You do not have permission to edit this page, for the following reasons:

This IP address has been blocked from editing Wikipedia.
This does not affect your ability to read Wikipedia pages.
Most people who see this message have done nothing wrong. Some kinds of blocks restrict editing from specific service providers or telecom companies in response to recent abuse or vandalism, and can sometimes affect other users who are unrelated to that abuse. Review the information below for assistance if you do not believe that you have done anything wrong.

The IP address or range 44.201.0.0/16 has been blocked (disabled) by ‪ST47‬ for the following reason(s):

The IP address that you are currently using has been blocked because it is believed to be a web host provider. To prevent abuse, web hosts may be blocked from editing Wikipedia.
You will not be able to edit Wikipedia using a web host provider because it hides your IP address, much like a proxy or VPN.
We recommend that you attempt to use another connection to edit. For example, if you use a proxy or VPN to connect to the internet, turn it off when editing Wikipedia. If you edit using a mobile connection, try using a Wi-Fi connection, and vice versa. If you are using a corporate internet connection, switch to a different Wi-Fi network. If you have a Wikipedia account, please log in.
If you do not have any other way to edit Wikipedia, you will need to request an IP block exemption.

How to appeal if you are confident that your connection does not use a web host's IP address:
If you are confident that you are not using a web host, you may appeal this block by adding the following text on your talk page: ((unblock|reason=Caught by a web host block but this host or IP is not a web host. My IP address is _______. Place any further information here. ~~~~)). You must fill in the blank with your IP address for this block to be investigated. Your IP address can be determined here. Alternatively, if you wish to keep your IP address private you can use the unblock ticket request system. There are several reasons you might be editing using the IP address of a web host (such as if you are using VPN software or a business network); please use this method of appeal only if you think your IP address is in fact not a web host.

Administrators: The IP block exemption user right should only be applied to allow users to edit using web host in exceptional circumstances, and they should usually be directed to the functionaries team via email. If you intend to give the IPBE user right, a CheckUser needs to take a look at the account. This can be requested most easily at SPI Quick Checkuser Requests. Unblocking an IP or IP range with this template is highly discouraged without at least contacting the blocking administrator.

This block will expire on 23:54, 31 July 2024.

Even when blocked, you will usually still be able to edit your user talk page, as well as email administrators and other editors.

For information on how to proceed, please read the FAQ for blocked users and the guideline on block appeals. The guide to appealing blocks may also be helpful.

Other useful links: Blocking policy · Help:I have been blocked
Your IP address is in a range that has been blocked on all Wikimedia Foundation wikis. The block was made by ‪AntiCompositeNumber‬. The reason given is Open proxy/Webhost: Visit the FAQ if you are affected .
- Start of block: 13:55, 18 August 2022
- Expiry of block: 13:55, 18 April 2025
Your current IP address is 44.201.244.194. The blocked range is 44.201.0.0/16. Please include all above details in any queries you make. If you believe you were blocked by mistake, you can find additional information and instructions in the No open proxies global policy. Otherwise, to discuss the block please post a request for review on Meta-Wiki. You could also send an email to the stewards VRT queue at stewards@wikimedia.org including all above details.

You can view and copy the source of this page:

((Short description|Medical care quality improvement process))
((Use dmy dates|date=April 2022))
((More citations needed|date=June 2021))
'''Clinical audit''' is a process that has been defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change

The key component of clinical audit is that performance is reviewed (or audited), to ensure that what ''should'' be being done ''is'' being done, and if not, it provides a framework to enable improvements to be made. It had been formally incorporated in the healthcare systems of a number of countries, for instance  in 1993 into the United Kingdom's National Health Service (NHS), and within the NHS there is a clinical audit guidance group in the ''Clinical'' audit comes under the clinical governance umbrella and forms part of the system for improving the standard of clinical practice.

==History==

The first recorded medical audit was done by Sinan Ibnu Thabit, Chief Physician of Baghdad dan Abu Batiha al-Muhtasib (market inspector) at the request of [[Abbasid Caliphate|Abbasid]] Caliph [[Al-Muqtadir]] after medical malpractice resulted in death of a patient. Following the investigation, the first medical licensing examination has been introduced, and only physicians who pass the exam can practice medicine. According to Ibnu Al-Ukhuwwa in his book, Ma'alim al-Qurba: fi Ahkam al-Hisba, "If the patient is cured, the physician is paid. If the patient dies, his parents go to the chief doctor, they present the prescriptions written by the physician. If the chief doctor judges that the physician has performed his job perfectly without negligence, he tells the parents that death was natural; if he judges otherwise, he tells them: take the blood money of your relative from the physician; he killed him by his bad performance and negligence. In this honourable way they were sure that medicine is practiced by experienced, well-trained persons."

One of first clinical audits was undertaken by [[Florence Nightingale]] during the [[Crimean War]] of 1853–55. On arrival at the medical barracks [[hospital]] in [[Üsküdar|Scutari]] in 1854, Nightingale was appalled by the unsanitary conditions and high [[mortality rate]]s among injured or ill soldiers. She and her team of 38 nurses applied strict sanitary routines and standards of [[hygiene]] to the hospital and equipment; in addition, Nightingale had a talent for [[mathematics]] and [[statistics]], and she and her staff kept meticulous records of the mortality rates among the hospital [[patient]]s. Following these changes the [[death|mortality]] rates fell from 40% to 2%, and the results were instrumental in overcoming the resistance of the British doctors and officers to Nightingale's procedures. Her methodical approach, as well as the emphasis on uniformity and comparability of the results of health care, is recognised as one of the earliest programs of outcomes management.

Another notable figure who advocated clinical audit was [[Ernest Codman]] (1869–1940). Codman became known as the first true medical auditor following his work in 1912 on monitoring surgical outcomes. Codman's "end result idea" was to follow every patient's case history after [[surgery]] to identify errors made by individual [[surgeon]]s on specific patients. Although his work is often neglected in the history of [[Health assessment|health care assessment]], Codman's work anticipated contemporary approaches to [[quality control|quality monitoring and assurance]], establishing accountability, and allocating and [[resource management|managing resources]] efficiently.

Whilst Codman's 'clinical' approach is in contrast with Nightingale's more '[[epidemiological]]' audits, these two methods serve to highlight the different methodologies that can be used in the process of improvement to patient outcome.

==Integration into contemporary healthcare==

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.

As concepts of clinical audit have developed, so too have the definitions which sought to encapsulate and explain the idea. These changes generally reflect the movement away from the medico-centric views of the mid-Twentieth Century to the more multidisciplinary approach used in modern [[healthcare]]. It also reflects the change in focus from a professionally centred view of health provision to the view of the patient-centred approach. These changes can be seen from comparison of the following definitions.

*'''Standards-based audit''' – A cycle which involves defining standards, collecting data to measure current practice against those standards, and implementing any changes deemed necessary.
*'''Adverse occurrence screening and critical incident monitoring''' – This is often used to [[peer review]] cases which have caused concern or from which there was an unexpected outcome. The multidisciplinary team discusses individual anonymous cases to reflect upon the way the team functioned and to learn for the future. In the primary care setting, this is described as a '[[significant event audit]]'.
*'''Surgical audit''' – [[Data collection]] of all surgical cases, followed by ongoing review and assessment of performance and outcomes. Related to peer review, but is distinguished by aiming for inclusion of all cases carried out, rather than sampling alone.
*'''Peer review''' – An assessment of the quality of care provided by a clinical team with a view to improving clinical care. Individual cases are discussed by peers to determine, with the benefit of [[hindsight]], whether the best care was given. This is similar to the method described above, but might include 'interesting' or 'unusual' cases rather than problematic ones. Unfortunately, recommendations made from these reviews are often not pursued as there is no systematic method to follow.
*'''Patient surveys and focus groups''' – These are methods used to obtain users' views about the quality of care they have received.

==Clinical audits in the NHS==
In 1989, the [[white paper]], ''Working for patients'', saw the first move in the [[United Kingdom|UK]] to standardise clinical audit as part of professional healthcare. The paper defined medical audit (as it was called then) as

((blockquote|"the 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 quality of life for the patient."))

Medical audit later evolved into clinical audit and a revised definition was announced by the [[NHS Executive]]:

((blockquote|"Clinical audit is the systematic analysis of the quality of healthcare, including the procedures used for diagnosis, treatment and care, the use of resources and the resulting outcome and quality of life for the patient."))

The [[National Institute for Health and Clinical Excellence]] (NICE) published the paper ''Principles for Best Practice in Clinical Audit'',<ref name="nice1">((cite book |date=2002 |title=Principles for Best Practice in Clinical Audit |publisher=National Institute for Clinical Excellence |url=http://www.nice.org.uk/media/796/23/BestPracticeClinicalAudit.pdf |archive-url=https://web.archive.org/web/20120312151534/http://www.nice.org.uk/media/796/23/BestPracticeClinicalAudit.pdf |archive-date=2012-03-12))</ref> which defines clinical audit as

((blockquote|"a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, 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 was incorporated within Clinical Governance in the 1997 [[White Paper]], "[http://www.archive.official-documents.co.uk/document/doh/newnhs/newnhs.htm The New NHS : Modern, Dependable]", which brought together disparate service improvement processes and formally established them into a coherent Clinical Governance framework.

== Clinical audit process ==
[[Image:Clinical audit cycle.jpg|thumb|300px|right|The clinical audit process seeks to identify areas for service improvement, develop & carry out action plans to rectify or improve service provision and then to re-audit to ensure that these changes have an effect.]] Clinical audit can be described as a cycle or a spiral, ''see figure''. Within the cycle there are stages that follow the ''systematic'' process of: establishing best practice; measuring against criteria; taking action to improve care; and monitoring to sustain improvement. As the process continues, each cycle aspires to a higher level of quality.
These processes are related to [[change management]] methodology and use the techniques of [[PDCA|PDSA]] cycles, [[lean manufacturing|LEAN]], [[Six Sigma]], [[root cause analysis]] and [[Business process mapping|process mapping]].<ref>((cite web|url=http://www.hqip.org.uk/assets/Guidance/Local-clinical-audit-handbook-for-physicians-August-2010-FINAL.pdf|title=Local clinical audit: handbook for physicians|date=Aug 2010|access-date=17 Apr 2014|archive-url=https://web.archive.org/web/20120422201440/http://www.hqip.org.uk/assets/Guidance/Local-clinical-audit-handbook-for-physicians-August-2010-FINAL.pdf|archive-date=2012-04-22))</ref>

'''Stage 1: Identify the problem or issue'''

This stage involves the selection of a topic or issue to be audited, and is likely to involve measuring adherence to healthcare processes that have been shown to produce best outcomes for patients. Selection of an audit topic is influenced by factors including:
* where national standards and guidelines exist; where there is conclusive evidence about effective clinical practice (i.e. [[evidence-based medicine]]).
* areas where problems have been encountered in practice.
* what patients and public have recommended that be looked at.
* where there is a clear potential for improving service delivery.
* areas of high volume, high risk or high cost, in which improvements can be made.

Additionally, audit topics may be recommended by national bodies, such as [[National Institute for Health and Clinical Excellence|NICE]] or the [[Healthcare Commission]], in which NHS trusts may agree to participate. The [[Trent Accreditation Scheme]] recommends a culture of audit to participating hospitals inside and outside of the UK, and can provide advice on audit topics.

'''Stage 2: Define criteria and standards'''

Decisions regarding the overall purpose of the audit, either as what should happen as a result of the audit, or what question you want the audit to answer, should be written as a series of statements or tasks that the audit will focus on. Collectively, these form the audit ''criteria''. These criteria are explicit statements that define what is being measured and represent elements of care that can be measured objectively. The ''standards'' define the aspect of care to be measured, and should always be based on the best available evidence.

* A criterion is a measurable outcome of care, aspect of practice or capacity.  For example, 'parents / carers are involved in negotiating or planning their child's care'.
* A standard is the threshold of the expected compliance for each criterion (these are usually expressed as a percentage).  For the above example an appropriate standard would be: 'There is evidence of parent / carer in care planning in 90% of cases'.

'''Stage 3: Data collection'''

To ensure that the data collected are precise, and that only essential information is collected, certain details of what is to be audited must be established from the outset. These include:

* The user group to be included, with any exceptions noted.
* The healthcare professionals involved in the users' care.
* The period over which the criteria apply.

Sample sizes for data collection are often a compromise between the statistical validity of the results and pragmatical issues around data collection. Data to be collected may be available in a computerised information system, or in other cases it may be appropriate to collect data manually or electronically using data capture solutions such as [http://www.formic.com Formic], depending on the outcome being measured. In either case, considerations need to be given to what data will be collected, where the data will be found, and who will do the data collection.

Ethical issues must also be considered; the data collected must relate only to the objectives of the audit, and staff and patient confidentiality must be respected – identifiable information must not be used. Any potentially sensitive topics should be discussed with the local [[medical ethics]] committee.

'''Stage 4: Compare performance with criteria and standards'''

This is the analysis stage, whereby the results of the data collection are compared with criteria and standards. The end stage of analysis is concluding how well the standards were met and, if applicable, identifying reasons why the standards weren't met in all cases. These reasons might be agreed to be acceptable, i.e. could be added to the exception criteria for the standard in future, or will suggest a focus for improvement measures.

In theory, any case where the standard (criteria or exceptions) was not met in 100% of cases suggests a potential for improvement in care. In practice, where standard results were close to 100%, it might be agreed that any further improvement will be difficult to obtain and that other standards, with results further away from 100%, are the priority targets for action. This decision will depend on the topic area – in some 'life or death' type cases, it will be important to achieve 100%, in other areas a much lower result might still be considered acceptable.

'''Stage 5: Implementing change'''

Once the results of the audit have been published and discussed, an agreement must be reached about the recommendations for change. Using an action plan to record these recommendations is good practice; this should include who has agreed to do what and by when. Each point needs to be well defined, with an individual named as responsible for it, and an agreed timescale for its completion.

Action plan development may involve refinement of the audit tool particularly if measures used are found to be inappropriate or incorrectly assessed. In other instances new process or outcome measures may be needed or involve linkages to other departments or individuals. Too often audit results in criticism of other organisations, departments or individuals without their knowledge or involvement. Joint audit is far more profitable in this situation and should be encouraged by the Clinical Audit lead and manager.

'''Re-audit: Sustaining Improvements'''

After an agreed period, the audit should be repeated. The same strategies for identifying the sample, methods and data analysis should be used to ensure comparability with the original audit. The re-audit should demonstrate that the changes have been implemented and that improvements have been made. Further changes may then be required, leading to additional re-audits.

This stage is critical to the successful outcome of an audit process – as it verifies whether the changes implemented have had an effect and to see if further improvements are required to achieve the standards of healthcare delivery identified in stage 2.

Results of good audit should be disseminated both locally via the [[strategic health authority|strategic health authorities]] and nationally where possible.
Professional journals, such as the [[BMJ]] and the [[Nursing Standard]] publish the findings of good quality audits, especially if the work or the methodology is generalisable.

== Clinical audit promotion==

While clinical audit makes great sense, there can be problems in persuading hospitals and clinicians to undertake and apply clinical audit in their work. Nonetheless, in the UK clinical audit is one of the corpus of [[clinical governance]] measures that are required to be enacted throughout the NHS.

Outside the UK, [[hospital accreditation]] schemes, such as the [[Trent Accreditation Scheme]], have promoted the development and execution of clinical audit as a part of [[clinical governance]] in places such as Hong Kong and Malta.

== See also ==
* [[Healthcare Quality Improvement Partnership]]
* [[Clinical Governance]]
* [[Trent Accreditation Scheme]]
* [[SNOMED CT]]

== References ==
*Healthcare Quality Improvement Partnership. [https://web.archive.org/web/20091016051514/http://www.hqip.org.uk/criteria-of-best-practice-in-clinical-audit/ Criteria of best practice in clinical audit]
*Healthcare Quality Improvement Partnership. [http://www.hqip.org.uk/clinical-audit-resources-3/ Clinical audit resources]
*Department of Health, ''Working for patients''. London: The Stationery Office, 1989  (Cm 555)
*NHS Executive, ''Promoting clinical effectiveness. A framework for action in and through the NHS''. London: NHS Executive, 1996
*National Institute of Clinical Excellence, ''[https://web.archive.org/web/20050828114806/http://www.nelh.nhs.uk/nice_bpca.asp Principles of Best Practice in Clinical Audit]''. London: NICE, 2002  ((ISBN|1-85775-976-1))
*Swage T.; ''Clinical governance in health care practice''. Oxford: Butterworth-Heinemann, 2000
*Clinical Governance Support Team, ''[https://web.archive.org/web/20051125164148/http://www.cgsupport.nhs.uk/Resources/Clinical_Audit/1%40Introduction_and_Contents.asp A Practical Handbook for Clinical Audit]''. 2004
*''[https://web.archive.org/web/20041108232153/http://www.rcpath.org/resources/pdf/clinical.pdf Clinical governance and re-validation: the role of clinical audit]'', Education in Pathology. 2002;117:47–50
*''[http://www.archive.official-documents.co.uk/document/doh/newnhs/newnhs.htm The New NHS, Modern, Dependable]'', London: HMSO, 1997, ((ISBN|0-10-138072-0))
*Jones T., Cawthorn S.; ''[https://web.archive.org/web/20051030022009/http://www.evidence-based-medicine.co.uk/ebmfiles/WhatisClinAudit.pdf What is Clinical Audit?]''. Evidence Based Medicine, Hayward Medical Communications, 2002
*''[https://web.archive.org/web/20101121191920/http://www.uhbristol.nhs.uk/files/nhs-ubht/3%20How%20to%20Choose%20%26%20Prioritise%20Topics%20v3.pdf How to choose and prioritise audit topics]'', UH Bristol Clinical Audit Department. 2010
*''[http://webarchive.nationalarchives.gov.uk/20081215184834/http%3A//www.uhbristol.nhs.uk/documents/how_to_ca_brief_guide.pdf How to do clinical audit – a brief guide]'', UBHT Clinical Audit Central Office. 2005
*''[http://webarchive.nationalarchives.gov.uk/20081215184847/http%3A//www.uhbristol.nhs.uk/documents/how_to_audit_data.pdf How to collect audit data]'', UBHT Clinical Audit Central Office. 2005
*''[http://webarchive.nationalarchives.gov.uk/20081215184849/http%3A//www.uhbristol.nhs.uk/documents/how_to_analyse_audit_data.pdf How to analyse audit data]'', UBHT Clinical Audit Central Office. 2005
*''[http://webarchive.nationalarchives.gov.uk/20081215184858/http%3A//www.uhbristol.nhs.uk/documents/how_to_published.pdf How to get your audit published]'', UBHT Clinical Audit Central Office. 2005
*Ghosh R., ed; ''Clinical Audit for Doctors''. Nottingham: [[Developmedica]], 2009  ((ISBN|978-1-9068390-1-7))
((Reflist))

==External links==
*[http://www.dcbainc.com ''DCBA, Inc. ''] DCBA, Inc. provides clinical audit and [[clinical documentation improvement]] programs.
*[http://www.hqip.org.uk ''Healthcare Quality Improvement Partnership (HQIP) ''] Promoting quality for better health services, HQIP is funded by the Department of Health to increase the impact that clinical audit has on healthcare quality in England and Wales.
*[https://web.archive.org/web/20150412182714/http://www.clinicalaudit.com.au/ ''Clinical Audit Tool'']. PCS Clinical Audit Tool (CAT) is a population reporting enhancement to the leading GP Clinical Desktop Systems in Australian general practice
*[http://www.clinicalauditsupport.com "Clinical Audit Support Centre"] - provide accredited training and expert support in clinical audit and other quality improvement techniques.
*[http://www.nqican.org.uk "NQICAN - National Quality Improvement and Clinical Audit Network"] - brings together the regional clinical audit / effectiveness networks from across England.
*[https://web.archive.org/web/20160815024542/http://intelsoft.com.au/?cmd=getsql&sid=&id_site=1&resid=topic&id_tag=1 "WebQI - Quality Improvement Online"] - Clinical audit tool allowing rapid data collection and a range of reporting options.

((Health governance))
((Health care quality))

((DEFAULTSORT:Clinical Audit))
[[Category:Types of auditing]]
[[Category:Health care management]]
[[Category:Health care quality]]

Pages transcluded onto the current version of this page (help):

Clinical audit (edit)
Template:Ambox (view source) (template editor protected)
Template:Blockquote (view source) (template editor protected)
Template:Blockquote/styles.css (view source) (template editor protected)
Template:Catalog lookup link (view source) (template editor protected)
Template:Cite book (view source) (protected)
Template:Cite web (view source) (protected)
Template:DMCA (view source) (template editor protected)
Template:Dated maintenance category (view source) (template editor protected)
Template:Dated maintenance category (articles) (view source) (template editor protected)
Template:FULLROOTPAGENAME (view source) (template editor protected)
Template:Find sources mainspace (view source) (template editor protected)
Template:Health care quality (edit)
Template:Health governance (edit)
Template:Hlist/styles.css (view source) (protected)
Template:ISBN (view source) (template editor protected)
Template:Main other (view source) (protected)
Template:More citations needed (view source) (template editor protected)
Template:Navbox (view source) (template editor protected)
Template:Ns has subpages (view source) (protected)
Template:Pagetype (view source) (protected)
Template:Reflist (view source) (protected)
Template:Reflist/styles.css (view source) (protected)
Template:SDcat (view source) (protected)
Template:Short description (view source) (protected)
Template:Short description/lowercasecheck (view source) (protected)
Template:Use dmy dates (view source) (template editor protected)
Template:Yesno (view source) (protected)
Template:Yesno-no (view source) (template editor protected)
Template:Yesno-yes (view source) (template editor protected)
Module:Arguments (view source) (protected)
Module:Catalog lookup link (view source) (template editor protected)
Module:Category handler (view source) (protected)
Module:Category handler/blacklist (view source) (protected)
Module:Category handler/config (view source) (protected)
Module:Category handler/data (view source) (protected)
Module:Category handler/shared (view source) (protected)
Module:Check for unknown parameters (view source) (protected)
Module:Check isxn (view source) (template editor protected)
Module:Citation/CS1 (view source) (protected)
Module:Citation/CS1/COinS (view source) (protected)
Module:Citation/CS1/Configuration (view source) (protected)
Module:Citation/CS1/Date validation (view source) (protected)
Module:Citation/CS1/Identifiers (view source) (protected)
Module:Citation/CS1/Utilities (view source) (protected)
Module:Citation/CS1/Whitelist (view source) (protected)
Module:Citation/CS1/styles.css (view source) (protected)
Module:Disambiguation/templates (view source) (protected)
Module:Find sources (view source) (template editor protected)
Module:Find sources/config (view source) (template editor protected)
Module:Find sources/links (view source) (template editor protected)
Module:Find sources/templates/Find sources mainspace (view source) (template editor protected)
Module:Message box (view source) (protected)
Module:Message box/ambox.css (view source) (protected)
Module:Message box/configuration (view source) (protected)
Module:Namespace detect/config (view source) (protected)
Module:Namespace detect/data (view source) (protected)
Module:Navbar (view source) (protected)
Module:Navbar/configuration (view source) (protected)
Module:Navbar/styles.css (view source) (protected)
Module:Navbox (view source) (template editor protected)
Module:Navbox/configuration (view source) (template editor protected)
Module:Navbox/styles.css (view source) (template editor protected)
Module:Ns has subpages (view source) (protected)
Module:Pagetype (view source) (protected)
Module:Pagetype/config (view source) (protected)
Module:Pagetype/disambiguation (view source) (protected)
Module:Pagetype/setindex (view source) (protected)
Module:Pagetype/softredirect (view source) (protected)
Module:SDcat (view source) (protected)
Module:String (view source) (protected)
Module:Unsubst (view source) (protected)
Module:Wikitext Parsing (view source) (protected)
Module:Yesno (view source) (protected)

Return to Clinical audit.

Retrieved from "https://en.wikipedia.org/wiki/Clinical_audit"