How to conduct a clinical audit, differences between research and clinical audit, medical audit, History of audit, benefits of audit, standard, criteria, benchmarks, compare performance, examples of clinical audit, audit cycle, types of audit, NABH, JCI, QAPI, PDCA, Hospital accreditation,

1. Clinical Audit

2. NICE Definition
“A quality improvement process
that seeks to
improve patient care & outcomes
through systematic review of care
against explicit criteria and
the implementation of change”

3. Clinical Audit- Definitions
- A tool to find out what you are doing,
compare it to expected conditions and
recognize what you should ideally be doing
- Taking note of what we do, learning from it,
changing (if necessary) and re-evaluating the
change

4. History
 Florence Nightingale
 Crimean war, 1854
 Unsanitary condition was the reason for
the high mortality rates
 Strict sanitary routines and hygiene
standards and kept records of the
changes done and the mortality rates.
 Mortality rates fell from 40% to 2%

5. Classification

6. Auditor- Types
 First party auditor - Internal
 Second party auditor - User
 Third party auditor - Independent
entity
(Accreditation)

7. Clinical audit and medical audit
‘Clinical audit’ is used as an umbrella
term for any audit conducted by any
professionals in hospitals and the audits
conducted exclusively by doctors is
referred to as medical audits, although
the term ‘clinical audits’ could also be
used.

8. Benefits
 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.

9.  Develops openness to change.
 Provides assurance: meeting evidence-based
best practice.
 Helps in listening to patients, understanding
their expectations.
 Helps in the development of local guidelines or
protocols.
 Minimizes error or harm to patients.
 Reduce incidents/complaints/claims.

10. Types of Audit
 Standards based audit - guidelines, literature
 Critical incident reviews - death, serious side effects
 Peer review - ask other groups to evaluate you:
interesting cases, critical events etc
 Random case note audit - to keep a tab
 Patient surveys/Focus groups - user driven

11. Clinical Audit
Is not research
BUT
makes use of research methodology - to
assess practice

12. Clinical Audits Research
Determines whether the right
thing is being done
Discovers the right thing to do
Never involves experiments on
healthy volunteers/ patients
May involve experiments on
healthy volunteers/ patients
Never involves a completely
new treatment
May involve a completely new
treatment
Compare pre set standards Involves hypothesis testing
Aims to improve the quality of
services provided
Aims to generate new knowledge
Initiated by service providers
and is practice based
Initiated by researchers and is
theory driven
It is an on going process It is an one- off process
Requires only basic statistic
analysis
Detailed statistical analysis of the
collected data

13. Clinical Audit is NEVER
aimed at….....
 Stimulating competition between
professionals
 Judging professionals as good or bad
 Threatening individuals suspected of poor
performances

14. How long will it take?
 Data collection, analysis and action plans
can be carried out in an hour or 2 or take 1
or more years to complete
 Depends on the design of the audit – needs
to produce meaningful data within the
available budget & time
 Implementation of required changes - most
time-consuming

15. Audit cycle

16. Stage 1- Identify Issues
 Feed back from users/patients
 Perceived deficiency in practice- Not in
strong areas
 Concentrate on clinical topics- where there
is a consensus that practice could most
definitely be improved.

17. Also need to consider…..
 Practical to undertake the audit?
 Can you get the needed information?
 Is the problem amenable to change?
 Is the topic a priority for the Department?
 Good standards/guidelines available? If
not, is there consensus/agreement on good
practice?
 Who needs to be involved to ensure
changes can be implemented?

18. Stage 2 – Define criteria
Criteria are simple, logical statements used to
describe a definable and measurable item
 Patients with a previous MI should be prescribed
aspirin, unless contraindicated.
 Patients with chronic asthma should be assessed at least
every 12 months.
 Patients should wait no longer than 1 hour in OPD
before consultation.
 In daycare, surgeries should start within 5 minutes of
their allotted time
 The blood pressure of known hypertensive patients
should be <140/85

19. Stage 2 – Define criteria- contd..
 Focus on one or two criteria- data collection
manageable- introduction of small changes to practice
possible.
 Audit being completed successfully within a reasonable
time span.
 Criteria chosen should be backed up with quoted
evidence (e.g. from a clinical guideline or a review of
the relevant literature).
 Suitable evidence -not readily available- consensual
agreement amongst colleagues

20. Stage 2 – Define Standards
 An audit standard quite simply describes the level
of care to be achieved for any particular criterion.
 Unlikely- to find actual percentage standards
quoted in the literature or in clinical guidelines.
 Arrive at the desired level of care (standard) by
discussing and agreeing the appropriate figures
with colleagues.
 No hard rule about standard setting – the agreed
level is based on professional judgment – Varies
between practices due to medical and social
reasons.

21. Stage 2 – Define Standards- contd..
 100% of patients with a previous myocardial infarction
should be prescribed aspirin, unless contraindicated.
 80% of patients with chronic asthma should be assessed
at least every 12 months.
 75% of patients should wait no longer then I hour in
OPD before consultation.
 95% of surgeries should start within their allotted times.
 70% of blood pressure measurements of known
hypertensive patients should be <140/85

22. Stage 3- Measurement
 Methodology
 Inclusion, Exclusion
 Sample
 How- Retrospective, Prospective
 Designing the tool
 Collect only needed data
 Proforma/ Checklist, Questionnaire…
 Set a time frame
 Collect only needed data
 Analysis

23. Stage 4: Compare performance
to set standards/ Benchmark
 Compare the captured data with the
expected
 Finalize the report
 Share with the department with suggestions
for corrective actions

24. FINAL REPORT CONTENTS
 Final report need to contain the following:
Introduction
Audit scope
Approach & Methodology
Audit findings
Recommendations
Conclusions

25. How to go about conducting a
Clinical Audit

26. PROBLEM / ISSUE IDENTIFICATION
“AUDIT ON ACCURACY OF IOL POWER CALCULATION”
 To calculate power of IOL – need axial length measure
 Axial length measured using - Ultrasound (A scan) & Keratometry
(K) reading
 Possibility of errors in calculating axial length + unpredictability
of formula used
 Needed to know if hospital met International standards

27. CRITERIA & STANDARDS
 The Royal College (UK) - benchmark standard -
85% of patients should have post -operative
refractions within ± 1.0 D sphere of the refraction
aimed pre-operatively
 The American Academy of Ophthalmology
National Eyecare Outcomes Network (NEON)
database – 78% of patients were within ±1.0 D of
target spherical equivalent

28. AIMS & OBJECTIVES
AIM:
Benchmark - 85% of patients undergoing cataract
surgery with IOL implantation should have post-
operative sphere within ± 0.75D of aimed (target)
refraction
OBJECTIVES:

29. APPROACH & METHODOLOGY
 Type of study
 Sample size (including sampling
methods)
 Inclusion and exclusion criteria
 Methodology
 How to approach the audit?

30. GATHERING DATA
 Need to develop a comprehensive proforma –
to ensure needed data is captured
 Think about & make provisions for variations
 Separate column for comments/unexpected
observations
 Consider trial run if unsure about data
collection

31. ANALYSIS OF DATA COLLECTED
 Enter all data into an excel sheet
 Simple calculations required
Average, Percentage, Ratio, sum etc….
 Analyse sub-categories to look for any
unexpected patterns or results

32. FINDINGS
Number of charts audited: 69
60 out of 69 patients i.e 86.5% of the
audited patients had post-operative
sphere within ± 0.75D of aimed
refraction.
52 out of 69 i.e 75.36% had post-
operative sphere within ± 0.50 D of
aimed refraction.

33. RECOMMENDATIONS
RECOMMENDATIONS:
 Should be relevant to the problem
 Needs to be very clearly described
SUGGESTIONS:
 If unsure if a particular recommendation is possible,
put is as a suggestion (e.g We could look into the
possibility of…….)

34. “Systems awareness and systems
design are important for health
professionals, but are not enough.
They are enabling mechanisms
only.
It is the ethical dimension of
individuals that is essential to a
system’s success”.