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Clinical audit plays an important part in the drive to improve quality of patient care and thus forms a cornerstone of clinical governance. We evaluated the standard of clinical audits conducted by all departments in a teaching hospital between 1996 and 1997.
Of a total of 213 audits carried out, 102 (48%) were ‘partial’ and only 29 (14%) were ‘full’. Recommendations for improvement emerged from 134 (63%) of the audits performed. In only 51 audits (24%) was the cycle completed by re-auditing, during the subsequent 3 years.
Most departments undertake clinical audits but failure to close the loop undermines their effectiveness and wastes resources.
Audit has been defined as ‘systematically looking at the procedures used for diagnosis, care and treatment, examining how associated resources are used and investigating the effect care has on the outcome and quality of life for the patient’1. The audit cycle involves observing practice, setting standards, implementing change and observing new practice. Completion of the audit cycle establishes the effectiveness of the audit in improving care of patients2,3. We evaluated the standard of clinical audits conducted over a 12-month period in a teaching hospital.
We reviewed a total of 213 audits carried out between 1996 and 1997 at St George's Healthcare NHS trust. The audit cycle was categorized into six stages4—stage 1, choosing a topic; stage 2, setting target standards; stage 3, observing practice; stage 4, comparing performance with targets; stage 5, implementing change and planning care; stage 6, repeating the audit cycle. A ‘full’ audit satisfied five of the six stages of the audit cycle, a ‘partial’ audit3 satisfied three stages and a ‘potential’ audit satisfied just two stages4. The ‘planning’ audit group included audits where a topic was chosen and only the intentions for audit were outlined. The ‘no audit’ group included those audits which were considered to be research projects. We also looked at whether recommendations were made to implement changes following each audit and whether these audits were re-audited in the subsequent 3 years.
Overall, 102 (48%) audits were partial and only 29 (14%) were full (Table 1). 33 (16%) were ‘non-audits’ and these included research projects, literature reviews and discussions only. Medical and surgical departments contributed most audits, providing 65 and 50, respectively. Recommendations for improvement emerged from 134 (63%) of the audits performed. Clinical support services (including physiotherapy, occupational therapy and dietetics) made recommendations in 19 (86%) of their 22 audits, medicine in 44 (68%) of their 65 and surgery in 30 (60%) of their 50. In only 51 (24%) was the cycle completed by re-auditing. Surgical departments re-audited the most (15 out of 50), clinical support services the least (3 out of 22).
The main finding is that most audits conducted in a teaching hospital did not fulfil the criteria for a ‘full’ audit. In only a quarter was the cycle completed by re-auditing—an essential process to ensure that quality of care improves and that the improvement is sustained1.
The low quality of audits and the low rate of completion of cycles are unlikely to be unique to this hospital or indeed to the UK3,5,6,7. Why should the performance be so poor? Often the responsibilities for conducting departmental audits fall upon the junior medical staff, and the rotational nature of their posts hinders completion of the cycle. Unsatisfactory arrangements may reflect a general lack of interest in the process by all those providing care. Also, collection of data for audit is often by retrospective review of hospital case notes, which can be time-consuming, labour-intensive and inaccurate. Prospective collection on a computerized database should improve efficiency and thus simplify re-auditing. Our study highlighted confusion over what constitutes an audit, since 16% of those examined were designated non-audit. Apart from their contribution to clinical governance, audits are important for continuing medical education1,8; but unless they are ‘full’, their educational value is doubtful.
Audits threaten to become a sterile activity undertaken by junior staff to fulfil the requirements of their posts. Those who conduct them must not lose sight of the main purpose of these exercises, to improve care, and regular audit of the audits would help to ensure that the time and money are well spent.
We thank the staff in the Clinical Audit department of St George's Healthcare NHS Trust for help in obtaining the audit projects.