How to Do a Clinical Audit or Quality Improvement Project

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What is a clinical audit?
An audit assesses if a certain aspect of healthcare is attaining a recognised standard. This lets care providers and patients know where their service is doing well, and where there could be further improvements. The aim is to improvement quality of care and to ultimately improve outcomes for patients.Audits are a quality improvement measure and one of the seven pillars of clinical governance. It allows organisations to continually work towards improving quality of care by identifying where they are falling short, allows them to implement improvements and re-audit or close the audit cycle to see if beneficial change has taken place.Clinical audits are a cycle with several steps:

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  1. Identifying a problem e.g. patients waiting too long in A&E
  2. Define standards/criteria e.g. Guidelines recommend that 95% of patients should wait <4 hour
  3. Collect data e.g. record over a week how long patients wait (determining that 92% wait for < 4hours)
  4. Analysis e.g. 92% vs 95% target, areas for improvement
  5. Implementing change e.g. action plan to help reach target
  6. RE-AUDIT e.g. do step 1-5 again

What is Quality Improvement?
Quality improvement (QI) aims to improve the patient experience. Whilst audit is often more clinically orientated, QI can focus on more holistic issues, e.g. the availability of hot drinks in A&E.  QI can be done using the “Plan Do Study Act” (PDSA) framework. PDSA cycles are iterative and have short time spans allowing improvement to be incorporated quickly.

How do audit and QI differ?
Audit and QI projects are essentially the same thing, they both look at how the state of various healthcare standards, and aim to improve them – it’s just that audits have a more formal standard to measure against and also tend to have a longer time period e.g. done once every few months.  PDSA cycles used in QI can be weekly or even daily.

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PDSA Cycle Source: NHS Institute for Innovation and Improvement

Why get involved in audit and QI?

  • Because you will help to improve patient care.
  • It’s a great way to show interest in a certain field
  • You’ll learn many transferable skills e.g. teamwork, time management
  • They can be presented at conferences, or written up formally for submission to a journal
  • Completed audits are extra CV points for specialist training
  • As a doctor, it may form part of your annual appraisal and assessments!
  • It is a mandatory requirement for UK junior doctors to progress in their training

How to get involved
There are 2 ways of getting involved in audit/QI:

  1. Joining an already organized audit
  2. Setting up an audit yourself

Joining an organized audit/QI project
These audits are already planned, and need people to help with the data collection (step 3). These may be good for people who haven’t done an audit before, or if they would like to get involved with one that is multicenter.

  • Ask doctors if they have any audits that you could help with
  • In the UK, trainee research collaboratives such as STARSurg run multicenter national audits. Here there is a protocol, and your role is to do the data collection at your site. The data is often processed centrally.
  • University societies such as Acamedics have many audits available for students to get involved with that have already been planned by doctors

PROS – good introduction to auditing, less time commitment
CONS – less flexibility, fewer skills learnt, fewer potential perks – e.g. conferences/CV points


Planning your own audit/QI project
In planning your own audit, you have free reign to pick something that you’re interested in, but still with senior oversight.

  • Use the SMART criteria when thinking about planning:

Specific        Choose a certain area that you’re interested in, and don’t keep it too broad. For step 1, your problem should be one short sentence.
Measurable  There that has something you can audit against; a local or national target (Choosing a national target may be easier to present at conference/get published.) Be sure to define your standards/criteria well, and that these                                                      are objective e.g. ‘Temp>38 degrees’ not ‘fever’
Achievable    Limit yourself to 1 or 2 outcomes. Ensure the data is easily collectable, and that you have all the relevant access before you start e.g computer logins. Are you at the hospital long enough to do several reaudits?
Realistic        Are you the right person for this audit? It is easier for a student to assess if a thromboprophylaxis assessment has been documented on a drugs chartsthan rates of a certain technique being used in theatre
Timely           Choosing something that can be done quickly will keep you motivated, and give you more opportunity to reaudit

  • Remember to get permission from the audit lead of the department and register it with the audit department.
  • Engaging all stakeholders or people whom your work will impact (nurses, physios, pharmacists, etc in addition to doctors) early on is vital, and gaining their feedback will be useful
  • Involving seniors may make step 5- implementing change easier, and will prevent you from doing an audit that is already being done.
  • Reauditing is a MUST. Doing this 3 times will achieve maximum marks in in most training applications. An audit that has a high turnover of patients and an easy change to implement is easier to reaudit than one with lower numbers of patients and a more difficult intervention

                CONS – bigger time commitment, more admin/planning


Summary

  • Audits and quality improvement are a good way to learn more about a certain field, show interest and learn new skills
  • Good planning is essential
  • Always reaudit!
  • Try and present your results locally or nationally, or even submit for publication
  • Report using SQUIRE Guidelines
  • Publish them – for example the Annals of Medicine and Surgery (www.annalsjournal.com) is indexed in PubMed and publishes audits.

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