What is audit?

Audit can be defined as a systematic review of aspects of practice that results in a change in that practice. Johnson defined medical audit as ‘a means of quality control for medical prac­tice by which the profession shall regulate its activities with the intention of improving overall patient care’. ‘A First Class Service’ (Department of Health, 1998) states ‘Clinical audit involves systematically looking at the procedures used for diagnosis, care and treatment, examining how associated resources are used and investigating the effect care has on the outcome and quality of life for the patient. Audit is a valuable tool to improve the quality of professional care and, ultimately, patient choice’.

Much of what is called audit is actually only fact gathering. The facts are essential to undertaking the audit, but unless the effects of the activity on patients are also included (i.e. outcome data) the facts alone cannot influence surgical practice.

Traditionally audit has been divided into medical and clinical audit. The term medical audit refers to an audit undertaken by doctors and consists of a review of clinical events; e.g. does one surgical procedure result in a better outcome compared with another? Clinical audit is usually taken as a review of all potential medical events surrounding the treatment of a patient. This will include nursing, physiotherapy, social aspects, etc. The boundaries between the two forms of audit are blurred and indeed ‘medical’ audit is merely a subset of clinical audit focusing only on the medical aspects. The majority of audits will consider aspects which are both medical and clinical.

The separation of the provision (and rationing) of resource from clinical audit is artificial. All medical activity costs money so an understanding of the management of the resources has to be included in the audit process. When healthcare resources are rationed, the limitation on funding is likely to have a direct effect on structure and process, and hence on outcome. ‘Total’ audit should include any activity which occurs in the delivery of healthcare to an individual patient or a group of patients.

It is, at least, a useful intellectual exercise to consider the financial implications of introducing a new technique. For example, arthroscopic stabilisation of the shoulder is a relatively new technique to appear in orthopaedic practice in the UK. If it is to be adopted by a hospital trust the following questions might need to be answered.

  Is there a surgeon who can perform the techniques?

  What training is required?

  What equipment is required? Is new equipment needed?

  What will the consumables cost and are they readily available?

  What are the operating theatre and ‘hotel’ requirements for the patients?

  What is the failure rate of the techniques, i.e. will there be a large number of patients who will need revision surgery or will be unsatisfied with the outcome?

  What is the rehabilitation time and when will the patients be able to return to work?

  And of course, how does this new technique compare with the usual accepted techniques when the same questions are asked?

Each and every surgical procedure could and probably should be examined in this way. In the example given above, data from prospective clinical trials comparing the new technique with the old are required to demonstrate a statistically significant improvement if the method is to be justified purely on the grounds of clinical benefit. For an individual surgeon, audit data showing that the results obtained by that surgeon are comparable to the results of the clinical trials are needed. The cost to the hospital, and the cost to the patient (in time off work, etc.) will also need to be calculated. Using data like

these there are several ways of justifying the introduction of a new technique as follows.

  The new technique is clinically better than the old — better outcomes (including patient satisfaction), decreased failure and decreased morbidity

  The technique is cheaper to patient, hospital or both.

  Patients can be treated more quickly using the new method, which produces the same results as the old method.