Janet Krska

Introduction: what is audit?

Audit concerns the quality of professional activities and services. Audit is carried out to determine whether best practice is being delivered and, equally importantly, to improve practice. Audit is part of clinical governance (see Ch. 9) – probably the key part – therefore it forms part of the quality improvement work which takes place within all NHS organizations. It can be described as ‘improving the care of patients by looking at what you do, learning from it and if necessary, changing practice’. In England, quality improvement is now part of the QIPP agenda: Quality, Innovation, Productivity and Prevention, which is a major programme of work, aiming to transform the NHS; improving quality of care and making efficiency savings.

Audit is based around standards of practice. The hallmark of a professional is that they maintain standards of professional practice, which exist to protect the public from poor-quality services. Audit provides a method of accountability, both to the public and to the regulator, which demonstrates that standards are being met or, if not, that action is being taken to remedy the situation. It also provides managers with information about the quality of the services their staff deliver. Although this may seem somewhat threatening, ultimately the aim of audit is to improve the efficiency and effectiveness of services, to promote higher standards and to improve the outcome for patients. It also allows changes in practice to be evaluated. Therefore it is an essential component of any professional’s work and an integral part of day-to-day practice.

Most healthcare professionals’ activities have an impact on patients, either directly or indirectly, so can be described as a clinical service. Audit of these services is therefore clinical audit. Clinical audit is defined by NICE 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’. All NHS trusts in the UK must support audit, so should have a central audit office which provides training and help in designing audits and collates the results of clinical audits. All NHS staff are expected to participate in clinical audit and the GPhC requires pharmacists to organize regular audits to protect patient and public safety and to improve professional services pharmacies. Community pharmacists in England must participate in two clinical audits each year, one based on their own practice and one multidisciplinary audit organized by their local primary care organization. Hospital pharmacists are required to be involved in clinical audits of Trust performance in areas of national priority.

There are few instances where pharmacists provide a clinical service to patients in isolation from other healthcare professionals. Providing advice and selling non-prescription medicines are examples of services which could be audited to comply with the requirement. Many services will impact on or be affected by services provided by other professionals, so can be regarded as multidisciplinary. Audit of these clinical services should ideally also be multidisciplinary. Users of services should also be involved in audit whenever possible, perhaps by asking patient representatives to join the audit team. They can provide important insight into what aspects of a service would benefit from audit and can help to set the criteria against which performance will be audited.

Relationship between practice research, service evaluation and audit

It is important to understand the relationship between practice research, service evaluation and audit. Practice research is designed to determine best practice. An example of this would be a randomized controlled trial of pharmacists undertaking a new service compared with normal care. In a controlled trial, patients are often carefully selected, using inclusion and exclusion criteria, special documentation and outcome measures are used, which may differ from those used in routine practice and all aspects of the service being studied must be standardized.

To implement a new service into routine practice, further development will be required. Many aspects of a new service are likely to differ from those used in a research situation and may differ between practice settings. All new services will then need to be evaluated, which may involve determining the views of service providers and users, collecting data on the outcomes for patients who use the service and finding out if publicity is adequate. Changes may be necessary if problems are identified during service evaluation.

Once a service is running smoothly it should then be subject to audit. This will involve setting standards for the service and measuring actual practice against these standards.

Although there are many similarities in the methods used to obtain data for research and for audit, there are important differences. In research, it is important to have controlled studies, to be able to extrapolate the results and to have large enough samples to demonstrate statistical significance of any differences between groups. None of these applies to audit. Audit compares actual practice to a predetermined level of best practice, not to a control. The results of audit apply to a particular situation and should not be extrapolated. Audit can be even applied to a single case; large numbers are not required and so the number included in an audit should be practical, to ensure resources are not wasted in carrying it out.

Types of audit

Audit may be of three types, depending on who undertakes it. These are:

Self-audit is undertaken by individuals and is part of a professional work attitude in which critical appraisal of actions taken and outcomes is continuous. While anyone can do self-audit, it is most likely to be used by pharmacists who work in isolation, such as in single-handed community pharmacies. There are many areas where self-audit can be conducted, e.g. smoking cessation services, owing and out of stock items and waste medicines.

Peer audit is undertaken by people within the same peer group, which usually means the same profession. Peer audit involves joint setting of standards by an audit team. For example, pharmacists from several hospitals which provide similar services could get together and audit each other’s service. Another way of doing this is benchmarking – a process of defining a level of care set as a goal to be attained. Here, standards may be set against those identified by a leading centre, such as a teaching hospital. Benchmarking in prescribing may involve the use of prescribing indicators (see Ch. 22) or comparators. A wide range of these has been developed to benchmark or audit good prescribing practice, available from the QIPP section of the DH website.

External audit is carried out by people other than those actually providing the service and so is perceived as threatening by those whose services are being audited. It may be more objective in its criticisms than self or peer audit, but there may be less enthusiasm for corrective action to improve services. If standards are imposed, there is a perceived threat if an individual’s performance is not of the standard required. Involving the providers of services to be audited in deciding what best practice should be and in making improvements makes external audit more acceptable. Multidisciplinary audit is the most common type of group audit and is usually preferred for clinical audit, but it is essential to ensure that one subgroup is not auditing the activities of another subgroup. This would lead to tensions and be counterproductive. For example, in an audit of doctors’ prescribing errors detected by pharmacists, pharmacists cannot set the standard for an acceptable level of errors without involving the doctors. If they are not part of the audit team, there is little chance of improvement. Pharmacists are often involved in carrying out audits of clinical practice, for example audit of prescribing against NICE clinical guidelines. NICE produces tools for clinical audit, baseline assessment and self-assessment to help organizations implement NICE guidance and audit their own practice. Pharmacists should work with prescribers in setting local standards for these audits.

In England, a National Clinical Audit and Patient Outcomes Programme, managed by the Healthcare Quality Improvement Partnership, enables national clinical audits to take place. Data are collected locally and pooled, but also fed back to individual Trusts, so that they can identify necessary improvements for patients. Pharmacists may be involved in collecting data for such audits. An example is shown in Table 12.1. This is an example of a clinical audit, for which data were collected from many centres and which has the potential to change practice.