How To Do a Clinical Audit: Baby Steps

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How To Do a Clinical Audit: Baby Steps

What is a Clinical Audit? 

                   "Audit is a review of current health practices against national guidelines and standards, which is designed to ensure that we provide the best level of care to our patients." 

In essence, a clinical audit involves comparing national guidelines and standards with the current practices in your ward, department, or hospital. It's a process of comparison. To do this, we need two things: first, what we are currently doing, and second, what we should be doing according to the standards and guidelines. Let's walk through the process:

1. Choosing a Topic/Problem:

  • This is often where many get stuck. What can be a topic for an audit? 
Let’s understand with an example: You work in an emergency cardiology unit, where many patients present with myocardial infarction and are treated with a thrombolytic agent (alteplase). After administering tPA, an ECG should be done at around 90 minutes to assess coronary reperfusion using the ST-segment criteria. However, you have noticed that sometimes the ECG is done after 120 minutes, or in some cases, not at all. This inconsistency is a problem and becomes the topic for the audit. You have chosen one metric (ECG at 90 minutes after MI) to compare with the standards. 
  • Tips for Selecting a Topic: Choose a manageable and relevant topic. If this is your first audit, start with something simple and familiar, ideally related to your specialty. It should be something you can control and influence within your department.

2. Finding Support & Guidance:

  • One of the best ways to ensure success is by seeking support from a colleague or senior who has already completed an audit. They can guide you through the entire process. If you cannot find someone to help, complete your audit on your own and become the person others in your department can turn to for support and guidance.


3. Finding the Standard Guideline:

  • Once you know what you are currently doing, the next step is identifying what you should be doing according to the standards. 
In the example above: You need to know the exact time from the guideline for when to perform an ECG after administering tPA in acute myocardial infarction patients. 
  • Ideally, you should search for your own hospital guidelines. If those are not available, you can ask your senior consultants to find out which international or national guidelines can be used for the audit purposes. 
  • In many healthcare settings, American, NICE, or European guidelines are widely accepted. 
    • Where to Search: You can use search engines like Google or Google Scholar, but prioritize official websites when downloading guidelines. 

    4. Collect Data Using a Questionnaire: 

    • When you have both the current practice and the guideline in hand, it's time to start gathering data to assess how closely your practice aligns with the standard. 
    • Getting back to the example: If you need to know whether you are doing ECGs at 90 minutes for all MI patients or not, you will have to collect data of MI patients in your ward to see what the department has been actually doing. 
    • Where to Find this Data: To collect this data, you have to look for patient notes or electronic health records for all myocardial infarction patients that presented to the unit and received tPA treatment in the last few months. 
    • Inclusion & Exclusion Criterias: You need to define some checkpoints or criteria that a patient should meet in order to be included in the audit. For example: the patient should be diagnosed with acute myocardial infarction, received thrombolytic treatment and survived for atleast 90 minutes after receiving the treatment. All those patients. who meet these criteria will be included. Some patients e.g., who were treated with primary coronary intervention will not be included in the process. 
    • Understand the data you need: From the patient notes you will need a few things e.g., patient's name, age, hospital number, date of admission, diagnosis, tPA administered or not, and was the ECG done at 90 minutes or not. 
    • Using a Questionnaire: You can not just use a pen and paper to write all this information down. To ensure consistent data collection, you will need a structured questionnaire. This will help standardize how you gather information and prevent missing important details.
    • Keep data collection manageable: Start small, and don’t overcomplicate it. Focus on one metric, like compliance with a single guideline. 
            Example of a simple questionnaire

    5. Analyze the Collected Data: 

    • Once you have collected the data, the next step is to analyze it. By converting your data into percentages or figures, you can clearly see gaps in practice and identify areas for improvement.
    • 90-Minute ECG Example: You will now analyze how many patients out of the total had an ECG done at 90 minutes. You will record this in a percentage form e.g.,75% patients who received tPA after an acute myocardial infarction had the 90-minute ECG done. 

    6. Writing the Audit Report

    • You are almost at the completion of your audit. From the results, you can see whether you are compliant with the guidelines or not, and if not then how far off are you from standard practice.
    • The next step is to write the audit report. If you have done the previous steps correctly, the report is already 50% written. 
    • A simple audit reports consist of the following:
      1. Audit Title 
      2. Aims & Objectives 
      3. Background 
      4. Methodology 
      5. Results 
      6. Conclusion / Recommendations

    7. Implementing Changes: Make an Impact

    • You can now present your audit to your colleagues and the department with suggestions to make some changes in order to be compliant with the standard guidelines.
    • Presenting Your Audit: You can present at a team meeting, or a teaching session in the form of a PowerPoint presentation. 
    • Once you’ve presented your findings, engage with the team to discuss feasible changes and recommendations. Remember, your goal is to 
    • Recommendations: Re-training of staff on guidelines, posters in the department, or  teaching sessions etc. 

    8. Closing the Loop: Re-Audit: 

    • Fast forward a couple of months, repeat the same process again and analyze results to see if their is an improvment in compliance with the guidelines.
    • Re-auditing is crucial because it closes the loop on your audit. It allows you to assess whether the changes you implemented have led to lasting improvements in practice. Without this, there is no way to know if the issues identified have truly been addressed."


    Summary: 

    • Doing a clinical audit for the first time is difficult and confusing for most of us who do not have any academic or research related experience. 
    • Remember, your first audit doesn’t need to be perfect. What matters most is that you’re taking the initiative to improve patient care. Start small, take one step at a time, and soon you’ll be able to look back at your completed audit with pride.
    • You can re-do the same audit again with improvements or start a new one.
    • The most important point that helped me do my first audit was to just take the audit one step at a time. In a couple of weeks I was done with my first audit.