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How to Perform a Clinical Audit

How to Perform a Clinical Audit

Definition of a Clinical Audit

This type of audit involves the assessment of the quality of healthcare that is provided to patients with the aim of improving care and recovery. It is carried out using standardized procedures with a view of reviewing the quality of care against the established criteria for quality. A clinical audit, like other forms of audits, allows the health institution to ascertain the strengths and weaknesses of its services to prevent a drop in quality of care that is delivered to patients. It also assesses the number, quality, and qualification of health personnel for the improvement of the general and specialized fields of care. Depending on the health care facility or jurisdictional requirements, audits may be carried out once a year or more.

Before starting an audit, highlighting potential problems that can impede the process helps to increase the success rate of the entire process. The difficulties can include access to records, short timeframe, inadequate audit approach, broad scope, and poorly defined objectives.

Processes of a Clinical Audit

To perform a successful audit that adds value to a healthcare institution, several steps should be taken. These steps include the following.

Select a Subject

The selection of a subject for an audit helps to simplify the process and focus efforts on aspects of health care that are in actual need of improvement. Therefore, it is necessary to select audit subjects that are critical to patient care and also help to improve the quality and working conditions of health care personnel (doctors, nurses).

It is vital to ensure that audits are in line with the aims and objectives of the health care service so as to gain the support of the decision-makers of the institution. Also, it is essential to ensure that audits cover critical areas of operation, such as surgery or pediatrics. Additionally, it is necessary to make use of jurisdictional standards while taking into consideration the prevailing conditions of the institution, which include the possible impact of the audit and available resources.

Consult with Stakeholders

It is crucial to involve all the relevant stakeholders right from the beginning of the audit. Make sure that the scope of the audit is in line with the guidelines and needs of the management. Do not begin an audit that is going to exceed the resources the administration is willing to put aside for the project.

Consult and consider the advice of the medical and non-medical staff of the institution. The information they provide is vital for the successful implementation of the final recommendations. Also, consider the opinions of patients as the entire process is mostly geared towards the improvement of the services offered to them.

Set Goals and Standards

Create audit goals and standards to assist with the measurement of information collected against expectations. In case an audit was once done before, make sure to check the standards used in conducting the previous audit. This step helps to standardize the results obtained.

Make use of national, regional, and local standards during the audit process. Work closely with the clinical personnel to ensure selected standards are realistic and conform to the goals of the institution.

Choose the Data Collection Process

The audit sample helps to make conclusions regarding the scope of the subject. It also influences the group of the patient population and other constraints. Use adequate cases to ensure a balanced result. The size of the clinic or health facility determines the appropriate number of cases required.

The audit should operate within an appropriate ethical paradigm. Depending on the type of audit and the constraints of the audit, data collection can be collective or based on individual cases. There should be consistency in data collection to ensure uniformity. Each individual involved in the audit must be aware and equipped to implement the selected methodology.

Design Data Template

The template should be designed to avoid the collection of unnecessary data. It should allow for the selection and assortment of concise information in an orderly and logical manner. When possible, the usage of an electronic or computer-based approach helps to ensure efficiency and proper time management. Confidentiality is crucial in this aspect of clinical audit, and it is maintained through the omission of personal patient information.

Test the Process

It is always crucial to test run the entire process. This step saves time and resources, which are, in most cases, limited. It also helps to highlight problems that may hamper the successful completion of the entire audit process, thereby given a chance for a rethink of a particular step or the whole process.

Perform Audit

After testing, check with all stakeholders to ensure they are familiar with the process involved and the exact timeframe. Periodic feedback is vital for the successful completion of the audit. Several software programs exist, which can assist with the analysis of data and the development of conclusions.

Prepare a Comprehensive Report

At this stage, it is always better to develop a report of the audit carried out concisely and straightforwardly for easy comprehension. The use of tables, graphs, diagrams, and appropriate illustrations helps with effective communication of findings, recommendations, and conclusions. Limits and challenges of the audit should be explicitly stated. An action plan for the successful implementation of recommendations must be presented to maximize the value that is obtainable from the audit.

Recommend Appropriate Audit Cycle

For the sustainability of the developed action plan, a suitable timeframe for a continuous audit cycle should be established. The audit cycle is critical to ensure that the energy and time spent does not constitute another wasteful endeavor. Also, a continuous audit cycle provides a form of feedback that helps to pinpoint areas of sustained improvement and areas that require a rethink of strategy. Results obtained from each audit cycle can be packaged into a seminar or a publication to add value to the existing body of knowledge and also obtain much-needed feedback from the larger society of professionals.


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