Audit and Audit Cycle

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Audit in healthcare is a process used by health professionals to assess, evaluate and improve care of patients in a systematic way. Audit measures current practice against a defined (desired) standard. It forms part of clinical governance, which aims to safeguard a high quality of clinical care for patients.[1]

Key features of audit are:[1]

  • Audit asks the question: 'Are we actually doing what we believe is the right thing, and in the right way?' (unlike research, which asks 'what should we be doing?').[2]
  • Audit can be used to evaluate various aspects of patient care:
    • Structure of care, eg the availability of a smoking cessation clinic in a locality.
    • Process of care, eg waiting times for an appointment at the smoking cessation clinic.
    • The outcome of care, eg the number of smokers who quit smoking for 1 year.
  • Audit should be transparent and nonjudgemental. The aim is to find out how the present provision compares with the desired standard. This information can then be used to plan improvements in the service. It is not intended to cause confrontation or blame.

The General Medical Council (GMC) states that, as part of good medical practice, maintaining and improving performance, doctors are required to:[3]

  • Take part in regular and systematic audit.
  • Take part in systems of quality assurance and quality improvement.
  • Respond constructively to the outcome of audit, appraisals and performance reviews, undertaking further training where necessary.

Doctors in the UK are asked to perform an audit during their first two postgraduate years.[1]

Audit will become part of general practitioners' revalidation. The Royal College of General Practitioners (RCGP) states:[4]

  • 'When revalidation is fully established, a GP's revalidation portfolio will be expected to contain information to demonstrate that he or she has taken part in clinical audit activity. This will normally be two full-cycle (initial audit, change implemented, re-audit to demonstrate improvement) audits during the revalidation period.'
  • This may be undertaken by several GPs working as a team.

The RCGP states that key points of audit for GPs are:[4]

  • Relevance of the topic chosen
  • Appropriateness of the standards of patient care set
  • Reflection on current care and the appropriateness of changes planned
  • Implementation of change for the GP's patients
  • Demonstration of change by the GP

Stage 1 - preparation

  • Choose a topic:
    • Preferably one which is a high priority for your organisation.
    • This may involve areas in which there is a high volume of work, high risks or high costs of care, or an area identified as a priority by patients.
  • Identify available resources, e.g:
    • Your organisation may have a local audit lead or office.
    • There may be existing guidelines defining desired standards for the topic you have chosen.

Stage 2 - select criteria

  • Define the criteria. This should be in the form of a statement, eg All patients with hypertension who smoke should be offered smoking cessation advice.
  • Define the standard - usually a target (percentage). This may be a minimum standard or an optimal one, depending on the clinical scenario.
For definitions of criteria and standards, see below.

Stage 3 - measuring level of performance

  • Collect the data:
    • May be from computerised records, manual collection, or both.
    • May be retrospective or prospective.
  • Analyse the data collected:
    • Compare actual performance with the set standard.
    • Discuss how well the standards were met.
    • If the standards were not met, note the reasons for this (if known).

Stage 4 - making improvements

  • Present the results and discuss them with the relevant teams in your organisation.
  • The results should be used to develop an action plan, specifying what needs to be done, how it will be done, who is going to do it and by when.

Stage 5 - maintaining improvements

  • This follows up the previous stages of the audit, to determine whether the actions taken have been effective, or whether further improvements are needed.
  • It involves repeating the audit (ie targets, results, discussion); hence the terms 'audit cycle' or 'audit spiral'.


An example of this cycle in practice is described by Benjamin.[1]

Definitions

Criterion:

  • A definable measurable item of healthcare that describes quality and which can be used to assess it, eg the number of people with coronary heart disease who have had their lipids checked within the last one year.
  • It is often best expressed as a statement, eg 'All patients with coronary heart disease should have had their lipids checked annually'.
  • Criteria should be evidence-based wherever possible.

Standard:

  • Describes the level of care to be achieved for any particular criterion.
  • For example, in the above scenario the standard chosen might be 80% (allowing for a number of patients to opt out, or for patients in whom testing is not appropriate - e.g those with terminal illness). For other scenarios (eg number of patients with chest pain reaching hospital within a set time), higher standards may be appropriate.

Advice on planning[1]

When constructing criteria and standards:

  • Make unambiguous statements.
  • Refer to the literature indicating current practice and guidelines, eg National Institute for Health and Clinical Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and the RCGP guidelines.[5]
  • Choose criteria and standards in line with current practice.

The choice of standard can be controversial and there are 3 options:

  • A minimum standard: the lowest acceptable standard of performance. Minimum standards are often used to distinguish between acceptable and unacceptable practice.
  • An ideal standard: the care it should be possible to give under ideal conditions, with no constraints.
  • An optimum standard: lies between the minimum and the ideal. Represents the standard of care most likely to be achieved under normal conditions of practice. Setting an optimum standard requires consensus with other members of the team.

Collecting data:

  • Identify which data need to be collected, how and in what form, and who is going to collect them.
  • Only collect information that is absolutely essential.

Tips for successful audit[1][6]

  • Adequate training and support for all staff involved.
  • Choose the topic carefully:
    • Audits are more likely to be effective where adherence to recommended practice is low.
    • Choose a topic with high priority (as above).
  • Enlist support from your organisation.
  • A team approach - involve all relevant staff.
  • Agree confidentiality of findings and a 'no blame' culture.
  • Allow sufficient time - protected time is helpful.
  • Good data collection and/or IT systems are required.
  • Set realistic standards (optimum rather than ideal) that are agreed by the team.
  • Deliver intensive feedback.
  • Consider publishing your audit.[5]

Further reading & references

  1. Benjamin A; Audit: how to do it in practice. BMJ. 2008 May 31;336(7655):1241-5.
  2. Smith R; Audit and research. BMJ. 1992 Oct 17;305(6859):905-6.
  3. Good Medical Practice; General Medical Council
  4. Guide to the Revalidation of General Practitioners, version 4.0. Royal College of General Practitioners (RCGP), June 2010
  5. University Hospitals Bristol - How To Guides, Clinical Audit. Accessed February 2010.; A readable summary for clinicians.
  6. Johnston G, Crombie IK, Davies HT, et al; Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care. 2000 Mar;9(1):23-36.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
Current Version:
Last Checked:
21/06/2010
Document ID:
1832 (v22)
© EMIS