Analysis of the Use of Clinical Audits in Healthcare

Introduction

The quality of health care system is important to patients and the Government. High level of quality patient care is the ultimate aim in current health care practices. Service providers wish to deliver quality health care. Patients are the appropriate authority to determine whether the experience of health care is good. Effectiveness of care pertains to treatment and support and helps us to judge whether staffs are, doing the right thing in a right way to achieve best clinical outcomes (Patel, 2010).Audit of services is therefore very important to ensure that the clinical practices are adhered to set professional standards and criteria. On the other hand health services are focusing on new information and knowledge for advanced clinical practice. Research is focused on this area in order to develop new practices and standards in health care system. Researches make changes to health care system by advancement of knowledge and practice.

The aim of this paper is to identify the difference between audit and research and analyzing the benefits and limitations of audit.

An overview of clinical audit.

‘Audit’ derived from a Latin word, which means an official inspection of an organization’s official accounts, by an independent body (Esposito & Canton, 2014). Clinical audit is measuring the quality of patient care provided against a set well defines standards (Yorston &Wormald, 2010).  It gives staff a systemic way of looking into their practice and making improvements (Bennadi et al, 2014). Pioneer of clinical audit is Florence Nightingale whose work was searching reasons for high mortality in hospitals in 1850’s. As per her assessment she reinforced cleanliness resulted in a drastic reduction in mortality rate. (Bennadi et al, 2010).

Clinical audit Vs research

Clinical audit and clinical research are entirely two different domains (Yorston & Wormald, 2010). Clinical audit and research involves some common components. Hence, there is a great deal of controversy (Bennadi et al, 2014) in both terms. Audit compares the current clinical practice against well-defined standard/criteria, while research aims to define the characteristics of good practice on an unknown land (Esposito & Canton, 2014). Audit focused on evaluating the existing practice; rather than discovering new information. Research is proven to be  a larger scale study that aims at establishing new practices or procedures to carry out a particular task in a different method. The focus of research is further development of existing practice. However, audit is monitoring a task to determine whether a particular task has undertaken as per set standards or criteria. Audits check the quality of the task or procedure (Bennadi et al, 2014). Audit is generally undertaken on a local basis; however it is not limited to. (Hughes, 2005).

Research aims to obtain new knowledge and to fill in any knowledge gaps.

Research focuses on defining questions, making inclusion and exclusion criteria’s for people or problems to address and any developing clinical interventions or outcomes. Research methods for data collection and analysis that is applied are suitable to the topics for research (Strauss and Sackett, 1998, Hughes, 2005).

Audit focuses on evaluating and analyzing the existing ones, not developing new practices (Difference between audit and research, 2014). But, research is aimed at developing new procedures to carry out in a more effective ways of carrying out. The focus on research is invention of new and further development of the old. The aim of an audit is to determine whether the standards and procedures are being followed and whether a task is completed properly. The aim of research is to add onto a body of research and to increase the amount of knowledge and learning available on a specific subject matter (Difference between audit and research, 2014). Also, unlike audits that measure tasks and procedures against a set out standard, research aims to test the hypothesis that is established by the researcher when beginning their experiments (Twycross &Shorten 2014).

Research considered as a broader field in the field of health. Research requires lot of education and training. Researchers undergo research education and training as a part of their university programme of study to gain the foundation to conduct a research (Hughes, 2005). In contrast, audit emphasized on areas, which needs improvement.   Audit can undertake by anyone who is interested in a particular field and few receive education and training (Nettleton and Ireland, 2000).

As per Hughes’s review, researchers involved in audit may benefit from approaches and techniques used to implement findings that could potentially serve to fill the research-practice gap. Equally, those involved in audit will benefit from sampling techniques in research that can help to improve generalisability.

Some similarities are identified between audit and research despite their differences.  Audit and research starts with a question, require data to answer questions, and systematic approach (Twycross &Shorten 2014), also both needs an investigator (Abbasi &Heath, 2005).

Difference between clinical audit and research is showed in the below table, which was adapted from Bennadi et al, 2014 and Twycross &Shorten 2014.

Clinical audit	Research
1	Audit uses comparison of current clinical practice	Research uses experimental methods such as randomised control trials.
2	Uses simple descriptive statistics to describe current practice standards.	Uses a range of statistics to make inferences.
3	Audit relates to a particular area of attention.	Research can be generalized to other populations.
4	Audit measures how well current practices are carried out against clinical policies and procedures.	Research provided evidences for clinical policies and procedures.
5	It is practice based.	Research is theory based practice.
6	Ongoing process of quality assurance.	One- off study.
7	No involvement of placebo treatment.	May involve placebo treatment.
8	No changes involved in treatments of patients.	Changes in treatment process.
9	Ethical approval is not required.	Requires ethical approval.

Benefits of clinical audit

Audit conducted against set standards (Patel, 2010, Hughes, 2005) in a cyclic (Tsaloglidou, 2009, Hughes, 2005) process to ensure tasks carried out correctly. At the end of audit cycle auditors are able to address the areas of improvement and give feedback to the personnel who are involved in that particular task. Reaudit should carry out after an agreed period of implementing changes (Bennadi et al, 2014). Regular auditing alerts the health care professional the shortfall (Patel, 2010) in health care delivery system. Also helps us to find out whether staffs are practicing as per standards set by the organization to achieve therapeutic (Patel, 2010) patient care, identifies the factors causing failure to make improvements (Yorston &Wormald, 2010). Therefore, organization can take actions to improve the area. “Every time an audit cycle is completed there should be further improvement in patient care” (Yorston and Wormald, 2010).

Audit and feedback often used in health care setting to improve health care professional performance.  Discrepancies in health care practices against set standards are highlighted in clinical audit that helps to identify the practices needed to improve for quality care (Esposito &Canton, 2014). Tsaloglidou explains that the key for quality assurance and consistent delivery of high quality health services is the appropriate organization of the health center environment.

The benefits of audit are apparent for health care professionals as it reduces frustration, reduces organizational and clinical error, improves communications between professionals and secures effective medical defense through risk avoidance (Tsaloglidou, 2009). An audit is not only a tool for monitoring change in clinical practice, but also an educational tool (Tsaloglidou, 2009). As the improvement of health care is a cost-effective procedure, audit is revealed to be a very useful tool in management

Limitations of clinical audit

Educational and training issue has a huge impact on carrying out an effective audit. Audit should not consider as a light work. It does require knowledge, experience and skills to perform effectively because auditing required to choose appropriate question, analytical method and to be undertaken in a sensitive (Hughes, 2010) way. In general, audit tends to be an activity that be undertaken by anyone without proper training and analytical skills with an aim to improve clinical practice. Nevertheless, it is very important for the staff member who will take on to implement the audit cycle to have proper training, supervision and protected time (Mercel et al, 2006).

Bowie et al identified that lack of protected time to conduct a clinical audit is a major disadvantage for health care professional. They have to do it within their own allocated clinical time. Therefore, it can potentially affect direct patient care when allocating clinical time for auditing. It is not possible to justify leaving wards understaffed and underfunded to undertake audit unless instant results are attained (Esposito &Canton, 2014, Ellis et al, 2000, Hughes 2005). Subsequently it causes additional workload on key staff members when undertaking an audit (Collis, 2006, Johnston et al, 2000).

Lack of support from management to make audit related improvements and changes with the view of providing quality patient care. Inadequate organizational monitoring of auditing activities and progress is a barrier to make changes in patient care.  It can lead to frustration and distress on auditors (Bowie et al, 2012, Hughes, 2005).

Indirect situational factors influence the success of auditing such as lack of time and resources, lack of supervision, lack of support from management, conflict within multidisciplinary team, negative attitudes associated with audit process ((Travaglia & Debono, 2009, Hughes, 2005).

A systematic review of Cochrane study of 140 studies tested the effectiveness of clinical audit outcome against other methods of study such as meetings and distribution of printed materials. Results were variable. Audit outcome ranges from negative outcome to very positive effect. When the audit was effective, results range from small to moderate. Moreover, the study concluded that effectiveness of audit is likely greater, when baseline adherence to recommended practice is low. Therefore, there is no clear scientific evidence to support the real effectiveness of clinical audit (Esposito & Canton, 2014, Ivers et al, 2014).

Conclusion

In general, clinical audit considered as an effective and cost effective method for continuous quality improvement even though there are numerous limitations. Therefore, it is important to pay more attention to clinicians having trouble in auditing and to determine what recommendations are made to make the audit more effective. In order to overcome the difficulties of audit, auditors need to be clear about the areas of clinical practice audited. In addition, it is very important to know the difference between audit and research to avoid inappropriate data collection while conducting an audit.  Clearly, audit and research serve two distinctive purposes.

References

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