Clinical audit: can we improve further?

Clinical audit is an important tool for comparing one’s practice against existing standards. The authors have analysed the Junior Doctor’s understanding of audit by performing a survey and questionnaire from 146 trainees, SpRs and SHOs from nine hospitals. The study showed that 107 (72.8%) performed audit and among those who performed audit, 52 (48.6%) experienced difficulty in obtaining data. This study highlights the importance of support needed to encourage the junior doctors to participate in audit programmes.

Clinical audit with its attendant benefits of constantly improving standards of healthcare is now an integral part of the healthcare service. In the era of clinical governance, guidelines about audit have been issued by the National Institute of Clinical Excellence and the National Centre for Clinical Audit in England have issued guidelines concerning clinical audit. However, we feel that the implementation of these guidelines at the local level still has room for improvement. In order to confirm an understanding of the principles of audit and assess the involvement of trainees in audit programmes, we conducted a survey, using a structured questionnaire, of surgical trainees in various specialties.

We designed a structured questionnaire that was distributed to trainees, from various deaneries involving three teaching hospitals, and six District General Hospitals. One hundred and forty-six trainees from various specialties were included in the survey involving both medical and surgical trainees. Incompletely filled questionnaires were excluded from the study.

One hundred and sixty-eight trainees were invited to participate. Twenty-one forms were incomplete and not included in the assessment. Of the 147 trainees who successfully completed the questionnaire, 42.1% (62 of 147) were in the specialist registrar (SpR) grade, and 57.8% (85 of 147) were in the senior house officer (SHO) grade. Seventy-nine per cent (67 of 85) SHOs were on a BST rotation, and 21.1% (18 of 85) were senior SHOs.

Eight-nine per cent (55/62) of SpRs and 85% (72/85) of SHOs felt they were comfortable with their understanding of the principles of audit. Fifty-two per cent (32/62) of SpRs and 37.6% (32/85) of SHOs had received formal training in the principles of audit, and how to conduct an audit. However, only 87% (48/62) of SpRs and 58.8% (50/85) of SHOs knew about the audit cycle.

Eighty-two per cent (51/62) of SpRs and 65.9% (56/85) of SHOs had performed audit in their careers. Fourteen per cent (16/51) of SpRs and 12.5% (7/56) of SHOs performed audit due to their own interest in the subject. Of those who responded, 35.3% (18/51) of SpRs and 55.4% (31/56) of SHOs performed an audit because they had been asked to do so by a senior staff member. Enhancing their curriculum vitae (CV) and helping to get further jobs was the reason for 33.3% (17/51) of SpRs and 32.1% (18/56) of SHOs performing audit. Sixty-three per cent (32/51) of audits conducted by SpRs and 50% (28/56) of audits conducted by SHOs actually resulted in a change in practice.

Sixty-one per cent (31/51) of SpRs and 37.5% (21/56) of SHOs found it difficult to obtain or collect data for the audit. 94.1% (48/51) of SpRs and 82.1% (46/56) of SHOs presented their audit; 33.3% (16/48) of SpRs and 10.9% (5/46) of SHOs presented their audit at an international or regional meeting, the rest of the audits were presented locally.

Thirty-one per cent (16/51) of SpRs and 23.2% (13/56) of SHOs had suggestions to improve audit in their hospitals namely training (12 SpR, 7 SHOs), hospital audit personnel involvement (6 SpR, 2 SHOs), consultant’s assistance (8 SpR, 8 SHOs), improving data retrieval facilities (3 SpR, 4 SHOs) and dedicated study time to carry out audit (12 SpR, 4 SHOs).

What is your training Grade? : SHO/PRHO/SpR/Other
Do you understand about audit? Yes/No
Have you had any formal training in audit principles? Yes/No
Do you know about the audit cycle? Yes/No
Have you involved / performed any audit? Yes/No If you have said Yes proceed to Question 6
Why have you performed audit? Interest/Asked to do/CV or job
Did you have to make any change in your practice? Yes/No
Was it easy to collect data for your audit? Yes/No
Would you like to give any suggestions to improve the audit? Yes/No? If so, explain
Have you presented your audit result? Yes/No If yes, where? Hospital- Unit/Regional/National or International

Audit has been defined as “A systematic critical analysis of the quality of medical care including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and the quality of life for the patient.”¹ It is an important tool for comparing one’s practice against existing standards.

Seventy-three per cent (107/147) of trainees had performed an audit, showing a widespread recognition and the importance of audit in clinical practice. This has important implications for healthcare improvement.

However, only 44% (64/147) had been trained to perform an audit. The rest were self-taught. Of those trainees who responded, 48.6% ( 52/107) faced difficulties in collecting data. This can be improved by providing better access to records and imparting regular formal training to trainees in liaison with the information technology and clinical audit department of the hospital.

Only 22% (23/107) performed an audit due to their own interest in the subject. While there is no doubt that audits add weight to the CV, interest in the subject and comparing ones practice against existing standards should be the over-riding reason for doing an audit. Twenty-one out of 94 (22.3%) of trainees presented their audits internationally or regionally.

Trainees should be encouraged to perform audit and they should receive formal training. The involvement and assistance of senior medical staff is vital to the setting up and smooth performance of an audit.² Junior doctors often feel that there is inadequate assistance from senior members of staff.³ Senior clinical staff member should be nominated to overlook and guide them through the audit.

Junior doctors posts are often only of short duration and they may find it difficult to complete the audit cycle.⁴ When involved in auditing, junior doctors welcome a dedicated time for audit during the week, have easier access to patient records, and co-operation from information technology departments.

AUDIT

Clinical audit: can we improve further?