A tool to start clinical audits at departments,

units and case teams of Adama Hospital Medical

College

A GUIDE TO
CLINICAL
AUDIT
Clinical Governance and
Quality Improvement Unit,
ADAMA HOSPITAL
MEDICAL COLLEGE

Prepared by: Wassie G. MD, MPH

January 2020
Table of Contents
1. Introduction ................................................................................................................................................. 2
2. Objective ...................................................................................................................................................... 3
3. Principles of Effective Clinical Audit .......................................................................................................... 4
4. Role and Responsibilities of departments .................................................................................................. 4
5. Frequency of Clinical Audit ........................................................................................................................ 5
6. Process of Clinical Audit ............................................................................................................................. 5
Stage-1: Planning for Audit ............................................................................................................................. 5
Stage-2: Standard and Criteria Selection ........................................................................................................ 8
Stage-3: Measuring Performances .................................................................................................................... 9
Stage-4: Linking Clinical Audit Findings with the Quality Improvement................................................... 10
Stage-5: Sustaining Improvement .................................................................................................................. 11
References .......................................................................................................................................................... 12

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 1. 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 review of change. (1, 2)

Clinical audit should be an integral part of clinical practice and preferably a multi-professional
activity. It informs health care providers whether they are providing care that will, (i) yield
improved outcomes for patients, (ii) bring about efficiency gains, and (iii) raise patient satisfaction
to higher levels.

The Ministry of Health has been focusing on improving the quality of health care through
designing and developing different policies and guidelines. The HSTP (health sector
transformation plan) has set out quality improvements as one of its pillars of excellence which are
believed to help the sector to accomplish its mission and vision. In line with this HSTQ (Health
Sector Transformation in Quality) guidelines developed a different approach to operationalizing
the national quality strategy with superior emphasis on clinical audit.
Providing acceptable quality of health service in health facilities is a big challenge. Clinical Audit
implementation guides uniquely designed by the ministry to link clinical audit findings with
existing platforms like morning sessions, seminars, grand round meetings, beside teachings plus
quality improvement system then to make clinical audit fundamental component of clinical
practice at the facility level.

Adama hospital medical college is a teaching institution were audits are done by students in the
learning process but not coordinated with quality improvement activities of the hospital so
recommendations might not be supported by the hospital or even may not be informed. Therefore
having these opportunities as teaching institution we better also focus on standard patient care
continuously followed for improvement in quality.
The aim of this audit guide is for provision of simple tool for guiding implementation or initiation
of the audit activity to be done continuously by the unit or departments.

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 2. Objective
General

 To create a culture of systematic integration of patient care with clinical audits as part of their
patient safety and quality assurance measures of the routine clinical and academic activities.
Specific

 To guide clinical audit implementation at the level of departments, units or case teams of the
AHMC
 To assist in starting the clinical audit practice as their routine clinical activities at each departments
of AHMC for quality service delivery.

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 3. Principles of Effective Clinical Audit

If health facilities and clinical departments aspire to conduct effective and successful clinical audit,
the following guiding principles should be considered:

CLIICAL AUDIT IS NOT TO BLAME SOMEONE, BUT TO IMPROVE CARE

1. Confidentiality should at all times be respected. No information regarding the health
status, treatment or stay of a patient in a health facility is to be divulged verbally or in
writing without the necessary prior consent. Making information anonymous before it is
used in audit could also be considered.
2. The organizational environment must be supportive towards clinical audit. Safeguard
patient care and they should encourage professional self-regulation, and lifelong learning.
3. A non-judgmental working environment should exist, i.e. the search should be for error
only. The results that are produced when searching for a deviation from agreed good
practices should not be used to denigrate and condemn health care providers.
4. Clinical audit is data driven. Clinical audit can only be undertaken if enough data is
available to ensure credible results are produced.
5. Clinical audit should be part of structured program to improve quality of care within a
facility.

4. Role and Responsibilities of departments

AHMC Quality and clinical governance directorate/unit

The Quality Unity or Directorate will have the following roles and responsibilities:

 Coordinate and support overall clinical audit programs of the hospital

 Support and facilitate publication of audit findings in journals, quality bulletin

Department/units/case teams

The team is preferably led by a senior physician, and depending on the needs, members of the
team can be recruited from residents, interns, general practitioners, clinical pharmacists,
nurses…etc. the team is expected to conduct clinical audits regularly. The team will be responsible
for:

 Align clinical audit program with the hospital audit program

 Identify audit checklist which already exist or prepare criteria for the audit topics through engaging
relevant experts

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  Lead the development of a plan or program of clinical audits
 Conduct analysis, interpret, develop and implement QI interventions based on audit findings
 Facilitate presentation of audit finding in the selected platforms
 Report audit findings to the quality unit with an improvement plan
 Take clinical audit activities as a measure of performance of clinical staffs
 Recognize and celebrate success stories
 Support and facilitate publication of audit findings in journals, quality bulletin
(N.B SOLUTIONS FOR IMPROVEMENT COULD BE CREATIVE PROCESSES THAT
SHOULD OTHERS LEARN FROM IT, AND HENCE SHARING THE EXPERIENCE IS ONE
OBJECTIVE)

5. Frequency of Clinical Audit

Hospitals should follow quality improvement activities which are designed from the evidences
collected through regular clinical audits on patient care. The recommended frequency is

 Each department of the hospital is expected to report its performances of clinical audit to
quality units in weekly base, but until we get familiar, one audit monthly should be
reported
 The hospital should compile and report performances of clinical audits to the respective
bodies in monthly base.
 Each clinical department in the hospital is expected to dedicate one day in a week to
discuss findings of clinical audits

6. Process of Clinical Audit

Clinical audit is a cyclical process which has five stages.

(PLAN - STANDARD SELECTION - MEASURE PERFORMANCE - LINK WITH QUALITY

IMPROVEMENT - SUSTAIN IMPROVEMENT)

Stage-1: Planning for Audit

There are three main steps in the planning process which includes:

1. Involving stakeholders
2. Determining/selecting audit topic
3. Planning the delivery of audit fieldwork

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 i. Involving Stakeholders (staffs, patients)

Ownership relates to involving the right stakeholders in the audit from the phase of planning up
to follow up of implementation of change interventions, monitoring improvements and sustaining
such improvements. Anyone involved in providing or receiving care can be considered a
stakeholder in clinical audit.

1. Department heads or Quality Focal Persons (seniors) from all respective departments. Their
involvement could either be direct participation during the audit or overseeing :
o Leadership role in the audit team
o Review of cases that do not achieve the expected level of performance
o Provide explanations as to how a care process happens currently
o Monitor the implementation of agreed actions
2. Chief Resident / Resident focal assigned for clinical audit/ General practitioner -
 Collection of data, analysis, interpretation and dissemination/presentation of findings
 Actively engaged in evidence generation and publication on audit findings
 Design quality improvement projects based on audit findings
 Provide explanations as to how a care process happens currently
3. Clinical Nurse- all level of health facilities, and their role will be:
 Collection of data
 Contribute to the analysis of audit findings, including analysis of problems,
interpretation and identification of potential interventions
 Assist in identification of actions to address areas requiring improvement
4. Clinical Pharmacist -
 Collection of data
 Contribute to the analysis of audit findings, including analysis of problems,
interpretation and identification of potential interventions
 Assist in identification of actions to address areas requiring improvement
5. Intern representative/ Intern focal assigned for clinical audit-
 Collection of data
 Contribute to the analysis of audit findings, including analysis of problems,
interpretation and identification of potential interventions
 Design implementation plan
6. Case team managers and Coordinators-
 Contribute to the analysis of audit findings, including analysis of problems
identified
 Secure resources required to support change
 Provide support to the clinical audit team
7. Clients: Act as a source for data, and their role will be:
 Direct- interview, client forum/focus group (if patients are involved in assessment)
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  Indirect- Complaint box, analysis of feedback/comments made at service user
forums
ii. Determining the Audit Topic

Audit topics are based on department /unit / case team priorities, concerns and procedure. Audit
topic prioritization matrix can be used. Maternal and child health, non-communicable diseases /
HTN, DM/ are Ethiopian national priority areas. As a result, these audits can have a priority over
the other topics

Audit Topic prioritization matrix:

Selection of the audit topic needs careful thought and planning, as clinical staff and service
providers have limited resources with which to deliver clinical audits. Mandatory audits will take
resource priority and this can be justified using prioritization matrix

Score 3- High level, Score 2- Medium level, Score 1- Low level, Score 0- No importance

No Criteria Topic 1 Topic 2 Topic 3

1. It is among the top ten/five
morbidity or mortality case
2. Topic is national/regional priority or
high interest of the hospital
3. Local evidence suggests unwanted
variation in practice
4. There has been a high level of
investment in new
equipment/intervention requiring
effectiveness to be measured
5. The topic concerned of high cost,
volume or risk to staff or users
6. Suggested in morning session, grand
round, seminar, death audit,
journals…

iii. Planning the Delivery of Audit work

Plan for discussion on plans, audit findings and change idea generation for
improvement as well as update on implementation progress and follow up on
appropriate platforms, include:
• Morning meeting, Grand round
• Seminar, Death audit presentation

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 • Journal presentation
• Case team forums
• Performance monitoring team meeting

Stage-2: Standard and Criteria Selection

The clinical audit team (Department level) review available evidences to find standards and audit
criteria’s against which the audit will be conducted.

These criteria are explicit statements that define what is being measured and represent elements of
care that can be measured objectively.

The standards define the aspect of care to be measured, and should always be based on the best
available evidence.

 The Experts then set standards based on:

 Reference to Local Guideline
 Reference to National Guideline
 Literature Review
 Lastly a check list is made comprising of:
 Standard Title: which summarizes area of focus for standard
 Standard Statement: Which explains level of performance to be achieved
 Standard Criteria: Provides the details of what needs to be achieved for the
standard to be met

Criteria can be classified into those concerned with:

1. Structure (what you need) Examples of criteria relating to structure include the numbers of
staff and skill mix, the provision of equipment and physical space.
2. Process (what you do) Process criteria refer to actions and decisions taken by practitioners
and users. Examples include assessment, education, documentation, prescribing, surgical
and other therapeutic interventions.
3. Outcome (what you expect) Outcome criteria are typically measures of the physical or
behavioral response to an intervention, reported health status and level of knowledge and
satisfaction. Sometimes surrogate or intermediate outcome indicators are used instead.

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N.B. The use of an objective criterion with an agreed standard of performance is a hallmark of
clinical audit. Sample of Criteria Vs Standard

Criteria Target Standard Met

Administration of Diuretics to pts with heart 100% of patients to achieve this level of care
failure ( Process)
Adequate Facilities for hand hygiene are 100% of areas
available. i.e. one wash basin per 6 beds
( Structure)

Stage-3: Measuring Performances

is the collection of relevant data about current practice in order to facilitate quality gap
identification.

Step 1: Data collection

Step 2: Data analysis

Step 3: Drawing conclusions

Step 4: Presentation of results

Data collection can be carried out using a checklist either individually or as group using a
standardized checklist derived from the standards set.

Data collection methods: - can be retrospective , prospective or cross-sectional

Sample selection methods and sample size: - Simple random sampling and convenience sampling
tend to be the most commonly used methods in clinical audit. Clinical audit is not research. It is
about evaluating compliance with standards rather than creating new knowledge, therefore sample
sizes for data collection are often a compromise between the statistical validity of the results and
pragmatic issues around data collection i.e. time, access to data, costs.

The sample should be small enough to allow for speedy data collection but large enough to be
representative. Example reviewing 10 patient charts using checklists

Data Analysis

This may involve transferring the data collected from the data collection tool onto summary sheets
(manual data collection) or onto a spreadsheet or database (ms excel,) for interpretation. The main
aim of data analysis is to answer the questions posed by the audit objectives; highlighting areas of
good practice and areas that require particular attention or improvement. The type of data analysis

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depends on the type of information collected. This can range from simple averages and
percentages to sophisticated statistical techniques.

Drawing Conclusion

Cases of unacceptable care should then be reviewed in order for the team to:

 Clearly identify and agree on areas for improvement identified by the clinical audit.
 Analyze the areas for improvement to identify what underlying, contributory or deep-
rooted factors are involved. Tools like process mapping, fishbone diagrams, and 5 whys
can be used to explore root causes.
Report Writing and Presenting Results

The following points can be used as a guide while writing a clinical audit report for documentation

 Title of the clinical audit

 Background to the clinical audit, that is, reason for selection of the subject
 Design of the clinical audit including:
 Aim and/or specific objective/s to express clearly the intention of the audit
 Time period for data collection
 Data collection strategy, that is, retrospective, concurrent or prospective
 How data were collected
 Quality-of-care measures used in the audit
 Analysis of the findings including:
 Score
 Problems or shortcomings in patient care identified
 Root causes of the problems
 Specific improvements needed

Data graphics are a good way of communicating this information to others. The most commonly
used form of data graphics in clinical audit are tables, graphs and charts.

Stage-4: Linking Clinical Audit Findings with the Quality Improvement

All audits should be accompanied by a quality improvement plan in order to achieve the required
improvements in practice.
To link findings of the audit to QI (quality improvement) activities of the hospital:
 Develop the team charter
 Set clear aim statement
 Put measures
 Develop change ideas
 Test the change ideas

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  Implement the change ideas
 Scale up the experience

The change idea generated and be tested might be interesting finding so that it could be published
or shared for other institution and will be graduated.

Stage-5: Sustaining Improvement

Although improving performance is the primary goal of audit, sustaining that improvement is
crucial
Components to be considered to sustain change ideas are:
1. Monitoring the quality improvement plan
2. Performance indicators
3. Evaluating audit quality
4. Dissemination and celebrating success
5. Re-audit
6. Standardization
7. Remove the old syste

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References

1. FMOH. Clinical Audit implementation guide, , September 2019

2. National Institute for Clinical Excellence (NICE). 2002. Principles for Best
Practice in Clinical Audit.
3. FMOH. Health sector transformation in quality, 2016
4. FMOH. Ethiopian national health care quality strategy
2016-2020.
2016 – 202

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