What Is Clinical Audit?

Audit is essentially a tool whereby we measure the standard of our patient care against prescribed standards. This enables us to assess the quality of care and implement changes if required in order to improve. Unless no improvement is required, an audit project is not complete until the standard has been re‐measured to demonstrate the improvement. Audit should be undertaken regularly in dental practice in order to evaluate standards of care and make any necessary adjustments.

Definition of Clinical Audit

Clinical audit is a central part of Quality Improvement and is defined 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’ (National Clinical Audit Advisory Group (NCAAG), 2009).

However NCAAG believes the contribution of clinical audit within the new quality assurance framework within the NHS should be:

• To define what constitutes good quality care (usually described in guidelines, based on scientific evidence and clinical experience).
• To assess the quality of care provided (clinical audit, patient experience surveys, critical incident enquiries, qualitative methods).
• To improve the quality of care provided (education, performance review, incentives, regulation, redesign, legislation).

NCAAG also believes that clinical audit has a very important role to play in the emerging quality assurance framework, as this depends upon the high‐quality data which clinical audit creates.

While recognising what clinical audit is, it is equally important to recognise what it is not. In this regard it is important to distinguish clinical audit from two other activities with which it is frequently confused: research and service reviews.

• Clinical audit aims to assess the extent to which care is consistent with best practice and/or achieves expected outcomes. In contrast, research aims to establish and define what constitutes best practice. Research plays a valuable role in enhancing quality by producing knowledge to inform guidelines of best practice.
• Clinical audit differs from service reviews, which aim to provide a snapshot description of the state of a service, usually in one locality (although it may take a nationwide perspective) and are usually concerned with inputs rather than processes or outcomes. Such reviews are generally one‐off with no attempt to re‐review (NCAAG, 2009).

The Audit Spiral

The audit spiral has been described as an ongoing development and evolution of a clinical audit project as new developments take place (Bucknall et al., 1992). Thus the audit cycle is never complete as healthcare is constantly evolving (Figure 24.1).

The audit spiral:

• Measures performance against prescribed standards. Is change required?
• If so, perform a root cause analysis to ascertain any underlying cause of the problem.
• Draw up an action plan and decide who will implement it.
• Make changes.
• Re‐measure.
• Repeat with any necessary adjustments for new developments.

Audit thus seeks to improve clinical practice.

Planning a Clinical Audit

Choosing an Audit

Audit should only be undertaken if the necessary improvements are achievable. For this reason it is important to involve all stake holders, including staff, who will need to implement the changes, and also budget holders, at an early stage. There must be a commitment to act on the findings.

Audit should address:

• Anything which is not working as well as it should.
• Outcomes of treatment performed regularly.
• Risk.
• Complaints.
• Adverse incidents.
• Legal issues.
• Compliance with standards such as National Institute for Health and Care Excellence (NICE) guidelines, guidelines produced by Royal Colleges and specialist societies, local guidelines.

Designing an Audit

Design of a clinical audit is very important. The following features should be considered:

• The title should state the objectives and what you are measuring.
• Decide on a standard against which to measure. This may be a national or local guideline or recommendation. National guidelines are tailored for local use, so that local guidelines may be developed from them.
• Identify sources of data for collection – where the data will be collected from.
• Identify persons involved:
  • Lead person for this clinical audit project.
  • Other people involved.
  • Outside assistance required.
• Identify materials needed, such as access to a computer.
• Decide on any exclusions from the data to be collected.
• Only record data that are going to contribute to achieving the objectives.
• Decide on number of cases and time scale.
• Choose a sample in such a way as to avoid bias.

When the Data Have Been Collected

Analyse the data and decide whether there is a problem. The cause of the problem may not be immediately obvious. It is therefore advisable to carry out a root cause analysis to find any underlying cause.

Root Cause Analysis (RCA)

This is a very important stage. It involves discovering the reason for the problem. RCA provides a retrospective review of an incident or event in order to identify:

• What happened.
• How it happened.
• Why it happened.
• How solutions can be developed and fed back to staff (National Patient Safety Organisation, 2011)_.

RCA uses a defined critical analysis approach. It can be used with groups of staff as a helpful investigative tool to identify why something keeps happening, or why there is a series of near‐miss incidents. You can also use other methods such as ‘brain storming’ or ‘brain showers’, ‘five whys’ and the ‘fishbone diagram’ to explore and drill down further into the causes of an incident (National Patient Safety Organisation, 2011).

The analysis is used to identify areas for change, recommendations and solutions that aim to minimise the recurrence of the incident in the future.

The Fishbone Diagram

This may be helpful when there is an underlying problem which may not immediately be obvious. It involves drawing a skeleton of a fishbone on which each spine is labelled with a cause of the problem, as follows.

How to Do a Fishbone Diagram (Figure 24.2)

1. Draw a fishbone structure. Record in the head of the fish the problem, situation or effect you are analysing. Decide what the primary causes of this problem might be and label the spines on the diagram accordingly. Potential ways to identify primary causes are patients, processes or systems, equipment, environment, resources, staff or communication.
2. For each of the primary cause spines, think of ideas of causes that could be attributed to the primary cause. Attach your ideas (which are referred to as secondary causes) to the relevant primary spine as secondary spines. Attach any further explanations of a cause (which are referred to as tertiary causes) to the relevant secondary spine.
3. When you have finished thinking up ideas, decide if you want to set priorities among the potential causes or if you feel that you need to investigate any of the causes thought of.
4. Use your conclusions to develop an action plan to address causes of the problem or to investigate further.
5. You could use ‘asking ‘Why?’ five times’ or ‘process mapping’ (see the next sections) to investigate further.

Asking ‘Why?’ Five Times

Ask ‘Why?’ five times. Why has the problem occurred? Why has this occurred? etc., until the real underlying cause is discovered.

Process Mapping

Make a diagram of the stages of a process and analyse each stage. Remember, it may be the system which is at fault and not how it is implemented (Healthcare Quality Quest, 2007).

Implement Change and Re‐audit

An action plan is drawn up, with specific named persons responsible for ensuring that it is implemented.

When changes have been implemented for an appropriate length of time, repeat the measurements in order to show the improvement.

The first audit cycle is then complete.

Repeat this process at regular intervals, adjusting to take account of new developments. This is the audit spiral.

The Audit Template

The template provided here has been drawn up so that you can create your own audit projects by following the different stages which are identified and explained in the template.

In the following sections of this chapter the template has been used to provide ideas for audit projects with ‘recipes’ for how these may be performed. These might be used as laid down, or adapted to make them more relevant to your clinical practice.

Audit Ideas and Recipes

The following audits have been provided to give ‘recipes’ and ideas for future audits. They are divided into:

• Patient‐related audits:
  1. Audit of patient record keeping.
  2. Audit of patient consent to treatment.
  3. Audit of quality of periapical films.
  4. Audit of radiological evaluation recorded in patient notes.
  5. Audit of unerupted maxillary canine teeth.
  6. Audit of emergency management of enamel/dentine tooth fractures in permanent teeth.
  7. An audit of the management of caries in the primary dentition.
  8. Audit of patient satisfaction by survey.
  9. Audit of delivery of oral health promotion advice.
• Practice‐related audits:
  1. Audit of emergency drugs in dental practice.
  2. Audit on storage and dispensing of drugs held in general dental practice.
  3. Audit of equipment checks necessary for providing basic conscious sedation techniques in dentistry.
  4. Audit of washing and decontamination of instruments.
  5. Audit of sterilisers.
  6. Audit of storage and use of sterilised instruments.
  7. Audit of laboratory return times.
  8. Audit of patient waiting times.
• Staff‐related audits:
  1. Audit of basic life support training.
  2. Audit of hand hygiene.
  3. Audit of use of personal protective equipment.
  4. Audit of training in child protection.

Patient‐Related Audits

1. Audit of Patient Record Keeping

The following areas of a patient’s clinical notes can be audited for accuracy and completeness according to Faculty of General Dental Practice (UK) recommendations (Faculty of General Dental Practice, 2009):

1. Minimum data set of patient details and demographics recorded for all dental examinations.
2. Classification of patients according to risk status for:
   • Caries.
   • Periodontal breakdown.
   • Oral mucosal health.
   • Likelihood of endodontic failure.
3. Currency of medical histories.
4. Currency and completeness of dental histories.
5. Quality of written reports on radiographs.
6. Quality and comprehensiveness of diagnosis and treatment plans.
7. Recording of the causes of endodontic problems.
8. Proportion of patients according to whether they are new patients, recall patients or patients attending for an unplanned visit.
9. Recall intervals for patients with different oral health profiles.

In this audit we suggest that you choose one or several areas from the list above to examine more carefully using audit. An example of an audit template is included here to help in data collection.

An Example of a Record Keeping Data Template

2. Audit of Patient Records of Consent to Treatment

3. Audit of Periapical Radiographic Film Quality

4. Audit of Radiological Evaluation Recorded in Patient Notes

5. Audit of Unerupted Maxillary Canine Teeth

6. Audit of Emergency Treatment of Enamel/Dentine Tooth Fractures in Permanent Teeth