How to undertake an audit

This Tool describes the various methods of audit and when they could be used.

Method

Performance is often broken down into the three aspects: structure (what you need), process (what you do) and outcome of care (what you expect). You may choose to focus on any of these three components, or your audit might flow from one to another to include all three aspects in your design.

Structural audits might concern you undertaking audit in relation to what resources you have got such as diagnostic equipment, premises, access to support services, skills, staffing etc.
Process audits focus on what was done to a patient or how the general practice nurse (GPN) or team operate; for example how clinical protocols and guidelines work in practice, waiting times, patient recall for investigations, treatment, record keeping, communication etc.
Auditing outcomes relates to the impact of the GPN or services provided on the patient: improvements, adverse events. You might audit endpoints of providing care such as the effectiveness of care or services on patients’ health, patient satisfaction or convenience.

Undertaking audit as part of an evaluation

Audit is a technique you can use to monitor then maintain or improve the quality of care and services provided, for example by the individual GPN or by a practice. It is the method used 'to assess, evaluate, and improve the care of patients in a systematic way, to enhance their health and quality of life'.1 Clinical audit includes all the non-clinical components of audit too.

You cannot monitor the contribution of a GPN to the quality of care in a clinical area in general practice without looking at access to and availability of care, how good the communication is between staff and with patients, the evidence for your clinical protocols and so on. Everyone in the practice team plays their part. Staff in general practice only operate effectively if they are working in a well-connected way within the wider team across primary care and with others in the hospital or community.

The main steps of the audit cycle as represented in the diagram overleaf are:

prioritise and select the topic of your audit, working with others in your team or practice
set objectives: relating to the reason(s) why the audit is being carried out
review the literature for that topic and agree the criteria and standards that you think are reasonable
design the way in which you will do the audit
collect the data and look at it
feedback the findings; meet with colleagues or your team to discuss the findings and determine the reasons for the satisfactory or disappointing results
make a timetabled action plan to implement any changes that are needed
review your standards – you might keep the standards you previously set, or drop the standards if the initial thinking was unrealistic or raise them if the previous standards were not challenging enough
re-audit to create improvements and then successive audit cycles.

Steps in the Audit Cycle

Draw up and carry out your audit protocol

Here is an example audit protocol you could work through in your general practice team as a method of evaluation.

Select the focus of the audit

Categories justifying selecting a clinical audit topic as a priority

An audit topic should concern an area that has at least one of the following characteristics:

•high cost •high risk • high volume • caused concern

The topic or focus of the audit has to be important - to you, your patients, your practice or the NHS in general or central to local or national initiatives. If the audit is about a clinical condition, then it should concern a common problem, or be related to an aspect of practice with potentially serious consequences if there is underperformance. If it is about practice systems, then choose to audit an issue where the audit exercise should help you to work more effectively or efficiently. There must be the potential to make improvements through the audit. There is no point in demonstrating that additional resources are needed to improve some process if there is no chance at all of gaining those additional resources, however hard you try.2

The categories that an audit normally falls into include the service or staff involved in relation to:

assessing the frequency or volume of a service
risks associated with aspects of providing care or a service
problems associated with delivering care or a service
effectiveness of aspect(s) of the delivery of care or a service
cost of aspect(s) of delivering care or a service.

Consider if the problem underpinning a topic you are about to select is amenable to change. If not, is there any point in selecting it and carrying out the audit unless that is part of a business case to justify investing resources?

Who will be involved?

Include the GPN(s) and those other members of the practice team who are directly involved in the task or role being audited and those who will be collecting the data. Decide who is writing the audit protocol and who will search for evidence to enable you to set standards and criteria. Include in the audit team those who need to agree solutions or find resources if the audit shows that change is necessary. Appoint a lead if there is no-one in this role already. Link to others relevant to the audit who work in different settings: such as the local pharmacist or community podiatrist.

Set simple, measurable, achievable, realistic and timely (SMART) objectives

You should be clear about the reason(s) for doing the audit, and the objective you set should link to that - eg to define the extent of potential risk areas. The objectives should be relevant and understandable to everyone taking part. Keep in mind that the end result is making improvements to patient care. The quality and nature of the endpoints of your audit should relate to the objective(s) you set for the audit. You need to have some idea of your endpoint(s) when you set the objective(s).Some examples of audit that are worthwhile include objectives such as:

assessing whether or not standards are being met
determining if standards are improving
monitoring levels of compliance or concordance with treatment or advice
improving clinical effectiveness
changing inadequate current practice.

Set criteria

These help you to appraise the indicators of the level of care available (eg from a GPN). The level of performance captured in your audit results describes the extent to which these criteria are met. Criteria are explicit statements that define what is being measured. They represent elements of care that can be measured objectively.2

Set standards

Standards are indicators of the level of care that you want to achieve. They may be those that you have agreed as a practice team, are promoted by others, such as in the general practice Quality and Outcomes Framework (QoF), or in other published literature, such as systematic reviews or national clinical guidelines.3

Data collection

Decide what information you wish to collect and how to collect it in a reliable way, minimising bias as far as possible. You may need to pilot the collection of data to see how it works out and solve any problems that arise. Decide if the data collection is retrospective, concurrent or prospective. The data collected must be valid and accurate. The data should be readily available on your computer system or from patient surveys. You will not have time or resources to track down information that is hard to locate.

Define the sample

The number in your sample and the trouble you take to get a representative sample will depend on the accuracy or degree of confidence you need to have in the findings, and what kind of resources you have got - such as time, funds, staff skills etc.

Data analysis

Decide who will look at the data, how the analysis will be done and how the interpretations will be made.

Feedback the findings

Feedback should be to the people involved in the audit and anyone who will need to make changes. You might be feeding back findings further afield, in staff appraisal or re-registration portfolios, or to the primary care trust as part of the QoF.

Draw up the action plan

The action plan needs to be timetabled and specific about who does what, how and when - and it needs to be realistic. The need for any extra resources should be predicted and the action plan should specify how resources will be obtained. If the actions or changes mean new responsibilities for health care assistants or other staff, then you need to anticipate their training requirements and decide whether essential training is undertaken in work or paid time.

Convene an implementation group

Everyone concerned in the action plan of the audit will need to discuss progress with whoever is taking the lead. If it is a complex audit or crosses more than one health setting, you will probably need an occasional group meeting to oversee progress and agree on when and how you will re-audit.

Re-audit

You will want to re-audit if your initial audit showed gaps in the care you are providing and you have made changes as a consequence, to see if you are now meeting the criteria and standards you had set, or how far off you are.

References

Irvine D, Irvine S (eds). Making Sense of Audit. Oxford: Radcliffe Medical Press; 1991.
Wakley G, Chambers R. Clinical Audit in Primary Care. Demonstrating Quality and Outcomes. Oxford: Radcliffe Publishing; 2005.
Department of Health. Investing in General Practice: The New General Medical Services Contract. London: Department of Health; 2003