Chairman: Dr. Kamal Ahmad Saeed
Presentation: Meeran Earfan
“We must formulate some method of hospital report showing
as nearly as possible what are the results of treatment
obtained at different institutions. This report must be made
out & published by each hospital in a uniform manner, so
that comparison will be possible. With such a report as a
starting point, those interested can begin to ask questions
as to management & efficiency.
In a similar way all the important by products depend in the
end on demonstration that the patient can be helped.”
(Taken from a lecture by Ernest Amory
Codman 1896-1940 to The Philadelphia County Medical Society just
prior to the First World War)
“ … surgery without audit is like playing cricket without
keeping the score.”
(Hugh Brendon Devlin 1932-1998, Founding
Director of the Surgical Epidemiology and Audit Unit, Royal College
of Surgeons of England)
Clinical audit is a process used by clinicians
who seek to improve patient care. The process
involves comparing aspects of care (structure,
process & outcome) against explicit criteria.
Structure – what is in place
The people, their training, their knowledge, the way they
are led, the equipment, their organization, the way they
are paid, etc.
Process – what you do
How referrals are processed, what diagnostic tests are
done, the antibiotics that are used, the thromboembolic
prevention that is customary, the use of intensive care,
the policy of feeding & mobilization after surgery, the
discharge policy, etc.
Outcome – the results you get
Wound dehiscence rate, readmission rates, mortality,
freedom from progression, reduction in symptoms,
improvement in quality of life, return to work, etc.
If the care falls short of the criteria chosen, some change in the
way that care is organized is proposed, it may be required at one
of many levels:
An individual who needs training
An instrument that needs replacing
At team level e.g. nurses undertaking procedures instead of, or
in addition to, doctors
At institutional level e.g. new antibiotic policy
At regional level e.g. provision of a tertiary referral centre
At national level e.g. screening programmes & health education
There are a number of types of audit that take place within an
• morbidity and mortality meetings
• local/regional audit
• national or international comparative audit.
The debate between Surgical &
We need to consider the differences rather than similarities
between the so-called ‘Surgical specialties’ & those that are
traditionally called ‘Medical specialties’. While the distinction
between the two is becoming increasingly blurred (Physicians
spend most of their times consulting & prescribing medications,
surgeons undertake a large number of invasive procedures), it is
nevertheless an important one.
The archetype of the non-surgical model of care is as follows:
A large body of evidence exists to show that an intervention works.
This could be a meta-analysis of randomized trials that have
shown that a reduction in mean arterial BP brought about by
use of hypotensive agents results in significant reduction in the
rate of strokes. In order for the physician to confer this benefit on
the patient, all that he or she needs to do is prescribe the
appropriate drug to the right patient. IT DOES NOT MATTER
WHO GIVES THE DRUG TO THE PATIENT; THE
EFFECTIVENESS OF THE DRUG IS ALREADY KNOWN &
The Nice Thing about Surgery
Surgical operations are different. If an operation is decided by a
surgeon for a patient, it probably does matter who performs it.
Is a trainee likely to obtain the same results as an
Does it matter that the operation is being done in a district
general hospital rather than a regional centre?
Even if the operation is going to be done by one of two
specialists of equal experience, it is still likely that one
surgeon will perform the same operation in a very different
Step-By-Step Guide for
Doing An Audit
From Bailey & Love’s Short
Practice of Surgery
Stage 1 – preparing for audit
Think broadly. Audit can be used to monitor change, to ensure that current best
practice is being implemented, or to inform your own patients what the probability of
good & adverse outcomes is likely to be.
Funding. All audit takes time & consume resources.
Ownership. Try to involve all those parties that may have some stake in the results
of the audit. Consider involving patients at the outset.
Skills. Many hospital provide courses or have units with staff who have the
necessary expertise required to conduct an audit on a project.
Time. Be realistic about the time the audit is going to take.
Teamwork. You are unlikely to be able to do it all. Most projects need a leader. A
sense of teamwork with all those concerned being actively involved is a formula that
is most likely to succeed.
Stage 2 – selecting criteria
Think big. Criteria being audited should be important.
It must be measurable. Criteria should be explicit & amenable to measurement.
Check guidelines. If possible, consult published guidelines from reputable sources.
Systematic reviews. In areas where guidelines have not been produced, try
consulting systematic reviews.
Process or outcome. Think hard about the criteria you are going to audit. Will your
goals be best served by using process measures or outcome measures?
Case mix. Whatever criteria are chosen, some form of adjustment for case mix will
be required. Age, social class & mode of admission are usual but think hard about
co-morbidity & disease severity.
Stage 3 – measuring the level
Routine data. It is worth checking whether routine data in the area of interest are
collected by your own institution or any external agency.
Electronic data. If available these data are worth considering because of ease of
Medical records. Patient registers are notoriously incomplete but should still be
Abstract data. Before going to any data source decide what it is that you want to
know. Design a data abstraction instrument, in essence a questionnaire, so that you
will be able to determine what data was present & what was missing.
Legalities. Prior to abstracting any data, check what your local/national
arrangements are in terms of the ethical considerations of the project & also issue
relating to data protection.
Stage 4 – making improvements
Barriers. Before trying to change anything, try & work out what barriers to change
Feedback. Feedback of results to the participants in the audit is usually insufficient,
in itself, to result in change.
Discussion. It is far better to use the audit result as a basis for discussion in order
to explore ways of improving the service.
Implementation methods. Other areas such as industry use a variety of techniques
in order to bring about change.
Clinical governance. It is prudent to use established structures to bring about
improvements in surgical care.
Stage 5 – sustaining improvement
Re-audit. It is usually not necessary to go through the whole process another
time. Instead, periodic review with some kind of monitoring may be sufficient.
Structural change. It is important to make sure that the change resulting in
improved care is easier for the clinician to undertake than the practice that it
Cultural change. Sustained improvement is difficult to achieve unless it is
something that the organization is striving to do.