An audit improves the quality of patient care by looking at current practice and modifying it where necessary.1 If you notice a problem on the wards, therefore, and you believe that the current clinical practice is not the best practice, it could be an opportunity for you to set up your own audit. It is important to distinguish between audit and research, because these two terms should not be used interchangeably. Research is concerned with discovering the right thing to do—audit is about ensuring that it is done correctly.2
In the United Kingdom the General Medical Council and the Postgraduate Medical Education and Training Board expect junior doctors to engage with quality improvement. Worldwide, students and junior doctors are encouraged to get involved with audit; evidence of this is often requested on job application forms, and it is also a common topic for discussion at interviews for specialty training. Doing an audit is an opportunity for you to make a difference in your department or hospital, and your efforts will be recognised if patients’ care is improved.
If you are struggling to set up an audit from scratch then ask to join an existing audit in your department and help your team to complete it. Alternatively you could collaborate with your predecessors to re-audit the projects they set up, and this way you will be able to help complete the audit cycle (figure ⇓ ).
The steps in the audit cycle
Make sure you register the audit with the audit department. The trust keeps a register of all ongoing audits to make sure the necessary data are available. Doing this will allow the trust to know what doctors are doing to improve patient care and will ensure that audits are not repeated unnecessarily—you don’t want to reinvent the wheel (box).
Identify a problem in your department or hospital. Which areas of practice could be improved to make services run more smoothly? For example, you could audit an area of high volume, such as pathology requests; or of high risk to staff, such as needlestick injuries; or an area of high risk to patients, such as incorrect prescribing; or of high cost, such as unnecessary admissions to hospital. Choose a topic that you are enthusiastic about. Remember to select a topic relating to an important aspect of care, because the aim is to improve clinical excellence. If you know which specialty you are interested in, you could explore topic options within this field. If you are struggling for ideas, ask your consultant or audit department.
You will need to compare current practice with the broadly acceptable guidelines or standards available. In the UK, clinical guidelines are available from the National Institute for Health and Clinical Excellence (www.nice.org.uk), the National Library for Health (www.evidence.nhs.uk/about-us), the Scottish Intercollegiate Guidelines Network (www.sign.ac.uk), and hospital guidelines. You can find service standards from the Department of Health (www.dh.gov.uk), from national service frameworks,3 and from royal college guidelines. If there are no standards in place, you may have to develop your own standards based on the best available evidence. If you need help with your literature search, ask your trust librarian.
You will need support with setting up your audit. Discuss ideas for topics with your consultant and a member of staff in the audit department who may be able to help you plan your audit. Have clear aims and objectives and make them SMART: specific, measurable, achievable, realistic, and timely.4 To save confusion, and so that you do not overburden yourself, do only one audit at a time.
What data do you need to collect? Will they be all on patients over a stated time, retrospective data, or prospective data? Retrospective data look back, so you are using data that other people have written down. They might not all be correct, but analysing them will be quick to do, and for this reason most students audit retrospectively collected data. Prospective data look forward, so you can collect the data as the situation arises, but you might have to wait.
Where do you find the data? Routinely collected data might be available on the department’s database or in the patients’ notes. Non-routine data are collected from other sources, such as request forms. Ask ward clerks or the audit department to help you find the required data.
Who will collect the data? Collecting data on your own offers the advantage of setting your own pace as well as receiving full credit for your work, but you will need to consider whether you will need more pairs of hands. Working as a team to achieve results can be fun and rewarding.
How will you collect the data? You can create a brief data collection tool using an Excel sheet. Make sure patient identifiable data are not recorded. Instead, use a unique number.
How many data do you need to collect? In general for your audit you will need a minimum sample size of about 50, as this will be enough to result in a true representation of your findings. Larger sample sizes tend to be used in national audits because the size of the population is much larger in comparison with the local population of your hospital.
If you need help with statistics, ask your university affiliated statistician for advice or read a book outlining basic statistics.5
Think of reasons why standards are not being met. Discuss these ideas with your seniors, including registrars or consultants. You can draw up an action plan consisting of recommendations to improve the area you looked at. If recommendations are made, ensure that they are specific and practical. Indicate who has agreed to do what and by when, and set realistic deadlines to achieve these goals.
You will most likely need support from your consultant or another key leader to get the message out there. Work as a team to share your findings and suggested actions for improvement with the relevant audience. You could do this by presenting your recommendations at a departmental meeting or at your hospital’s grand round, through educating staff with tutorials, and by displaying posters on the wards outlining the highlighted recommendations.
Repeat the audit after a period of time following your implementations. It is suggested that you wait a minimum of six months before re-auditing to ensure that best practice has been embedded. Hopefully, the results will show that the recommendations put in place resulted in an improvement. Sustaining improvement is critical to the successful outcome of an audit. It is important that the recommendations are continued when you move on to a new rotation or a different hospital. If you are leaving the hospital at the end of the year, ask your consultant or another permanent senior member of staff to oversee the recommendations that were put in place.
You should also receive a certificate of completion, which you can add to your portfolio as evidence of understanding and involvement in audit.
Now you have done all the hard work, you should share your results with the relevant audiences. Liaise with seniors about presenting your project in upcoming meetings (local, national, international). Aim to re-audit to demonstrate that change in practice has taken place. Perhaps you could also write up your audit for publication. Talk to your consultant about which journals would be most suitable to submit your project to and then follow the submission guidelines on the website of your chosen journal.
You approach your consultant about an idea to audit record keeping, and he agrees to support you in your project. You meet with a member of staff from the audit department, who advises you on how to plan the project. Your plan is SMART: specific, measurable, achievable, realistic, and timely.4 You will assess the quality of the written clinical records by reviewing 50 sets of notes using a pro forma that allows each set of notes to be scored, over a period of one week.
The audit shows that note keeping is inadequate. Members of staff in the department need to be informed on how to improve their note keeping
You decide to educate the department about your findings and discuss how record keeping can be improved, by presenting your results at a departmental meeting. You explain that posters highlighting areas for improvement will be on the walls of the department.
After six months of implementing these changes, you re-audit the project using the method described above. The standard of note keeping has improved. As you are coming to the end of your rotation you ask the consultant to educate future junior doctors who will work in the department about good note keeping and suggest that the posters should be kept on the walls of the department.
