How to utilise a clinical audit to achieve 'equity and excellence' in healthcare

The NHS needs to rethink its quality assurance structure and the way it reports and measures its performance of patient experience, patient safety and clinical effectiveness of care,

Nurses who are nearer to the patient and understand their needs will need to inform and shape the quality agenda and be very much part of the quality governance structure.  This is further supported by a document published by the Healthcare Quality Improvement Partnership that stresses that nurses need to be very much involved in the decisions of the organisations operational strategy and have their voices sounded at board level.

Furthermore, if nurses are to succeed there needs to be a reduction of internal bureaucratic system that could impose a stumbling block in promoting quality care to patient.

Clinical audit is now an integral part of the integrated governance process within all NHS organisations in the UK. Since the development of clinical governance in late 1990s the standard of clinical audit is significantly raised through the support of National Institute for Health and Clinical Excellence and the Healthcare Quality Improvement Partnership leading to better care for patients and service improvement. 

The definition of clinical audit provided by NICE is: “a quality improvement process that seeks to improve patient care and outcomes through systematic review against explicit criteria and the implementation of change.” Clinical audit is best illustrated as a cycle (see figure 1, attached right).

The key components of the audit cycle as illustrated in the diagram are:

• Knowing your topic
• Selection of appropriate criteria and setting standards to be measured against
• Measuring current practice
• Comparing results with standards
• Changing practice
• Re-auditing to make sure practice has improved

There are many adaptations of the clinical audit cycle and they all follow the same basic stages. If the cycle remains continuous, in theory, patient care should be improved.

Within the NHS system, nurses constitute the majority of ward staff, therefore it is necessary to involve them during the planning stage, as they are the staff that provide the majority of direct patient care and will be a key component of ensuring that the outcome of clinical audit is accurate.

Furthermore, as clinical audit is a clinically led initiative to improve the outcomes of patient care, a collaborative approach would need to be adopted with medical staff when carrying out an audit. 

Quality has been defined in terms of safety, effectiveness of care and patient experience. When planning to undertake an audit it is worth considering audit triggers. For example, is it clinical or non-clinical related? Have there been recent serious untoward incidents? Have there been complaints? Does the current practice need to change to meet CQC requirements? Or it could simply be that we need to develop a service and develop a business and marketing strategy by undertaking an audit or survey in order to understand patient needs? Figure 2 (attached right) explains these in a diagrammatical format.

Differences between audit and research exists and needs to be understood. According to HQIP, “research is about obtaining new knowledge and finding out what treatments are the most effective. Clinical audit is about quality and finding out if best practice is being conducted.” In order to carry out an audit a standard needs to be identified and appropriate criteria’s selected in order to know at what compliance level is being practiced.

When planning an audit the use of a quality assurance benchmarking toolkit has been cited as one way in which members of the nursing, midwifery and health visiting professions can focus on the fundamental and essential aspects of care (Badham et al 2006), thereby improving the patient experience.

The essence of a care toolkit continues to be developed by focus groups of stakeholders. For example, a focus group made up of carers, patients and professionals has proposed a new benchmark for pain management. Furthermore, Essence of Care stages are similar to the six stages outlined in figure 1.

The stages involved are:

1. Stage One: Agree best practice
2. Stage Two: Assess clinical area against best practice
3. Stage Three: Produce and implement action plan aimed at achieving best practice
4. Stage Four: Review achievement towards best practice
5. Stage Five: Disseminate improvements and or review action plan
6. Stage Six: Agree best practice

The Essence of Care benchmarking toolkit identifies 11 “fundamental aspects of care”, each with its own set of benchmarks. These include:

• Continence, and bladder and bowel care.
• Personal and oral hygiene
• Food and nutrition
• Pressure ulcers
• Privacy and dignity
• Record-keeping
• The safety of clients with mental health needs in acute mental health and general hospital settings
• Principles of self-care
• Communication
• Health promotion
• Care environment

Andrew Lansley has singled out clinical audit as key driver for the government’s vision for the NHS. In Equity and Excellence: Liberating the NHS he states: “At present, Patient Related Outcome measures (PROM’s), other outcome measures, patient experience surveys and national clinical audit are not used widely enough. We will expand their validity, collection and use. The department will extend national clinical audit to support clinicians across a much wider range of treatments and conditions, and it will extend PROM’s across the NHS wherever practicable.”

The use of national frameworks such as the essence of care will support this vision and develop effective PROMs. Nurses need to be very much part of the audit work and to support the practice that challenges current practice and ensures openness, transparency, patient engagement hence supporting the delivery of better outcomes of patient care via clinical audit.

Clinical governance

The term clinical governance has encapsulated a range of initiatives and measures by the Department of Health, by which NHS organisations are responsible for providing quality services to its patients. According to Charnock this range of initiatives includes the following:

• Clinical audit and standard setting
• Clinical effectiveness, incorporating evidence based practice
• Clinical risk management and, as a structural reasoning to lessons learned from complaints
• Continuing professional development
• Professional self regulation
• Service accreditation
• Research and development

Clinical effectiveness has become the backbone of the nursing profession and is the central focus for medicine and other allied professions. Clinical effectiveness has been used as an umbrella for an array of terms that encompass; evidence based practice, outcomes research, clinical audit and clinical governance. All these attempt to monitor the effectiveness of medical and nursing interventions in order to enhance the quality of patient care.

Defining and measuring the quality of healthcare is central to improving clinical practice, and is a fundamental part of clinical governance. Quality of healthcare can be recognised in terms of three criteria such as patient safety; patient experience and effectiveness of care.

One potentially powerful and widely used method of quality improvement is to establish the extent to which clinical practice complies with identified review criteria and integrating three dimensions of high quality care within the audit framework for example safe care, effectiveness of care and positive patient experience. 

The degree of compliance, or lack of it, highlights areas where improvements can be made. This is the basis of clinical audit. In summary, as outlined in figure 3a, clinical governance encompasses a wide range of issues with the aim of improving quality of care by strengthening existing quality systems, the delivery of evidence-based practice and a learning organisation.

The relationships between the chief components of clinical governance are shown in figure 3a and the author has added two elements to the figure namely leadership and patient involvement. Leadership is central to implementing change and the identification of people to lead change in their areas of practice is often part of audit processes.

Clinical governance is, therefore, the method by which NHS trusts can improve the quality of healthcare services and one of its most important elements is clinical audit.

Table 1 provides definitions of a ‘criterion’ and ‘standards’ with examples; however, using recommendations from clinical practice guidelines to develop criteria and standards could save time and additional work.

Standard setting is informed nationally and locally for example by National Service Frameworks or locally using the trust policy. National standards that have been set needs to be evidence basede and are reviewed for example through the National Institute for Clinical Excellence.

Determining the key stakeholders in audit processes and obtaining their involvement is critical to secure the correct inputs for audits. Clinical audits usually involve people who either experience, deliver or provide resources for healthcare services.

The involvement of key stakeholders such as patients themselves will ensure that the audit tool developed will be realistic as by having a service user group the feedback provided ensures that questions asked in an audit measures the needs of the patient. This is one way to measure compassion, as if the patient is satisfied with the care then this supports that compassionate care is given.

Examples of the stakeholders that may be approached in audits include:

• Patients
• Medical directors
• Nurses
• Consultant doctors or nurses
• Medical secretaries
• GPs
• Directors of quality and service improvement
• Service leads
• Audit facilitators
• Educational facilitators
• Governance facilitators
• Information team members
• Medical records team members

From my experience it has been observed that staff sometimes see clinical audits as a burden and that there is little or no meaning to the whole process. This could be due to a number of factors such as:

• Poor design of clinical audit and in appropriate selection of review criteria
• Lack of understanding of what is clinical audit as a result of no training or not easy to access local information
• Heavy workload within the clinical environment
• Bureaucracy, such as needs to be approved via various senior team members before audit could go ahead
• Not enough resources to carry out the clinical audit

However, overcoming the above issues, clinical audit could lead to an improvement in the quality of service such as improvement in care of the patients, enhanced professionalism of staff and efficient use of resources.

The debate about appropriate methodology for audit is complex and a number of publications on audit have looked at examining, interpreting, and disseminating the principles of audit or criteria for good practice in audit to doctors, nurses, and other healthcare professionals.

Once a topic is selected and the criteria have been agreed to be measured against the selected quality standard, I suggest using the audit’s feasibility scoring grid shown in table 3. Table 2 was an earlier version and table 3 has been modified based on the current NHS climate and proven to be useful from my experience.

Table 3 provides a useful check whether to proceed with the audit, for example using the principle based on table 2 few layers have been added to table 3 shaded in grey and ensures that audits unlikely to succeed in table 2 could be worth considering or will usually succeed by adopting table 3.

Questions such as patient and carer involvement, involving other team members and meeting CQC outcomes give the project a better chance of quality output and ultimately benefitting the patient.

Nurses are bound by codes of conduct, for example to ensure that patient data remain confidential. Clinical audits must adhere to the Data Protection Act 1998 and Caldicott principles and, therefore, patients must not be identifiable. Patients must be made aware that the information they give may be recorded, may be shared in order to provide them with care, and may be used to support clinical audit and other work to monitor the quality of care provided. These ethical considerations underpin the requirement to undertake clinical audit and to monitor and improve quality care.

The Health Professions Council Standards of Proficiency states: 2c Critical evaluation of the impact of, or response to, the registrant’s actions.

The registrant must:

• be able to audit, reflect on and review practice
• understand the principles of quality control and quality assurance
• be aware of the role of audit and review in quality management, including quality control, quality assurance and the use of appropriate outcome measures
• be able to maintain an effective audit trail and work towards continual improvement
• participate in quality assurance programmes, where appropriate
• understand the value of reflection on practice and the need to record the outcome of such reflection
• recognise the value of case conferences and other methods of review

The Nursing and Midwifery Council Code states: you must work with colleagues to monitor the quality of your work and maintain the safety of those in your care. After the audit data has been collected and analysed it is necessary to develop an action plan outlining how and by whom the gaps will be solved and including how long this will take. After implementation good practice is to conduct the audit cycle to see if improvements have been made and sustained.

Clinical auditors should spend time verifying criteria and standards, therefore, and explaining their significance to staff. The more that nurses are actively involved in setting standards and criteria, and the better they recognise their relevance, the more authentic the audits. Clinical audits are more likely to be effective if they contribute to patient experience, safety, and improve effectiveness of care linked to healthcare efficiency.