1. Practical Considerations for Allied Health Professionals
CLINICAL AUDIT
Practical Considerations for Allied Health Professionals

2. Clinical Audit Clinical effectiveness Process for comparing
Improving standards of care
A clinical audit is an integral part of any quality improvement process. The essence of an audit is to demonstrate clinical effectiveness. This is usually done by a process of comparing, comparing to a standard practice or guideline or by current available evidence. The end result of the audit process is an outcome where standards of patient care is further improved.

3. Clinical Audit
Clinical audit is 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, process 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.
Principles of Best Practice in Clinical Audit
Literature provides numerous definitions for clinical audit. An internationally recognised definition comes from the Principles of Best Practice in Clinical Audit published by the National Institute for Health and Clinical Excellence in the UK.
The definition highlights important aspects of conducting a clinical audit such as:
Systematic review of care
Comparing against a criteria
Implementing change
As well as highlighting that that change can occur at an individual, team or service level.

4. Goals of Clinical Audit
Improve patient care
Improve health outcomes
Translate research into practice
The clinical audit process is not set up to establish the most effective care practices – that is what clinical research is all about. Clinical audits sets out to bridge the gap between research and clinical practice. Through the clinical audit process, one can compare research and practice, identify any barriers, gaps or inconsistencies and develop a quality improvement plan based on the findings of the audit.
The primary goals of a clinical audit are to:
Improves patient care – This will include ensuring there is consistency of care and less practitioner variation, best care practices are provided in a timely manner as well as ensuring that the patient/consumer perspectives of care is taken into consideration.
Improve health outcomes – With improved patient care, it is highly likely that there would be improved health outcomes. Although most of the time this may tend to focus on quantitative health outcomes such as better blood pressure, increased walking speed or improved range of movement, it is also necessary to take into consideration a patient’s/consumer’s quality of life as an outcome.
The promotion of best practice in clinical care can lead to a better understanding of evidence-based practice and enable the effective translation of research into clinical practice. This will also ensure that decisions and actions are justified based on scientific evidence, not by trends, anecdotes or intuition.

5. Why do a clinical quality audit?
Benefits all stakeholders in health care
Monitor clinical performance
Continuous improvement in the standards of patient care
Used as a change management tool
Allows for the best use of resources
Overall improved satisfaction from consumers
Clinical audits offer numerous benefits of all stakeholders in healthcare, both the consumer/patient and the health professionals.
Clinical audits are an excellent tool to monitor clinical performance – ensuring that care is provided in a timely manner, adhering to best standards or guidelines as well as making sure that there is consistency of care and less health practitioner variation.
As performance is regularly monitored, there will be a process in place to ensure that there is continuous improvement in the standards of care provided to the patients/consumers.
The results of a clinical audit can be used as a change management tool. An audit will help identify areas of good practice and areas were improvements are needed. Any decision making on any change in a process or practice would then be based on scientific evidence.
Consistency in clinical decision making brought about by an audit will assist in reducing variation in care practices and lead to the best, most cost-effective use of available resources.
The ultimate goal of a clinical audit is to ensure that patients as consumers of health are overall satisfied with the care provided to them. 5

6. The Audit Cycle Answers 3 key questions
What are you trying to accomplish?
What changes can be made to produce an improvement?
How will you know that such changes have produced an improvement?
The clinical audit cycle should take into consideration answering 3 key questions:
What are you trying to accomplish? – are you wanting the audit to identify areas for improvement or areas of excellence? Are you trying to change a practice or policy?
What changes can be made to produce an improvement? Do you need more staff? More resources?
How will you know that such changes have produced an improvement? Always consider the need for evaluating the implementation of changes brought about by a clinical audit 6

7. Audit & feedback cycle Review of current practice – AUDIT
(Problem identification)
Set standards of care – protocols
(clinical indicators)
Improved practice
Modify if necessary
Implementation
The audit feedback cycle begins with a review of current practice to assist in identifying a problem. The next step will be to identify a set of standards or clinical indicators to act as benchmarks for comparison. The implementation of audit will need rigorous monitoring in the collection of data. The data would then be analysed to form any recommendations for an action plan. The implementation of the action plan is always an ever evolving one that can be modified if necessary. The audit is always cyclical and provisions should be made on when to revisit and evaluate outcomes of any change in practice or policy brought about by the audit findings.
Monitor practice - AUDIT
Analyse findings
FEEDBACK

8. Problem Identification
Focus on areas that there is perceived inadequacy
Look at research evidence
Clinical governance
Complaints
New standards/guidelines are made available
In identifying a problem, the main goal should be achieving the best outcome for the consumer. This should always be considered when selecting an area to be audited. In identifying a problem, health practitioners, managers and health consumers should all be actively involved in identifying areas that need improvement.
Audits should also look to available research evidence for guidance. As well as be directed by clinical governance and complaints from consumers. It is also worth reviewing if new and updated standards and guidelines are made available.

9. Setting Standards Evidence-based research Consensus-based standards
Gold standard
Where possible, standards chosen should be derived from evidence-based research. This needs a meticulous process of literature searching and critical appraisal of research. Research published by institutions like the Cochrane Collaboration or the National Institute for Health and Clinical Excellence are an excellent resource for credible methodologies.
When there is limited evidence-base, a consensus technique can be used, which determines the best opinion from current practices. However, this technique can be open to biases from personal and professional beliefs of those involved. A common practice is to conduct a Delphi exercise, where questionnaires are sent to a group of individuals who are relevant to the topic.
Ultimately, healthcare settings will determine the “gold standard” by which the audit will be measured against based on whichever approach they have opted to take.

10. Measurement Structure Criteria Process Criteria Outcome Criteria
What is needed to implement the standard
Process Criteria
What needs to be done to implement the standard
Outcome Criteria
What is the expected to be achieved by implementing the standard
Measuring structure, process and outcome are the three key areas for selecting the type of audit criteria
Structure criteria pertains to the resources or what is needed to implement the standard. This involves facilities and resources available in a healthcare setting as well staff expertise, time and the organisational structure. Examples of measurement of structure include facilities, staffing levels, use of protocols, mechanisms for advice and information for patients and relatives.
Process criteria refers to what needs to be done to implement the standard – the actions to take and the decisions to make. These processes may include the history, examination, investigation, treatment and follow-up care. It is imperative that the process of care be clearly defined to enable reliable comparison of data.
The quality of health care should ideally be evaluated by the outcome it achieves. Outcome criteria relates to anticipated results of the intervention – what is expected to be achieved by implementing the standard. Measurement in outcome criteria usually takes two forms, an outcome measure or an outcome indicator

11. Patient Perspective and Input
Satisfaction measures
Experience measures
Outcome measures
In choosing a measurement tool, it is always important to consider the perspective and inputs of the health consumer. The patient should always be consulted at all stages of the audit process as health services exists to provide services and outcomes to patients. The patient perspective can be measured in terms of:
Satisfaction measures - Satisfaction measures provide a global assessment of the services received by the patient or the outcomes of care from the consumer’s perspective. They are useful in monitoring trends, but are non-specific and will provide minimal insight into the cause of any issues with the care provided.
Experience measures - Patient reported experience measures gather more specific feedback from patients in relation to the process of care they have received. These measures provide valuable insight to where services may have any deficiencies from the patient’s perspective.
Outcome measures - Patient reported outcome measures can either be disease specific or global in nature. These measures collect information regarding the patient’s perception of their health following an intervention.

12. Clinical indicators
Also called process indicators, performance indicators
They define your standards of care by setting a specific and objective measure.
They describe an element of clinical care
Example: PEG insertion prior to head/neck cancer surgery
Can be a measure of compliance only, or include timeliness or other elements
Clinical indicators are widely used in measuring elements of care, assessing the quality and safety over a period of time. Clinical indicators measure the process, structure and/or outcomes of patient care.
The define the standards of care by setting a specific and objective measure. Often, clinical indicators identify rates of occurrences, describing and element of clinical care, which may be either under or above an expected a standard level.
Other indicators can be in relation to compliance to a protocol or the timeliness of providing a certain service.

13. Auditable clinical indicators
Make your clinical indicators auditable
Retrospective audits - the information must routinely be in medical records
Prospective audits - information collected on purpose built data sheets as you go (harder to set up)
Write the clinical indicator carefully – make sure you can measure it.
In choosing a clinical indicator, ensure that it is auditable, meaning the indicator is easy to examine and verify from your data source as audits can take the form of a
Retrospective audit – where one may look through and review historical records or data.
Prospective audit on the other hand allows for accurate real time accrual of data which reflects current rather than historical practice. Prospective audits have the added advantage where data sheets can be developed on purpose in regards to the data wanting to the collected and this data which never makes it into the notes will be accessible.
Either way, one must ensure that the chose clinical indicator is measurable.

14. Auditable clinical indicators
Define eligibility - the patients who will /will not be expected to get the care.
Are there exceptions? For instance if patient admitted over a weekend do you expect the same timeliness of care?
Define the compliance standards for eligible patients (% compliance)
In determining which clinical indicator to use, you must also clearly define the eligibility of the population you will be measuring – will it be the patients who will or will not be expected to get the care?
Exceptions must also be clearly stated – for instances will you exclude patients admitted over the weekend as there might be expected issues with the timeliness of the delivery of care.
Lastly, one must also define the compliance standards for eligible patients – will it be set at 100%, 80%?

15. Audit data What audit data will you collect?
Keep it simple = manageable.
What do you really need to know?
What demographics are important?
(often none)
Enable double checking if required
A final note on the audit data that you will collect:
Keep it simple – this will ensure that the data is manageable and can easily be analysed and verified if needed.
Always ask the question of “what do you really need to know” = this will allow you to target the information needed and reconsider data that may be superflous
Do you really need demographic data? Often, data regarding gender, age, place of residence are not needed, so why collect them?
It is also wise to put in place a process where double checking of data to allow verification.

16. How to sample Sample size?
Often don’t need many for an in-house quality audit. Consider the proportion of your patients (10 patients may be 20% of your annual patient population if n=50)
Sample bias – don’t cherry pick. Consecutive admission is good and simple.
Determination of sample size is important to ensure that meaningful results are obtained. There are of course statistical considerations to ensure that the data collected is robust enough to justify the suggestions and recommendations of the audit or evaluation.
Although it would be ideal to have a larger sample size, often it is not needed if you are conducting an in-house quality audit. Consider the proportion of your patients – auditing 10 patients from an annual patient population of 50 already means you have sampled 20% of your population.
Also ensure that all audited cases/patients are randomly chosen, do not cherry pick. This will lessen any risk for systematic bias that can influence your findings.

17. Data management
Collect data onto specifically developed tables/ spread sheets
Set it out in an order that makes auditing easier & time efficient
Setting out a data management plan is always integral to the efficient and effective analysis of data. One can use specifically designed data collection tools or software or simply use an excel spreadsheet. Excel will allow you to format the data easily and provides you the opportunity to do calculations and analysis very quickly using the in-built formulas or a specifically written one.
Using a word table and a calculator will also do the same job, but just a little slower.
Always ensure that the lay out of the data will make auditing easier and time efficient.

18. Achieving Change Developing an action plan Training System-wide change
Behavioural change
In order to achieve change in services, an action plan must be developed. The plan should be based on the analysis of audit data, comparing the indicators against a set standard will often reveal where areas need to be improved to meet best practice. The final outcome of the plan should always be focused on clinical effectiveness.
In considering how to develop your plan, think about areas that may need to be addressed to achieve clinical effectiveness; areas like
Education – Often a lack of education is a major reason for poor clinical practice. Incorporating education in your action plan may relate to one-to-one mentoring of staff, seminars, workshops, access to current literature.
System-wide change is often needed if the audit identified that there are problems or issues in regards to access to supplies systems of documentation, staff skills mix or work load. Examples of strategies might be providing staff with increased access to resources, or increasing staff numbers or case mix.
Behavioural change needs to occur if the audit has identified that staff performance is the primary reason for failure to meet best practice standards. The audit team must analyse the data to identify the reasons for poor performance. Strategies might focus on improving staff morale or improving staff confidence with further training or looking into the strategies that improve staff well-being.

19. Reflection post-audit
Clinical audit must be cyclical
Sustainability of change
Share your success story!
The clinical audit must not end with the action plan. It is always imperative that re-auditing be conducted to re-evaluate how the action plan has addressed the identified issues. Has the actions suggested been successful in improving clinical practice? It will assist the service provider to demonstrate any improvements or indicate that there are still areas that need to be addressed.
One must also reflect on the sustainability of change – the goal is for quality improvement to be an ongoing process and the incorporating a process of re-auditing will ensure that ongoing change will be sustained in the long term.
Also reflect that conducting an audit may not mean that there are areas that need improvement, often it will also demonstrate that the service has exceeded a service standard and this is something worth celebrating. So share your success stories!

20. How can iCAHE help? ASPIRE
The ASPIRE for quality is an evidence-based tool developed by the International Centre for Allied Health Evidence to evaluate clinical service performance in South Australian Local Health Networks.
Lizarondo L, Grimmer K, Kumar S. Assisting allied health in performance evaluation: a systematic review. BMC health services research. 2014;14(1):572.
iCAHE has developed the ASPIRE for quality framework to assist allied health practitioners to evaluate their clinical service performance as a means for improving the quality of allied health services.
This framework is based on a systematic review of the literature on performance evaluation systems, layered with a local snapshot of current practice in performance evaluation in South Australian health networks.
The ASPIRE model captures the core elements of performance evaluation which include prioritisation of clinical area for evaluation, upfront articulation of goals, careful identification of performance measures, mapping of measures to information sources, analysis of performance data and reporting of results, and evaluation of the performance evaluation system
ASPIRE utilises a collaborative approach between allied health practitioners and experienced researchers who are skilled in providing evaluation training and also in undertaking performance evaluation. The researchers provide strong initial support and guidance which gradually reduces to enable practitioners to establish and maintain independence and promote a sense of ownership of the performance evaluation system. The ASPIRE model is ideal in building capacity that can increase the likelihood of allied health practitioners conducting performance evaluation in the future.
Visit the iCAHE website to learn about this tool.

21. Acknowledgments We would like to recognise the contributions of
Dr Julie Luker
Ms Deb Kay
We would like that recognise the contributions of Dr Julie Luker and Ms Deb Kay in assisting with the development of this module. 21

22. References
Buckingham, R., J. Potter, and A. Wagg, Clinical Audit of Healthcare, in Pathy's Principles and Practice of Geriatric Medicine. 2012, John Wiley & Sons, Ltd. p
Johnston, G., et al., Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care, (1): p
Patel, S., Identifying best practice principles of audit in health care. Nurs Stand, (32): p. 40-8; quiz 49.
Seddon, M. and J. Buchanan, Quality improvement in New Zealand healthcare. Part 3: achieving effective care through clinical audit. N Z Med J, (1239): p. U2108.