be required to implement resulting changes in practice (e.g.
managers, referrers, trust board members).
As many of the above groups as possible should be represented on the clinical audit project
team. If individuals are unable to attend team meetings, then they will need to be consulted and
kept informed about the clinical audit project throughout the process.
Key stakeholders should be involved in the clinical audit project
from the start
THE CLINICAL AUDIT PROJECT TEAM
A clinical audit project team works together from the early stages when decisions are being
made about what to audit and how to design the audit. Roles and responsibilities within the
team will need to be identified, for example audit project lead, data collector.
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W WW WWHA HA HA HA HAT TT TT IS IS IS IS IS THE THE THE THE THE DIFFERENCE DIFFERENCE DIFFERENCE DIFFERENCE DIFFERENCE BETWEEN BETWEEN BETWEEN BETWEEN BETWEEN M EDICAL M EDICAL M EDICAL M EDICAL M EDICAL AND AND AND AND AND CLINICAL CLINICAL CLINICAL CLINICAL CLINICAL
A AA AA UDI T UDI T UDI T UDI T UDI T ? ?? ??
Clinical audit tends to be used as an umbrella term for any audit
conducted by professionals in health care
Audi ts conducted by doctors are often referred to as medi cal audi ts, although the term
clinical audits could also be used. It is important to stress that very few health care procedures
i nvolve j ust one professi onal di sci pli ne and that non-cli ni cal staff such as recepti oni sts,
secretaries, porters, managers, etc. play a vital role in the quality of the service provided. Clinical
audit, therefore, is usually a multi-disciplinary activity. M any clinical audits are also multi-sectoral,
that is, they may involve health and social services, primary and acute care providers, education
and health.
I II IIS SS SS SERVICE SERVICE SERVICE SERVICE SERVICE EV EV EV EV EVALU ALU ALU ALU ALUA AA AATION TION TION TION TION THE THE THE THE THE SAM E SAM E SAM E SAM E SAM E AS AS AS AS AS CLINICAL CLINICAL CLINICAL CLINICAL CLINICAL A AA AAUDIT UDIT UDIT UDIT UDIT? ?? ??
Service evaluation may be defined as:
A set of procedures to judge a service s merit by providing a systematic assessment
of i ts ai ms, objecti ves, acti vi ti es, outputs, outcomes and costs (NHS Executi ve,
1997).
There are many different approaches to service evaluation. Whichever method is used, the
process should provide practical information which helps to inform the future development of a
service.
Clinical audit may be one activity which takes place during a service evaluation, alongside
other activities such as routine data gathering, incident reporting, and interviews with staff and
service users.
In order to conduct an evaluation, services need to consider their aims, objectives and then
identify their key evaluation questions. Further texts to assist in service evaluation are listed at
the end of this book.
H HH HHOW OW OW OW OW DOES DOES DOES DOES DOES CLINICAL CLINICAL CLINICAL CLINICAL CLINICAL A AA AAUDIT UDIT UDIT UDIT UDIT DIFFER DIFFER DIFFER DIFFER DIFFER FROM FROM FROM FROM FROM RESEARCH RESEARCH RESEARCH RESEARCH RESEARCH? ?? ??
Clinical audit is not research, but it does make use of research
methodology in order to assess practice
Key differences between clinical audit and research are outlined in Table 1.1.
Although research and clinical audit are two distinct activities with different purposes, they
are interrelated in several ways, as described by Black (1992):
Research provides a basis for defining good-quality care for clnical audit purposes.
Clinical audit can provide high-quality data for non-experimental evaluative research.
Research into the effectiveness and cost-effectiveness of clinical audit is needed.
Research needs to be audited to ensure that high-quality work is performed.
6
E EE EEXAM PLES XAM PLES XAM PLES XAM PLES XAM PLES OF OF OF OF OF DIFFERENT DIFFERENT DIFFERENT DIFFERENT DIFFERENT TYPES TYPES TYPES TYPES TYPES OF OF OF OF OF STUDIES STUDIES STUDIES STUDIES STUDIES IN IN IN IN IN AN AN AN AN AN IN IN IN IN IN- -- -- P PP PPA AA AATIENT TIENT TIENT TIENT TIENT
UNIT UNIT UNIT UNIT UNIT FOR FOR FOR FOR FOR ADOLESCENTS ADOLESCENTS ADOLESCENTS ADOLESCENTS ADOLESCENTS WITH WITH WITH WITH WITH EA EA EA EA EATING TING TING TING TING DISORDERS DISORDERS DISORDERS DISORDERS DISORDERS
A study to examine whether adolescents admitted to the unit benefit most from group or
individual psychotherapy is research.
A study to examine whether the following standard set by staff at the unit is being
achieved: All adolescents admitted to the unit will receive a team assessment within two
days of admission to decide whether they will receive group or individual psychotherapy ,
is a clinical audit project.
A study involving: (a) collecting information about service users to see whether the service
is reaching the target population, and (b) obtaining feedback from service users, referrers
and providers about various aspects of the service (e.g. accessibility,
acceptability, effectiveness) is a service evaluation.
T TT TTABLE ABLE ABLE ABLE ABLE 1.1 1.1 1.1 1.1 1.1 Differences between research and clinical audit. Adapted from M adden (1991) and Differences between research and clinical audit. Adapted from M adden (1991) and Differences between research and clinical audit. Adapted from M adden (1991) and Differences between research and clinical audit. Adapted from M adden (1991) and Differences between research and clinical audit. Adapted from M adden (1991) and
F FF FFi rth- i rth- i rth- i rth- i rth-Cozens (1993) Cozens (1993) Cozens (1993) Cozens (1993) Cozens (1993)
RESEA RCH RESEA RCH RESEA RCH RESEA RCH RESEA RCH CLINICAL AUDIT CLINICAL AUDIT CLINICAL AUDIT CLINICAL AUDIT CLINICAL AUDIT
Ai ms t o est abl i sh w hat i s best pr act i ce Ai ms t o est abl i sh w hat i s best pr act i ce Ai ms t o est abl i sh w hat i s best pr act i ce Ai ms t o est abl i sh w hat i s best pr act i ce Ai ms t o est abl i sh w hat i s best pr act i ce Ai ms t o eval uat e how cl ose pract i ce i s t o Ai ms t o eval uat e how cl ose pract i ce i s t o Ai ms t o eval uat e how cl ose pract i ce i s t o Ai ms t o eval uat e how cl ose pract i ce i s t o Ai ms t o eval uat e how cl ose pract i ce i s t o
best pract i ce and t o i dent i f y w ays of i mprovi ng t he best pract i ce and t o i dent i f y w ays of i mprovi ng t he best pract i ce and t o i dent i f y w ays of i mprovi ng t he best pract i ce and t o i dent i f y w ays of i mprovi ng t he best pract i ce and t o i dent i f y w ays of i mprovi ng t he
qual i t y of heal t h car e pr ovi ded qual i t y of heal t h car e pr ovi ded qual i t y of heal t h car e pr ovi ded qual i t y of heal t h car e pr ovi ded qual i t y of heal t h car e pr ovi ded
Is desi gned so t hat i t can be repl i cat ed and so Is desi gned so t hat i t can be repl i cat ed and so Is desi gned so t hat i t can be repl i cat ed and so Is desi gned so t hat i t can be repl i cat ed and so Is desi gned so t hat i t can be repl i cat ed and so Is speci f i c and l ocal t o one part i cul ar pat i ent group Is speci f i c and l ocal t o one part i cul ar pat i ent group Is speci f i c and l ocal t o one part i cul ar pat i ent group Is speci f i c and l ocal t o one part i cul ar pat i ent group Is speci f i c and l ocal t o one part i cul ar pat i ent group
t hat i t s resul t s can be general i sed t o ot her t hat i t s resul t s can be general i sed t o ot her t hat i t s resul t s can be general i sed t o ot her t hat i t s resul t s can be general i sed t o ot her t hat i t s resul t s can be general i sed t o ot her r esul t s ar e not t r ansf er abl e t o ot her set t i ngs r esul t s ar e not t r ansf er abl e t o ot her set t i ngs r esul t s ar e not t r ansf er abl e t o ot her set t i ngs r esul t s ar e not t r ansf er abl e t o ot her set t i ngs r esul t s ar e not t r ansf er abl e t o ot her set t i ngs
si mi l ar gr oups si mi l ar gr oups si mi l ar gr oups si mi l ar gr oups si mi l ar gr oups
Ai ms t o gener at e new know l edge/ i nc r ease t he Ai ms t o gener at e new know l edge/ i nc r ease t he Ai ms t o gener at e new know l edge/ i nc r ease t he Ai ms t o gener at e new know l edge/ i nc r ease t he Ai ms t o gener at e new know l edge/ i nc r ease t he Ai ms t o i mpr ove ser vi c es Ai ms t o i mpr ove ser vi c es Ai ms t o i mpr ove ser vi c es Ai ms t o i mpr ove ser vi c es Ai ms t o i mpr ove ser vi c es
sum of know l edge sum of know l edge sum of know l edge sum of know l edge sum of know l edge
Is usual l y i ni t i at ed by r esear c her s Is usual l y i ni t i at ed by r esear c her s Is usual l y i ni t i at ed by r esear c her s Is usual l y i ni t i at ed by r esear c her s Is usual l y i ni t i at ed by r esear c her s Is usual l y l ed by ser vi ce pr ovi der s Is usual l y l ed by ser vi ce pr ovi der s Is usual l y l ed by ser vi ce pr ovi der s Is usual l y l ed by ser vi ce pr ovi der s Is usual l y l ed by ser vi ce pr ovi der s
Is t heor y dr i ven Is t heor y dr i ven Is t heor y dr i ven Is t heor y dr i ven Is t heor y dr i ven Is pr ac t i c e Is pr ac t i c e Is pr ac t i c e Is pr ac t i c e Is pr ac t i c e - based - based - based - based - based
Is of t en a one Is of t en a one Is of t en a one Is of t en a one Is of t en a one - -- -- of f st udy of f st udy of f st udy of f st udy of f st udy Is an ongoi ng pr ocess Is an ongoi ng pr ocess Is an ongoi ng pr ocess Is an ongoi ng pr ocess Is an ongoi ng pr ocess
M ay i nvol ve al l oc at i ng ser vi c e user s r andoml y M ay i nvol ve al l oc at i ng ser vi c e user s r andoml y M ay i nvol ve al l oc at i ng ser vi c e user s r andoml y M ay i nvol ve al l oc at i ng ser vi c e user s r andoml y M ay i nvol ve al l oc at i ng ser vi c e user s r andoml y Never i nvol ves al l oc at i ng pat i ent s r andoml y t o Never i nvol ves al l oc at i ng pat i ent s r andoml y t o Never i nvol ves al l oc at i ng pat i ent s r andoml y t o Never i nvol ves al l oc at i ng pat i ent s r andoml y t o Never i nvol ves al l oc at i ng pat i ent s r andoml y t o
t o di f f er ent t r eat ment gr oups t o di f f er ent t r eat ment gr oups t o di f f er ent t r eat ment gr oups t o di f f er ent t r eat ment gr oups t o di f f er ent t r eat ment gr oups di f f er ent t r eat ment gr oups di f f er ent t r eat ment gr oups di f f er ent t r eat ment gr oups di f f er ent t r eat ment gr oups di f f er ent t r eat ment gr oups
M ay i nvol ve admi ni st r at i on of a pl acebo M ay i nvol ve admi ni st r at i on of a pl acebo M ay i nvol ve admi ni st r at i on of a pl acebo M ay i nvol ve admi ni st r at i on of a pl acebo M ay i nvol ve admi ni st r at i on of a pl acebo Never i nvol ves a pl ac ebo t r eat ment Never i nvol ves a pl ac ebo t r eat ment Never i nvol ves a pl ac ebo t r eat ment Never i nvol ves a pl ac ebo t r eat ment Never i nvol ves a pl ac ebo t r eat ment
M ay i nvol ve a compl et el y new t r eat ment M ay i nvol ve a compl et el y new t r eat ment M ay i nvol ve a compl et el y new t r eat ment M ay i nvol ve a compl et el y new t r eat ment M ay i nvol ve a compl et el y new t r eat ment Never i nvol ves a compl et el y new t r eat ment Never i nvol ves a compl et el y new t r eat ment Never i nvol ves a compl et el y new t r eat ment Never i nvol ves a compl et el y new t r eat ment Never i nvol ves a compl et el y new t r eat ment