Clinical Audit Handbook: A Practical Guide to Clinical Audit in the Gaza-Strip
STEP 1: Choosing the Topic
The topic can be chosen from different
aspects, but should always be relevant.
It can cover aspects of patient care, 
service delivery and organization or
.cost effectiveness. It should fall within
one of the following categories:
· High priority within the organization
· High volume of work
· High costs
· High risks
· Patient needs
Setting the AIM & OBJECTIVES
It is always important to set a firm aim along with specific objectives you want to achieve with the audit. The aim is the overall goal, which is then broken down into smaller objectives.
Example 1:
AIM
Improve care for patients with ST Elevation myocardial infrarction (STEMI) and Non-ST Elevation myocardial infarction (non-STEMI).
OBJECTIVES
Ascertain that patients receive the correct drug treatment following STEMI and non-STEMI.
Improve prescription of Quadruple Therary for patients following STEMI and non-STEMI.
Example 2:
AIM
To improve care of women attending with PROM.
OBJECTIVES
Assessment the management of women presenting with PrelabourRupture of the Membranes (PROM) at term and assess how inpatient management compares with the hospital’s current clinical practice guideline.
STEP 2: Setting the Standard: Identification of Best Available Evidence
This is a crucial step as the standard
is the quality of care that you want
to achieve in your organization. It is
the practice you are going to
compare the practice in your
organization to. It is also what you
want to achieve in your organization.
How can Standards be identified?
Local Guidelines
The best starting point is always to look for local guidelines. As this is the service your organization decided to provide and it should always be based on Best Evidence. Make sure these guidelines are not out of date and have been updated.
International Guidelines
If no local guidelines are available, then international guidelines are the next step. These are also based on best available evidence. The disadvantage they might have is that they are not always relevant for your reality.
Systematic Reviews / Metaanalysis / Literature Review
If none of the above are available, which should only be the case in rare circumstances, then a literature review needs to be done to IDENTIFY the BEST EVIDENCE. Here the first reference should always be systematic reviews followed by metaanalysis. Take Care to critically appraise such evidence and make sure it is strong and methodically sound.
Example 1:
AIM & OBJECTIVES
Improve care for patients with ST Elevation myocardial infrarction (STEMI) and Non-ST Elevation myocardial infarction (non-STEMI).
Ascertain that patients receive the correct drug treatment following STEMI and non-STEMI.
Improve prescription of Quadruple Therary for patients following STEMI and non-STEMI.
SETTING the STANDARD
NICE guidelines (as well as other international guidelines) recommend that ALL patients should be on quadruple therapy (betablocker, statin, aspirin and ACE inhibitor) following STEMI and non-STEMI, except for contraindications such as intolerance.
Example 2:
AIM & OBJECTIVES
To improve care of women attending with PROM.
Assessment the management of women presenting with PrelabourRupture of the Membranes (PROM) at term and assess how inpatient management compares with the hospital’s current clinical practice guideline.
SETTING the STANDARD
Local hospital guidelines recommend for ALL women with prelabour PROM to have: recording of vital signs, CBC, CTG, HVS, sterile speculum examination, antibiotic therapy only if delay to delivery > 18 hours or clinical indications and digital per vagina examination only if indicated ie in active labour (see example section).
STEP 3: Measuring Performance
This is the step that involves data collection, data analysis and audit presentation to the team concerned.
Data collection
This can be done retrospectively usually by looking through admission records or hospital notes.
Retrospective data collection has the advantage of needing less time, but, depending on the quality
level of documentation, it can be incomplete.
Another way is to collect data prospectively. This often needs a
longer timeframe to perform the audit (depending on the cases
presenting daily), but data collection is more complete with this.
However, it can have a significant bias, if healthcare professionals
know an audit is being performed, their approach and actions might differ from their usual behavior (the Harrison Effect).
For all purposes it is always important to devise a data collection sheet that is simple to fill in and mainly comprises tick boxes for answers, to make analysis easy.
· Data collection has to be anonymous (no names, only file numbers on papers or electronic records)
· Do not collect unnecessary data
Sample Size
In clinical audit, sample size is always a compromise between getting a representative sample to get an idea about how the cases examined are being managed and practical possibilities of collecting the data. Meaning that sample size can be much smaller than for research purposes, when a certain new point is being examined and needs to be made. Depending on prevalence of the problem around 50 is usually a good number. In rare cases (ie Management of congenital aortic stenosis), less might be appropriate, whereas very common presentations (ie Management of Myocardial Infarction) more will be necessary.
Data Analysis
Data can be analyzed and understood with the help of simple descriptive statistics like frequencies, percentages, mean, mode and median. These can be calculated ‘by hand’ or with the help of programmes such as EXCEL.
Data Presentation
It is a very important factor in clinical audit that all data should be presented to the team that it concerns. This is best done in a formal meeting, when minutes are taken. It can be within a hospital audit meeting when several audits are being presented to the team.
Presentation has to be done in a clear and easy to understand way that involves the following sections in the presentation:
· Background (reasons for choosing the topic)
· Aim & Objectives
· Standards
· Methods (prospective / retrospective data collection, what was looked at)
· Results
· Conclusions
· Recommendations
It is good to show results in an easy to understand way, often charts help audiences to quickly grasp the results.
Any audit presentation should have 3 – 4 recommendations (possibly less, especially if no need for improvement is found). It is important not to make too many, as then it might be possible to formulate a coherent and workable action plan.
STEP 4: Implementation of Change
Formulation of an Action Plan
This is possibly the most important, but also the most difficult part in the audit cycle. Here the team needs to be motivated to take up the ideas and accept the findings in the audit.
At the audit presentation an action plan has to be drawn up. This has to answer the following questions and guides the successful implementation of change:
1. What is needing to be done?
2. Who is going to be responsible for doing it?
3. When is the change going to be completed?
The action plan should be formally decided and documented.
Audit Lead
This is the area of the Audit Lead. Every department should stipulate one consultant to be the audit lead. His responsibility is to keep track of audit activity, keep minutes and decisions, such as action plans, at meetings, stimulate more audit activity and keep track which audits and re-audits need to be done.
STEP 5: Sustaining Improvements
Sustaining improvements means to check after a given period of time (usually 6 or 12 months) if the
intended improvements have been realized. It is important to only do this after implementation of the
recommendations. As without their implementation, no change in practice can be expected.
In fact, this step is best be done in form of a straight forward ‘re-audit’. Meaning to take the same approach and design in order to look at the same factors, so that these can be compared. At this point, it might appear that results are now meeting the expected standard for the healthcare service and then the audit cycle is complete. In other cases, it might show that the standard is still not properly and fully met and therefore more changes and improvements need to be put into place to further improve the practice. This has then again to be checked after 6 – 12 months with another reaudit to check the affect.
Ongoing Quality Improvement
Systematic clinical audit is therefore an ongoing process, which is never really finished. On the other hand, it has to be done perpetually and be integrated as an ongoing process into clinical care and healthcare service management. It is the cornerstone for quality assurance in any health system and is and essential tool in ensuring patient safety.
Please look on the following links for examples of audits performed in Gaza, as well as for more information:
Some examples of clinical audits performed in the Gaza-Strip
News and Events
Clinical Audit Support: contact details for practical help