Auditing Audit: A Review of Medical Audits in a University Hospital
Akheel A. Syed
University Hospital of Wales, Heath Park, Cardiff, CF14 4XW
Audit began with the principle that any money
raised for government purposes should have
the accompanying safeguard of an external
check on how that money is spent. The earliest
surviving mention of a public official charged
with auditing government expenditure is a
reference to the Auditor of the Exchequer in
1314 (National Audit Office 2010). The Audit
Commission for Local Authorities in England and
Wales was established in 1983 by the Local
Government Finance Act 1982 (Audit
Commission 2010). The Commission is a public
corporation and its role was extended to
include National Health Service authorities in
1990.
Two types of audit are in use in the
health sector. The first has been in use for a
number of years and takes the form of mortality
meetings and multi-disciplinary team meetings
in which deaths, complications, problems with
admissions, and delays in discharge are
discussed (Sellu 1996). The second is Clinical
Audit. The 1989 White Paper, Working for
Patients, defined medical audit as ‘a systematic,
critical analysis of the quality of medical care,
including the procedures used for diagnosis and
treatment, the use of resources, and the
resulting outcome and quality of life for the
patient’ (Department of Health 1989).
The general principles of clinical audit
are firstly, to establish standards of good clinical
practice, drawing from published local, national
or international guidelines where appropriate;
secondly to evaluate the current local practice
Syed AA. Auditing audit: a review of medical audits in a university hospital. scribd.com 2010 Jul 25; doc ID:34834272
and assess variation from the standards; thirdly,
to recommend changes in local practice so as to
reflect the standards of good clinical practice;
and fourthly, to re-audit to determine whether
the intended improvements have taken effect. I
reviewed clinical audits of the medical
directorate in the University Hospital of Wales
undertaken from January 1992 to December
1998 to assess the quality of the audit cycle.
Methods
I included original clinical audits undertaken by
the medical directorate of the University
Hospital of Wales, a teaching hospital in Cardiff,
Wales, from January 1992 (when minutes of
audit meetings began to be maintained by the
clinical audit department) to December 1998.
Original audits were followed-up for re-audits
and completion of the audit loop up to June
2000. I searched PubMed by authors’ names for
publications ensuing from these audits as a
surrogate marker of quality. I also examined
attendance records at audit meetings from
January 1997 to June 2000.
Results
There were a total of 34 clinical audits during
the study period of which 23 (68 %) were
original audits and 11 (32 %) re-audits. All
identified deficiencies in current practice.
Twenty of the 23 original audits (87 %) made
recommendations for change or produced local
guidelines.
Eight of 23 original audits (35 %) were
re-audited; three were re-re-audited. Two re-
audits compared with the original audit. Three
publications ensued from the 34 clinical audits
(9 %). Two were part of multicentre Royal
College of Physicians of London national audits
and one was a group publication.
May-00
Jan-00
Sep-99
May-99
Jan-99
Sep-98
May-98
Jan-98
Sep-97
May-97
Jan-97
0% 20% 40%
Attendees
Figure 1: Attendance at clinical audit meetings from January 1997 to June 2000.
Discussion
Clinical audit is an important subject on the NHS
agenda and is encouraged by the Department of
Health, the royal colleges, the National Institute
for health and Clinical Excellence and other
bodies. However, the audit process itself has
escaped scrutiny. It is clear from this study that
clinical audit was generating guidelines.
However, re-audit and closure of the audit cycle
was rare.
The clinical audit department began
recording minutes of clinical audits from
January 1992. Until 1997, the minutes of audit
meetings did not record details of specified
objectives or standards against which the topic
was audited. The original data was not
maintained for reasons of privacy and
Syed AA. Auditing audit: a review of medical audits in a university hospital. scribd.com 2010 Jul 25; doc ID:34834272
Mean attendance at audit meetings
over 2½ years was 35 % (Figure 1). There were
10 % apologies per meeting. There was no
seasonal variation in attendance.
60% 80% 100%
Absentees
confidentiality and the impracticalities of data
storage. Thus, it was not possible to assess
whether topics were audited against local,
national or international guidelines and
standards. Likewise, it was also not possible to
assess quality. However, publications in peer-
reviewed indexed journals were rare.
Attendance rates at audit meetings were poor
throughout with no apparent seasonal
variation. Whilst clinical commitments and
other pressing duties no doubt contribute to
absenteeism, non-attendance may reflect low
priority accorded to clinical audit by practising
clinicians.
One of the key reasons for the low
priority and lack of popularity of clinical audit
may be that doctors have not been convinced
that it improves quality (Sellu 1996). Clinical
audit could be improved by producing practical
evidence-based clinical guidelines and
integrated care pathways with clear,
measurable outcomes.
Acknowledgements
The findings of this audit were presented at the
University Hospital of Wales in September 2000. I
thank Dr J S Davies for suggesting the topic of the
audit and the clinical audit department for assistance
in collecting material.
Department of Health (1989). Working for patients.
London: Her Majesty's Stationery Office.
National Audit Office (2010). History of the National
Audit Office. London: National Audit Office (Archived
by WebCite at
http://www.webcitation.org/5rU63Qle3)
Sellu, D. (1996). Time to audit audit. BMJ 312:128-9
© Akheel A. Syed, United Kingdom.

References
Audit Commission (2010). Our history. London: Audit
Commission (Archived by WebCite at
http://www.webcitation.org/5rU6VVgPg)

Syed AA. Auditing audit: a review of medical audits in a university hospital. scribd.com 2010 Jul 25; doc ID:34834272