• 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
• the word ‘auditing’ has been derived from
Latin word “audire” which means “to hear”.
• Clinical Audit is a mandatory element of the
Professional Competence Scheme in some
countries for all Surgeons / Medical
Practitioners according to the Medical
Practitioners Act 2007 on 1st May 2011.
• Measurement - Measuring a specific element
of clinical practice
• Comparison - Comparing results with the
• Evaluation - Reflecting the outcome of audit
and where indicated, changing practice
Difference between medical audit and
that of surgery
• In medical audit usually a pharmaceutical
intervention have explicit standards and
outcome that can be measurable.
• Most of the guidelines are evidence based.
• Eg: diabetes sample audit.
• In surgical audit, it is difficult to set standards
and to apply.
• So we need to measure the variations in
• Eg: mortality rate following radical cystectomy
in a centre of international standing will
definitely differ from that of a remote area.
• National audits (e.g. in the UK, the National
Institute for Health and Clinical Excellence –
• local/hospital audits.
• Define the audit question.
• Identify the body of evidence and current
• Design the audit to measure performance
against agreed standards.
• Measure over an agreed interval.
• Analyze results and compare performance
against agreed standards.
• Undertake gap analysis : If all standards are
reached, re audit after an agreed interval.
• If there is a need for improvement, identify
possible interventions such as training, and
agree with the involved parties.
• Re audit.
Common areas in the scope of an audit include:
• 30 day mortality and significant morbidity;
• length of hospital stay;
• positive and negative outcomes
• operation-specific complications
• use of investigations
• justification of management
• patient satisfaction.
• use evidence-based research and guidelines
where ever possible(cochrane collaboration);
• adapt existing local guidelines for local
• use an accessible library for evidence about
effective practice and develop new guidelines;
• look to the specialty group to define
• the information necessary to answer the audit
• collect prospectively or retrospectively.
• follow up data collected.
• Data can be collected from a register, medical
records data, review of referrals, or from
previous appointment schedules.
• The evaluation of work by one or more people
of similar competence to the producers of the
• It constitutes a form of self-regulation by
qualified members of a profession within the
Eg: morbidity and mortality meetings
• Peers are other surgeons with comparable
training and experience.
• It can often also be helpful to include other nonsurgical members of the team in the review group
e.g. surgical trainee or senior nursing staff.
• This should be conducted in an atmosphere of
confidentiality, of trust and teamwork, and be
seen as an evolving process.
• Grand rounds as the name suggests are hardly
confidential peer review - but cases should be
presented as an educational exercise.
• They are good opportunities to learn from one
or more cases but do not replace formal
surgical audit meetings.
Make Changes and Monitor Progress
• Implementation involves not just making
changes but ensuring that everyone affected
is educated/ informed as to what changes are
being made and why.
• It can be at any level from staff to surgeons
• Then follow up the change achieved and then
re audit for better results.
What Resources are Required
• paper-based systems with notebooks or card
indexes, often with the help of sticky labels.
• As manual data recording and entry can be
tedious and prone to error, it is recommended
that advantage be taken where possible, of
automated or semiautomated entry, such as
bar codes, scanners
• It is recommended where ever practicable,
particularly for individuals in private practice.
• in addition to surgical audit data can be used
for multiple purposes such as billing, reporting
or clinical records
• reduce duplication and facilitate data
collection, verification and analysis.
• Logbooks used by surgical trainees provide an
opportunity to start a data collection system
as part of an ongoing process towards surgical
• Confidentiality in audit process is essential,
both from the point of view of the rights of
the individual patient and of the surgeon.
• It is also important to reassure participating
surgeons and other team members that peer
review discussions constitute confidential
professional peer review rather than a ‘witch
What Opportunities Arise from
• modify attitudes and approaches to clinical
• enhancing critical approaches and giving a
rational basis to local changes in clinical
• indicates deficiencies in knowledge and skills,
and to develop educational activities to
Systemic improvement opportunities
• Clear problems and deficiencies identified in
‘systems’ should lead hospital authorities to re
address the issues.
• Similarly individuals and teams can always
• Surgical audit and peer review are essential
components of continuing professional
• Bailey and love 26th edition.
• A Guide by the ROYAL AUSTRALASIAN COLLEGE OF
SURGEONS- surgical audit and peer review (2008)
• Professional competence scheme- guidelines for
surgical audit- RCSI ( NOVEMBER 2012)