• Clinical audit is an integral part of clinical governance and encompasses the methods by which existing practice is looked at and measured against defined standards. This is to ensure an agreed level of quality is being met, facilitate ways to make improvement and to help identify and address any deficiencies in practice.

• Clinical audit differs in nature and purpose to clinical research.
• Clinical research is focused on establishing an evidence base of what best practice should be by hypothesis testing and research methodological process.
• This differs from clinical audit which aims to ensure that best practice, having been identified through clinical research, is being adhered to and that these standards are being met.
• In more simple terms it is a process of highlighting whether or not we are doing what we should be doing and if not how we can change things to ensure that we are.

• Clinical audit comprises four key stages (Figure 1):

Preparation and planning

• This stage involves identifying an area where there may either be problems or where there are certain standards that need to be met. This then necessitates the setting of standards for the quality improvement project.
• These could be derived at a:
• Local level – i.e. hospital derived
• Regional level
• National level – i.e. from a specialist organisation (i.e. BOAST guidelines)
• These standards/guidelines should be evidence based and should be objective and be able to be measured. They should also reflect best practice in the chosen area and facilitate the ability to make changes.
• This stage should identify where and how data should be collected.

Figure 1. HQIP Clinical Audit Cycle

Measuring

• Measurement of clinical practice requires the auditor to have:
• A population to audit:
  • This should be predefined with inclusion and exclusion criteria as appropriate and should be done over a specified time frame.
• A data collection tool, this can be either:
  • As part of a standardised collection tool from a local/regional/national organisation.
  • Devised by an auditor to look at specific quality measures.
  • Once data are collected they must be analysed before implementing change.

Implementing change

• This requires comparison of current practice, as collected during stage 2 of the cycle (Measuring), with best practice and identifying areas where change needs to be made.
• Changes made to practice are often in line with the other key areas of clinical governance, these can include:
• Education and training
• Clinical effectiveness
• Risk management
• Staffing management

Sustaining improvement

• This requires maintenance of the changes to practice in line with best practice standards. Again, this necessitates adherence to the other key components of clinical governance.
• One of the fundamental parts of clinical audit and sustaining improvement is re-audit. It is often referred to as completing the cycle and entails repeating the stages of clinical audit to provide objective evidence that the improvement is sustained.

• The clinical audit process allows best practice to be achieved by ensuring that evidence-based standards are being met. As new evidence emerges from clinical research, through the process of re-audit, something fundamental to the audit cycle, audit standards, can be modified to reflect this improvement practice.
• While hospitals have safe care/clinical governance leads and audit departments that overview quality improvement projects, a large number of audits are performed by staff directly involved in clinical care. This allows them to identify problems and see tangible changes to practice within their department as a direct result of the quality improvement procedures.
• While clinical audit can be an effective way to improve practice, it requires adequate engagement from staff. Alongside this, without hospitals having coherent strategies aimed at nurturing effective audits, valuable opportunities to improve practice will be lost.¹ Therefore, hospitals should have adequate processes in place to ensure that effective clinical audit can be undertaken.

1. Johnston G. Reviewing audit: barriers and facilitating factors for effetive clinical audit. Qual Health Care 2000; 9: 23–36.