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• Please see speaker notes below for
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Promoting quality for
better health services
Criteria and indicators of best
practice in clinical audit
Clinical audit cycle
Stages of clinical audit cycle
• Stage 1 – Preparation & planning
• Stage 2 – Measuring performance
• Stage 3 - Implementing change
• Stage 4 – Sustaining improvement (including
re-audit)
Stage 1 Preparation and Planning
• Criterion 1
– The topic for the clinical audit is a priority
• Indicators
– 1.1 Topic reflects a local service, specialty or national priority
where care could be improved or refined through clinical audit
– 1.2 Key stakeholders, clinical and non-clinical, agree that topic
is a priority
Stage 1 Preparation and planning
• Criterion 2
– The clinical audit measures against standards
• Indicators
– 2.1 Standards are based on best available evidence
– 2.2 Standards are referenced to source and link provided
– 2.3 Standards are agreed by clinical audit team, clinicians and
patients
– 2.4 Standards are expressed in a form that enables
measurement
Stage 1 Preparation and planning
• Criterion 3
– The organisation enables the conduct of clinical audit
• Indicators
– 3.1 Written plan describes structures and processes to support
clinical audit
– 3.2 Staff have time to participate
– 3.3 Organisation provides administrative and practical support
– 3.4 Necessary training is identified and provided
– 3.5 Financial costs are identified and met
Stage 1 Preparation and planning
• Criterion 4
– The clinical audit engages with clinical and non-clinical
stakeholders
• Indicators
– 4.1 All clinical disciplines relevant to audit topic should be involved
– 4.2 Senior clinicians show commitment and provide leadership
– 4.3 Ownership of clinical audit findings at most senior level where
there is power to implement change
– 4.4 Stakeholder roles and accountabilities are clearly defined
– 4.5 Stakeholders are involved from beginning to end
– 4.6 Active communication is maintained throughout the process
Stage 1 Preparation and planning
• Criterion 5
– Patients or their representatives are involved in the
clinical audit if appropriate
• Indicators
– 5.1 Patient group to whom standards apply is clearly defined
– 5.2 Standards include patient priorities and patient-defined
outcomes
– 5.3 Patients/carers are recognised as key stakeholders
– 5.4 Patient members of clinical audit team are fully informed about
what is expected of them....
– 5.5 .....and are given basic training as necessary
– 5.6 Patients are kept informed about timescales,
progress, results and actions
Stages of clinical audit cycle
• Stage 1 – Preparation & planning
• Stage 2 – Measuring performance
• Stage 3 - Implementing change
• Stage 4 – Sustaining improvement (including
re-audit)
Stage 2 Measuring performance
• Criterion 6
– Clinical audit method is described in written
protocol
• Indicators
– 6.1 Timetable for clinical audit is described including
completion and re-audit
– 6.2 Protocol describes methodology & data collection process
in detail
– 6.3 Consideration given to ethics, confidentiality & consent
and Caldicott principles applied
– 6.4 Methods are recorded so that re-audit can be undertaken
Stage 2 Measuring performance
• Criterion 7
– Target sample should be appropriate to generate
meaningful results
• Indicators
– 7.1 method of sampling best suited to measuring
performance against standards and scientifically reliable
– 7.2 sample size sufficient to generate meaningful results
– 7.3 sample allows for adjustment for case mix
Stage 2 Measuring performance
• Criterion 8
– Data collection process is robust
• Indicators
– 8.1 clinical audit utilises pre-existing data sets where possible
– 8.2 data collection tool and process have been validated
– 8.3 data collection process aims to ensure complete data
capture
Stage 2 Measuring performance
• Criterion 9
– Data analysed & results reported in way that
maximises impact of clinical audit
• Indicators
– 9.1 data analysed & feedback of results given within agreed
timescale to maintain momentum
– 9.2 results presented appropriately for each audience to
ensure that they stimulate & support action planning
– 9.3 results are communicated effectively to all key
stakeholders including patients
Stages of clinical audit cycle
• Stage 1 – Preparation & planning
• Stage 2 – Measuring performance
• Stage 3 - Implementing change
• Stage 4 – Sustaining improvement (including
re-audit)
Stage 3 Implementing change
• Criterion 10
– Action plan is developed and implemented to take
forward any recommendations made
• Indicators
– 10.1 plan to include both areas needing attention & those with
good compliance
– 10.2 plan to have agreement of stakeholders including patients
– 10.3 plan highlights who is responsible for each action with
timescales
– 10.4 plan identifies financial/resource implications
– 10.5 results & action plan is communicated widely
– 10.6 implementation is closely monitored and
progress regularly communicated
Stages of clinical audit cycle
• Stage 1 – Preparation & planning
• Stage 2 – Measuring performance
• Stage 3 - Implementing change
• Stage 4 – Sustaining improvement
(including re-audit)
Stage 4 Sustaining improvement
• Criterion 11
– Clinical audit is cyclical process that demonstrates
that improvement has been achieved & sustained
• Indicators
– 11.1 topic is re-audited to complete clinical audit cycle
– 11.2 where recommended action is not achieved topic is reaudited at agreed intervals
– 11.3 results of re-audit are recorded and disseminated
appropriately including to patients
HQIP website
HQIP website
Contact us
Healthcare Quality Improvement
Partnership
Email - lqit@hqip.org.uk
Website - www.hqip.org.uk
Promoting quality improvement for better healthcare