CLINICAL
AUDIT
Professor Syed Amin Tabish
FRCP (London), FRCP (Edin), FAMS, MHA (AIIMS)

Clinical Audit
‘Clinical audit is the systematic
critical analysis of the quality of
healthcare , including the procedures
used for diagnosis , treatment and
care, the use of resources and the
resulting outcome and quality of life
for the patient’.

Why Audit?
Audit allows one to see how near
one gets to the standards.
It shows how our systems and
every day PRACTICE let us down.
it gives us opportunity to change to
allow our efforts to be optimized.
Audit puts the control of the quality
of our work into our own hands.

The clinical audit cycle
National Institute for Clinical Excellence. Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press, 2002.

Audit Cycle
What we are doing ?
Collect (data or performance)
Comparison [Assess performance against criteria & standard]
Identify Needs for change
Implementing change
Define Criteria & Standards
Select the issue
Audit Cycle

Goals of Quality assurance
Increasing the capacity &
effectiveness of health services
Increasing efficiency of HS
Maintaining good standards for HS
Improving the outcome on
interventions
Increasing consumer satisfaction
Increasing effectiveness of
community participation

Elements, Criteria, Standards
Elements: represent the component
parts of an activity
Criteria: selected elements that are
precise, clear, effective, measurable, &
able to reflect the quality of that
activity
Standards: when the criterion has
been defined at a descriptive or
numerical level

The Consumer
Quality means from consumer
point of view:
A service that is available at all
time
Easily accessible
Feeling of comfort
Politeness of health providers
Disappearance of symptoms

Framework of Quality
Structure: Manpower,
drugs, equipment,
buildings, records, etc
Process: content,
configuration
Outcome: the results, the
impact

Quality Assessment
Collection of data
Analysis of trends
Interpretation of results
Corrective actions
Follow-up

Doing AUDIT
Audit is concerned with
monitoring performance against
established stadards, and
implementing appropriate change,
as necessary, to meet those
standards
Audit Cycle/Spiral:
Setting standards
Monitoring performance
Effecting change

Types of Standards
Protocols
Options
Guidelines: how the doctor
should behave in most instances
Standards: have a ring of
absoluteness among them
Criterion: standards with
flexibility (all diabetics should
have their feet inspected once a
year)

Monitoring Performance
Collection of data
Retrospective data
collection (death &
disaster type of case
reviews)
Prospective data
collection: collecting data
‘on the run’

Effecting change
Audit is all about change
Comparing present
behaviour against
standards and being willing
to change that behaviour in
order to bring yourself or
your practice up towards
those standards

Approaching Change
Education
Feedback
Financial reward
Financial penalties
Participation
Administrative change (terms
& conditions put in service
contract)

Achieving Change
Be involved
Choose a meaningful topic
Set suitable standards
Set an appropriate time scale
for change
Reward success
Change for the better in a
purposeful manner

CLINICAL AUDIT
It is primarily for accountability,
for management control, for
professional development
It is multidisciplinary: concerns
not only the clinical practice
within individual professions but
also demonstrates the
contributions made by each &
the organizational links between
them

Frame For Assessing Care
Structure Process Outcome
In which description , measurement,
comparison and evaluation of quality of
health care can be made.
QUALITY OF:
Building )
Equipments ) STRUCTURE
Systems )

Structure
Health care is likely to be more effective if it
carried out in comfortable surrounding with
right equipment and by most appropriate
people.
The presence of structure attribute increase
the chance of good quality of care but does
not assure it.
Quality assessed primarily on basis of
doctors performance, So the performance of
health professionals embodies the other two
constituents of quality (process& outcome).
Audit of Structure - assess quality of environment in which care is provided.

Audit of process
Process describe the care given by
practitioner i.e. what the practitioner
does , the sum of actions and decisions
that describe a persons professional
practice.
Treatments
Diagnosis / Intervention
Dr. / Patient Communication
Audit of process : describe quality of work done by health professionals.

Patient current and future health
status.
Definite indicators of health, and
describe effectiveness of care.
Success in outcome
Preventing Suffering of Illness
Audit of Outcome - assess the benefit achieved by patient.
Outcome

The benefits of audit to a practice
Bringing about change.
Reducing organizational and clinical
error.
Improving effectiveness.
Demonstrating good care.
Meeting patients’ needs and
expectations.
Stimulating education.
Promoting higher standards of hospital
and community care for patients.
Securing effective medical defense
through risk avoidance.

Methods of Clinical Audit
Peer Review
Audit should involve the Objective
Peer Review of patterns of care, be
sensitive to the expectations of
patients, & be used on scientific
evidence of good medical practice
Case for review can be selected
randomly or by pre-agreed criteria
Patterns of practice can be compared
with Guidelines

Methods of Clinical Audit
Adverse Patient Reaction involves
systematic identification and analysis of
events during a patient’s treatment which
may indicate some lapse in the quality of
care
Screening criteria are defined by the
participating clinicians:
Peri-operative deaths
Admission to ICU
Unplanned second operations
Unplanned readmissions

Methods of Clinical Audit
Criteria for whole hospital includes:
Admission because of complications of
out-patient management
Readmission for complications or
incomplete management of problems on
previous admission
Unplanned removal, injury or repair of
organ or structure during surgery/invasive
procedure
Unplanned return to theatre
Nosocomial infection

Methods of Clinical Audit-II
Pathology report varies significantly
from pre-operative diagnosis
Cardiac or respiratory arrest
Cardiac arrest within 48 hours of
surgery
Neurological deficit on discharge not
present at the time of admission
Unexpected transfer to a High
Dependency Unit
Unexpected death

Methods of Clinical Audit-III
Clinical Indicators:
monitoring of routinely generated
data within a specialty, in order to
identify exceptions or trends which
may merit detailed adhoc review
Includes Workload, Access
(waiting times), Appropriateness,
Outcome, Information. Efficiency
(Theatre sessions cancelled)

Methods of Clinical Audit
Topic Review
Analysis of an agreed topic may be carried
out by prospective study or by
retrospective analysis
A systematic review of a large enough
sample of similar cases in order to
identify, quantify & compare patterns of
practice
Indicators: colonic resection,
cholecytectomy, CABG, TURP,
prolapsed disc, orchidopexy,
hysterectomy, cataract, radical neck
dissection

Methods of Clinical Audit
Medical Records
Clinical guidelines for minimum
standards of records are required
Auditing the records of every
patient who had general
anesthesia or adverse reaction or
death

Clinical Audit Methods
Therapeutics
Audit of drug usage
Appropriateness
Route of administration
Serum monitoring
On what criteria are patients
selected/refused (diagnosis, disability,
disease, age)
How should treatment be conducted
(machine, safety, staff)
When should treatment cease

Methods of Clinical Audit
Other Methods
Diagnostic investigations (Radiology)
Autopsy
Random case Review
Patient Satisfaction
Comparative Audit (confidential
pooling of aggregated data, standard
definitions & formats of individual
doctors compared with their peers)

Audit of Outcome
Assessment of outcome is much
more difficult
Indicator: post-operative mortality
(account of severity of illness &
fitness of patient for operation be
taken)
Death certificates are unreliable
Random control trials for evaluating
outcome of surgical interventions is
universally accepted
Audit of quality of life after surgery

What matters
Patients are likely to be satisfied with
their treatment if medical and
nursing staff observe the rules of
communication, courtesy, concern,
competence & comfort
Prevention by control of their origin
is cheaper, more humane and more
effective than intervention by
treatment after they occur.

PLAN AN AUDIT
1. Define the nature of perceived problem.
2. Produce a clear written statements of
aims.
3. Select the most appropriate method.
4. Decide upon the other basic design
features.
5. Identify the main analysis to be made.
6. State who the audit will involve.
7. Start small.
8. Have a short time - scale.
9. Proceed step by step.
10. Indicate how the possible need for
changes to be handled.

Data Collection
1.Routine practice data.
2. Medical Records.
3. Practice activity analysis.
4. Prospective recording of specific
data.
5. Surveys.
6. Interviews.
7. Direct Observations.

How To Do It ?
1.Routine performance
monitoring.
2. Practice activity analysis.
3. Surveys and Interviews.
4.Direct observation.
5. Confidential enquiries.
6. Use of tracer.
7.Pracice visiting.

The stages of clinical audit
National Institute for Clinical Excellence. Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press, 2002.

Analysis
Analysis must reflect the audit aim.
Analysis should always be focused.
First step: examine the frequency of
occurrence of each item or event [example 8
out of 40 may be widowed , 15 out of 40 may
be taken more than one drugs…etc] each of
these could be expressed as percentage.
Next step construct the tables that shows
range of each item of data collected this will
highlight unusual event occurrence &analysis
can be focused
As the result production one or more tables
containing only data required.

Analysis - Presentation of
Data
ANALYSIS OF DATA PRODUCE
RESULTS THAT’S NEEDS TO BE
CONVERTED INTO INFORMATIONS
WHICH THE PRACTICE TEAMS CAN
UNDERSTAND AN TO WHICH THEY
CAN RELATED .
PRESENTED IN VISUAL WAY THAT
COMMUNICTE INFORMATIONS EFFECTIVELY.

PROBLEMS OF AUDIT IN PRIMARY CARE:
1. Difficulty in setting standards for many aspects
of primary care.
Why ??
a) lack of scientific evidence.!!
b) audit is relatively new activity – few area have
been examined and few audit validated.
c) process measure is not necessary correlate
well with outcome measures.
e.g a practice may have recorded B.P for all its patients
(100%)- but if
non of the patients with high BP are treated the
quality of care is low.
" remember –measuring activity dose not
necessary mean measuring quality"
e.g. referrals
DR A- High referral rate.
DR B – Low referral rate.

PROBLEMS OF AUDIT
2. Good quality care means improved outcome,
Outcome rather difficult to measure in G.P.
“AIM OF TREATMENT HYPERTENSION IS TO REDUCE
STROKES”
ABSOLUTE OUTCOME MEASURES , STROKES
NUMBERS
To justify improved care of
hypertensives, one has to look for
intermediate outcome measures.
e.g. Level of B.P. control – in treated
hypertensives. Good control usually results in
less strokes
HbA1c intermediate outcome measure in
diabetic care.

PROBLEMS OF AUDIT IN PRIMARY CARE
3. Good care should take into account
the patients’ views. This is usually
difficult in practice based audit.
However, patients’ views are vital
when auditing appointments or
availability AND satisfaction
4. The idea of Audit causes anxiety for
some doctors.
Expose – poor care and therefore
problems with PHC Administration or
problems within PHC Team.

Thank you
very much