Let’s from the outset say that we know in-depth detailed audits of all areas of clinical practice and healthcare services are essential.
It is with audit that we can collect evidence of compliance and identify risks and non-conformances to inform our quality improvement programmes and so improve patient care.
Ann Higgins, Clinical Director, Medical Audits Limited, kindly shares her experience with Hospital Hub…
But what does the research say?
The World Health Organization, on behalf of the European Observatory on Health Systems and Policies carried out a review in 2010 to look at the impact of audit and feedback on patient safety and patient outcomes(1).
In their review of over 170 studies, they concluded that while there is extensive evidence across Europe of the gap that exists between the care patients receive and the recommended standard of care, the impact of audit and feedback on improving practice is very much related to the timeliness and specificity of the feedback and the manner in which it is provided.
A Cochrane systematic review of 140 studies was carried out in 2012 and came to similar conclusions saying that audit and feedback provided potentially important improvements in professional practice(2). They concluded individualised, non-punitive immediate feedback, provided to individuals frequently and with clear actions for improvement had the most impact.
So let’s step back for a second…
We still need quality assurance (QA) auditing to evidence compliance. Agreed.
But what about quality improvement (QI) auditing?
For QI this audit data, according to the evidence from research, must be fed back to the relevant staff immediately, frequently, and with agreed actions, for any improvement to occur. If this is the case we need to reconsider how we audit, what we audit and we must have clear definitive standards to audit against.
Then, when we feed back the results, we need to concentrate on the facts and provide written evidence of the issue so the recipient will be very clear of the actual gap in practice and what needs to be done to close it.
So we have a problem then…
Traditionally audits were mostly very long, time consuming and contain very little guidance for the auditor as to exactly what the evidence of compliance should be.
If we are to learn from the research we need to make audits short, specific, fast and with detailed guidance for auditors as to the exact standard. And essential to the process, feedback and action plans need to be part of this audit process and not something that comes as an afterthought.
So what do we do…
Let’s examine a standard NHS ward as an example. The average ward is required to audit compliance with over 2,000 standards – every month. Standards that cover:
The list, we all agree is long and not exhaustive. If we are really honest, it’s a very difficult task to audit all the standards related to all the issues affecting the ward in the available time. And of course the audit is not going to achieve any improvements if the results are not fed back to staff with clear actions to guide improvements.
If we can accept that in the time available, every standard can’t be audited by staff for who audit is only a part of their job description, then we are on the road to a solution. Unfortunately, the reality is if audits take too long, ward staff just won’t be able to do them.
Review the content of audits
Review what we ask ward staff to audit. Have we become guilty of getting ward staff to collect too much data rather than targeting specific key standards at department level?
Should detailed audits, of every standard, be completed by specific audit staff and specialist teams less frequently and based on targeting areas with poorer compliance scores identified in ward audits?
Recognise auditing is not the goal
We need to remind ourselves that the goal is quality improvement not ‘doing the audit’. When we do this, we will target ward audits to the standards that will improve safety and outcomes most.
We need to provide ward staff with better audit tools, designed for their needs. These audit tools need to be concise, targeted to key standards and with very clear explanation of what is expected for compliance. Every audit system must be designed with these high impact principles.
We can then achieve REAL ownership of audit data, REAL quality improvement and REAL, long term positive changes to make our hospitals safer for all.
If you want more information on targeted, high impact audits contact the Medical Audits clinical team at firstname.lastname@example.org or call Ann or Charlotte on 0121 2708865.
1 – Using audit and feedback to health professionals to improve the quality and safety of health care. World Health Organisation (WHO) on behalf of the European Observatory on Health Systems and Policies, 2010.
2 – Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012 Jun 13;(6):CD000259. doi: 10.1002/14651858.