What is Clinical Audit?

- by Bachchu Kailash Kaini

Introduction

Clinical Audit is an integral part of clinical practice within the NHS. All healthcare professionals are expected to participate. The 1997 White Paper The New NHS and subsequent Government publications A First Class Service and Clinical Governance - Quality in the new NHS have reinforced the position of Clinical Audit at the heart of Clinical Governance[1].

The NHS Plan sets out a requirement for audit, “All doctors employed in or under contract to the NHS will, as a condition of contract, be required to participate in annual appraisal and clinical audit, from 2001”[2]. (Paragraph 10.10)

The General Medical Council makes clear in Good Medical Practice: Maintaining Your Performance, which refers that doctors “must take part in regular and systematic medical and clinical audit”[3].

The NHS Clinical Governance Support Team define clinical audit in their 'Practical Clinical Audit Handbook' as: 'clinical audit is a quality improvement process that seeks to improve the patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structures, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual team, or service level and further monitoring is used to confirm improvement in healthcare delivery.' Clinical audit is all about measuring the quality of care and services against agreed standards and making improvements where necessary.

History of Clinical Audit

Florence Nightingale undertook one of the first Clinical Audits during the Crimean War of 1853 – 1855. Florence recognized that injured or ill soldiers admitted to the barracks hospital had high mortality rates. In order to tackle the problem, she and her team of 38 nurses applied strict sanitary routines and high standards of hygiene in the hospital. These improvements resulted in a drastic reduction in mortality rates. Few other clinicians at this time used audits.
In 1912 another famous advocate for clinical audit, Ernest Codman (1869–1940) introduced his “end of plan idea”. US Physician, Codman established a plan to enable the tracking of patient treatment outcomes as a way to identify clinical misadventures. This would serve as the foundation stone for improvement of patient care in the future. He believed this information should be made public to help guide patients in their choice of physicians and hospitals. To support this theory Codman published his own hospital results entitled ‘A Study in Hospital Efficiency’. (Codman, E. A. Boston, Mass (1916)). This prompted the American College of Surgeons in 1918 to create the Hospital Standardisation Programme which provided accreditation criteria and standards which were later adopted by the Joint Commission on Accreditation of Hospitals. This Programme was not however implemented in the UK.
Despite the successes of Nightingale in the Crimea and Codman in Massachusetts, clinical audit was slow to catch on. This situation was to remain for the next 130 or so years, with only a minority of healthcare staff embracing the process as a means of evaluating the quality of care delivered to patients.

[1] The principle was established for doctors in the 1989 White Paper, Working for Patients. Successive initiatives extended it to all healthcare professionals culminating in 1997 in The New NHS and subsequently Clinical Governance – Quality in the NHS.

[2] The NHS Plan: A Plan for Investment, A Plan for Reform; DH, 2000

[3] Good Medical Practice, GMC, May 2001