7Choosing your subject area and focusing on the particular aspect or activity you want to review needs careful thought and planning. Any clinical audit project may need some investment of resources (time, commitment & technical understanding). The participation of staff in selecting topics enables concerns about care to be reported and addressed. Widespread participation in choice of topic is not always necessary, but it may have a role in reducing resistance to change (NICE 2002).

The audit topic could be arrived at as a result of a problem identified from every day practice. We have considered the 3 main aspects of the provision of healthcare which can be audited

Structural audits might concern you undertaking audit in relation to what resources you have available, such as diagnostic equipment, premises, access to support services, skills, staffing etc.

Process audits focus on what is done to a patient or how clinical protocols and guidelines work in practice, waiting times, patient recall for investigations, treatment, record keeping, communication etc. Under this section you may include personal audits for example an audit of your referral letters, reasons for emergency admission and other measurements that have direct impact on the way you deliver health care to patients.

Outcome audits You might audit endpoints of providing care, such as the effectiveness of care or services on patients’ health, satisfaction or convenience.

When choosing a topic consider

  • Is the topic concerned of high cost, volume, or risk to staff or users?
  • Is there evidence of a serious quality problem, for example patient complaints or high complication rates? Audit may sometimes be triggered by significant events.
  • Is good evidence available to inform standards, for example systematic reviews or national clinical guidelines?
  • Is the problem concerned amenable to change?
  • Is there potential for involvement in a locality or national audit project?
  • Is the topic a priority for your practice team?

Topics may come from:

  • National Strategy (e.g. NICE guidance)
    • Local strategy
    • New research evidence
    • Local problems
    • Previous Clinical Audits
    • Adverse incidents
    • Complaints and user views
    • Personal interest

Any audit topic chosen should be seen by the practice team as:

  • Likely to benefit the patient
  • Likely to benefit the practice
  • Relevant to professional practice (either personal or service)
  • Relevant to professional development
  • Significant in terms of the process and outcome of patient care
  • Having potential for improvement
  • Capable of holding the interest and involvement of team members
  • Likely to repay the investment of time, money and effort involved (Machado 1997)

Undertaking a Quality Impact Analysis may help youchoose your topic if more than one is suggested. For each topic consider the attribute below (CGSDU 2002) 

Frequency (how often does the situation or condition arise)

  • Degree of Risk (likelihood of something going wrong or not being done well)
  • Level of Concern (how important is the issue)
  • Severity of Outcome (degree of influence on health outcomes)

The Clinical Governance Support and Development Unit (CGSDU) propose a scoring system with a point for each of the four statements and where a score of 3 equates to high relevance / impact, 2 for moderate relevance / impact and 1 for low relevance/impact with 0 for no relevance / impact. By aggregating the scores in each of these four areas it is possible to define which, according to this model will have the greatest overall degree of impact. 

Table 2 summarises the main points that define the suitability of an audit proposal;

Good choice Poor choice
Patient centred Clinician centred unless of course the audit is designed specifically to measure clinician performance
Possible to measure Not possible to measure
Resources allocated (time / funds) Resources not allocated (time / funds )
Frequently occurring problem Only happens rarely ---- this point is sometimes irrelevant especially when dealing with a rare significant events or a small group of patients with clinical issues requiring specific management
Standards agreed No standards agreed
Good team involvement Relies on one or two individuals
Will be possible to change and improve Impossible to change even if needed

Aim

7bAt the outset the audit team should establish a clear overall purpose, a rationale for conducting the audit. This will help to ensure that the results are consistent with this initial intention and inform the process that should lead, where action was found to be necessary and then taken, to an improved service for patients. By considering the following action phrases the team will find it easier to focus on the audit question in a very specific way (Buttery, 1998):

  • To improve
  • To enhance
  • To ensure

For example:

  • To improve access to clinical services for patients with specific chronic conditions
  • To increase the proportion of patients with hypertension whose blood pressure is within the limits recommended by the British Hypertension Society Guidelines
  • To ensure that every patient with COPD has been offered immunization against influenza and pneumococcal pneumonia

Objectives

Objectives define your aim more precisely by describing the individual components of service delivery that is to be examined using audit methodology. Objectives must be clear so that at the end of the project you can demonstrate that you have met them. As an example if the aim were

To ensure that every patient with COPD has been offered immunization against influenza and pneumococcal pneumonia, then the objectives for the project could be;

  • To ensure that all patients with a diagnosis of COPD have been identified and are included on an effective register
  • To ensure that all patients on the COPD register have been immunised against influenza and against pneumococcal pneumonia
  • To ensure that all patients on the COPD register, but who have refused immunization have had their refusal recorded

To ensure that all patients on the COPD register but who have not been immunized against Influenza and Pneumococcal pneumonia, and who have no record of having refused immunization are contacted and offered an appointment.