Assess: Clinical audit as a quality improvement tool

5. Clinical audit as a quality improvement tool

Clinical audit can help with assessing the implementation of EBVM in practice, for personal and practice-level professional improvement.

Clinical audit is:

a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit measures and the implementation of change. (NICE, 2002)

Brief introductions to key elements of the stages of the clinical audit cycle are outlined in this chapter. For a more comprehensive overview, RCVS Knowledge has collated a wide range of quality improvement resources , including an e-learning course on clinical audit and a short summary infographic about the stages of clinical audit .

The key components of clinical audit are:

measurement (measuring a specific element of clinical practice)
comparison (comparing results with the recognised standard)
evaluation (reflecting on the outcome of an audit and where indicated, changing practice accordingly).

Figure 6 below shows the eight-stage clinical audit cycle from RCVS Knowledge , together with how these stages align with the commonly-used five-stage audit cycle defined by the National Institute of Health and Care Excellence (NICE, 2002).

Figure 6: The veterinary clinical audit cycle

The eight stages in the veterinary clinical audit cycle are listed in Figure 6 above, alongside related stages in the NICE five-stage audit cycle:

Choose a topic (Stage 1 of NICE audit cycle 'Preparing for audit')
Select criteria
Set a target (Stages 2 and 3 relate to Stage 2 of NICE audit cycle 'Selecting criteria')
Collect data
Analyse the data (Stages 4 and 5 relate to Stage 3 of NICE audit cycle 'Measuring performance')
Implement change (Stage 4 of NICE audit cycle 'Making improvements')
Reaudit (repeat steps 4, 5 and 6)
Review and reflect (Stages 7 and 8 relate to Stage 5 of NICE audit cycle 'Sustaining improvement')

Audit and research are different, although there can be overlap, and audits have potential to identify where further research is needed.

Research is concerned with discovering the right thing to do whereas audit is intended to make sure that the thing is done right. (Smith, 1992)

Table 11: Differences between clinical audit and research

Other articles on clinical audit including some comparisons with research include: Viner (2009); Wylie (2015); Waine & Brennan (2015) and Waine et al. (2018a, 2018b).

	Clinical Audit	Research
Purpose	To improve health care service: audits are designed and conducted to produce information to inform delivery of best care.	To improve knowledge: research studies are designed and conducted to derive generalisable new knowledge and to generate or test hypotheses.
Questions	How close is current practice to best practice? Does this service reach a predetermined standard? Are we doing the right thing and are we doing it the best way? Are we actually doing what we think we are doing?	What is best practice? What is the right thing to do and what is the best way to do it?
Knowledge generated	Provides knowledge primarily about the service being audited.	Provides knowledge about relationships between events and (possible) cause/s.
Aims/objectives	Measure current practice against defined criteria/standard(s).	Addresses clearly defined questions, aims and objectives.
Time frame	An on-going process.	Often a one-off project.
Sample size	Smaller, pragmatically based sample size.	Based on scientifically valid sample size (except some pilot studies).
Patients	Patients continue to experience normal treatment/management. Little disturbance to patients/owners.	May involve experiments on patients. May be extra disturbance to patients/owners.
Study design	No randomisation/allocation to intervention groups: the health care professional and owner have chosen intervention before clinical audit.	Study design may involve randomisation/allocating patients to intervention groups.
Methods	Involves an intervention in use ONLY (the choice of treatment is that of the clinician and owner according to guidance, professional standards and/or client preference) Never involves a placebo.	Quantitative research – may involve evaluating or comparing interventions, particularly new ones. Qualitative research – usually involves studying how interventions are experienced.
Data collection	Usually involves analysis of existing data but may include administration of simple interview or questionnaire.	Usually involves collecting data that are additional to those for routine care but may include data collected routinely. May involve treatments, samples or investigations additional to routine care.
Data analysis	Generally basic summary/descriptive statistics.	Extensive statistical analysis of data is routine. Data analysis methods vary depending on qualitative versus quantitative research.
Results	Specific and local to one patient group therefore not generalisable (although the audit process may be of interest to a wider audience).	Studies should be designed to be replicable and results may be generalisable.
Impact	Findings influence activities of an individual practice, or individuals within a practice.	Findings may influence the activities of clinical practice as a whole.