Clinical Audit

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Society has increasingly questioned quality of care and concepts of professional discretion or clinical freedom.The stark evidence of this shift in attitudes is shown in the demands of pressure groups, press coverage, calls for public inquiries, and the rise of complaints, legal challenges and claims for redress.

Yet patients and the public have not lost their respect and appreciation for the caring professions in the health service. Practitioners, patients, and the wider public all share equally in the need to establish and maintain confidence in the quality of clinical care. Audit is one way in which we can work to retain the trust and respect in an increasingly critical environment.As a quality improvement tool, audit can demonstrate that real efforts are being made by dedicated, hard-pressed staff to deliver high-quality professional care to all their patients.

According to National Institute for Health and Clinical Excellence (NICE), 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 implementation of change. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to  improvement in healthcare delivery. Basically, clinical audit is as a guideline what should be done, and if not, something improvement must be made.

Clinical audit is very important because it helps to improve the quality of services we offered. Besides that, it also:
- 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.

There are 5 steps in clinical audit process:

1. Preparing for the audit (involving stakeholders, including consumers, in the process) - during this step, we need to select a topic, defining the purpose of the audit, establishing or activating necessary structures, identifying skills and people needed to carry out audit and providing training to audit team as necessary. This is important to make sure that the next step can be done smoothly.

2. Selecting criteria - defining criteria and standards against which to assess the process and or outcome of care, drawing criteria from existing guidelines and or systematic reviews, prioritising criteria and making criteria explicit and subjecting it to external peer review. Topic is selected in a meeting and using all of the informations such as routine data, patient satisfaction survey, observation of care delivery, inputs from the stakeholders and enthusiasm of a certain care groups.

3. Measuring performance level - identifying the data to be collected (patient and case types, healthcare professionals and their involvement, time period), determining sample size, data sources, data extraction tools and techniques, reviewer training and method of analysis. Data collection can be either retrospective (data already collected routinely or available in a certain register ) or concurrent/prospective (data collected during the process of care)

4. Making improvement - the most important in audit is changes. By identifying the level and location of change (organisational, group, individual) the barriers to change establishing the environment for the audit and involving stakeholders, we can make a changes to the system. Some of the categories that needed changes are eliminate waste, improve work-flow, optimize inventory, change the work environment, enhance the producer-customer relationship, manage time and focus on the product or service.

5. Sustaining improvement - Although improving performance is the primary goal of audit, sustaining that improvement is also essential. Indeed, any systematic approach to changing professional practice should include plans to monitoring and evaluating change, maintaining and reinforcing the change.

References:
1. Lecture note on Briefing for Clinical Audit Practical Sessions by Prof.dr. Adi Utarini, MPH, M.Sc, Ph.D.
2. East Kent Clinical Audit service NHS and pdf.
3. Principles for Best Practice in Clinical Audit , Radcliffe Medical (pdf)
4. The Centre for Clinical Governance Research in Health, University of New South Wales, Sydney