ABC of audit

Definition

Audit is the process used by health professionals to assess, evaluate and improve care of patients in a systematic way in order to enhance their health and quality of life.

Is there a difference between auditing and research?

Yes!

Research  Audit 
Discovers the right thing to do Determines whether the right thing is being done
A series of ‘one-off’ projects A cyclical series of reviews
Collects complex data Collects routine data
Experiment rigorously defined Review of what clinicians actually do
Often possible to generalise the findings Not possible to generalise from the findings

Why do audit?

  • It improves quality of care as both an outcome and by the process of performing the audit.
  • It is an aid to continuing medical education.
  • There is a sense of personal and professional achievement. It may lead to a publication and can improve a CV.

The educational benefit from audit

  • Audit allows a critical review of current information (keeping up to date).
  • Audit highlights the need for specific knowledge/information, the acquisition of new skills and the development of existing ones.
  • Audit improves communication skills and enables attitudes to be modified when working with other members of the Primary Care Team.
  • Audit enables ‘self-evaluation’.
  • Audit promotes learning by answering the following questions:
        • What am I doing?
        • How am I doing it?
        • Why am I doing it in that way?
        • Can I do it better or differently?

How to carry out an Audit

The Audit cycle

 

The four main features of the audit cycle can be analysed to a greater depth.

  1. Identify the need for change
    This may come from personal experience. A problem may be identified from every day practice, and following this there is a feeling that something could or should have been done better. Problems can be identified in 3 basic areas of Practice work:

    • Structure: This refers to the input of care such as manpower, premises and facilities. Eg. ‘Are the numbers of emergency appointments enough to cope with demand?’
    • Process: This refers to the provision of care (looking at what is done and how it is done) Eg. ‘Are all patients on ACEI having urea & electrolytes checked?’
    • Outcome: This refers to the result of clinical intervention. Eg. ‘Are patients on lipid reducing regimes achieving target cholesterol levels?’
  2. Setting criteria and standards
    This is where you can say what should be happening.

    • A Criterion is an item of care or some aspect of care that can be used to assess quality. The criterion is written as a statement. Below are three criteria one relating to an audit in structure, one an audit in process and one an audit in outcome.
      • All patients requesting an urgent appointment will be seen that day. 
      • All patients with epilepsy should be seen at least once a year. 
      • All patients on Warfarin should have their INR within the recommended limits.
    • Criteria can be defined from recent medical literature, and the best experience of clinical practice these are called ‘Normative criteria’.
    • To make the criteria (statement) useful the Standard needs to be defined. A Standard describes the level of care to be achieved for any particular criteria. Eg. A standard may state: 98% of patients requesting urgent appointments will be seen the same day. 90% of patients with epilepsy should be seen at least once a year. 100% of patients on warfarin will have their INR within the recommended limits.
    • Standards must be set. The level of standard can often be controversial. There are basically 3 options:
          • A minimum standard. This describes the lowest acceptable standard of performance. Minimum standards are often used to distinguish between acceptable and unacceptable practice.
          • An ideal standard describes the care it should be possible to give under ideal conditions, with no constraints. Such a standard by definition cannot usually be attained.
          • An optimum standard lies between the minimum and the idea. Setting an optimum standard requires judgment discussion and consensus with other members of the primary care team. Optimum standards represent the standard of care most likely to be achieved under normal conditions of practice.
  3. Collecting data on performance
    Identify what data needs to be collected, how and in what form it needs to be collected, and who is going to collect it. Remember only collect information that is absolutely essential.
  4. Assess performance against criteria and standards
    With the information collected analysis is possible, and identification of any area of care below the predetermined standard of the criteria can be made. The results can then be used to develop an action plan ie what needs to be done, how it needs to be done, who is going to do it and when is it going to be done.
  5. Identify need for change
    The audit cycle is now almost complete, but without re-evaluating the care the practice is giving it is impossible to see if recommendations have been implemented and the level of care improved.

Remember: when constructing Criteria and Standards

  • Make unambiguous statements
  • Keep the task focused on the audit project
  • Refer to the literature indicating current practice
  • Choose criteria and standards in line with current practice
  • Ensure the criteria and standards are based on fact;

Carrying out Audit forSummative assessment

  • The choice of audit where possible should be chosen with guidance from your trainer.
  • The audit should not have been performed before in that practice.
  • Teamwork is a prerequisite for the summative assessment audit, and must be explicit in the writing up of the audit. Teamwork can be shown in data collection, literature searches, and standard setting.
  • It is hoped you will begin to form ideas within the first 2 months in of a general practice attachment. Allowing you time to review the literature, collect the data, analyse and write up the audit project within the next 4 months. It should be possible to complete the Audit project in the first 6-month practice attachment.

Writing up your audit project.

The submission should be typed in English, and normally be between 1500-3000 words. The work needs to have each page numbered and identified by your unique summative assessment code number. A word count is required at the end of the submission.

The following marking schedule is used to mark summative assessment audits. Each element must be present in the audit for it to pass.

Question  Criterion
Why was the audit done?  Reasons for choice

  • Should be clearly defined and reflected in the title
  • Should include potential for change
How was the audit done?
  • Criteria chosen
    • Should be relevant to the subject of the audit
    • Should be justified eg. literature
  • Preparation and planning should show appropriate teamwork and methodology in carrying out the audit
  • If standards are set they should be appropriate and justified
What was found? Interpretation of data

  • Should use all relevant data to allow appropriate conclusions to be drawn
What next?
  • Detailed proposals for change Should show explicit details of proposed change

If the answers to the questions in the table above are all in the positive, you will pass the audit section of summative assessment. Hopefully, these notes will help clarify some of the areas of audit over which people ‘fall down’.

Compiled by Dr David G AndersonTees Valley Vocational Training Scheme

Bibliography

  • Hall, Dwyer and Lewis Eds. The GP Training Handbook 3rd Edition Blackwell Science
  • Irvine & Irvine Eds. Making Sense of Audit Radcliffe Publications
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