Clinical audits raise standards without assigning blame

When conducting a clinical audit, you should never assess other people’s work without their knowledge. You must audit teams, not individuals, and you should be constructive and confidential. Do not assign blame, and remember that poor performance may be environment-related, not person-related.

These are the golden rules of Dr. Jane Adam, founding chair of the Audit and Standards Committee of the European Society of Radiology. She presented them during Saturday’s ESR audit session.

Clinical audits are carried out by relevant professionals in a no-blame, confidential environment. They are a positive way of raising standards and should not be punitive, said Adam, a consultant radiologist at St. George’s Hospital in London. Clinical audit is a tool designed to improve the quality of patients’ care, experience, and outcomes. It involves a formal review of systems, pathways, and outcome of care against defined standards and the implementation of change based on the results.

Adam identified three types of audit. A structure audit examines management structure, accommodation, equipment, staffing, and training. A process audit will consider aspects such as request-handling, waiting times, justification, optimization, doses received, machine usage, examination practices and protocols, and communication of reports. An outcome audit looks at patient satisfaction, complication rates, and diagnostic accuracy.

Selecting or developing standards will involve analyzing legal requirements and regulations, published research, local agreements, and consensus statements and recommendations by learned bodies. Local circumstances may dictate the choice and level of a standard.

Adam advocates a step-by-step approach: choose the topic, choose the standard, choose what you need to count (indicator) to see if the standard is met, decide how big a sample is needed, collect the data (retrospective or prospective), and compare performance with the standard. Then ask yourself what was achieved or not achieved, she said.

A self-audit can be very educational, as can an internal audit carried out in a unit or department. External audits, on the other hand, involve professionals from outside. In all cases, honesty, integrity, and confidentiality are paramount. Additionally, she noted that audits are not designed to be statistically robust, and are indicative, not definitive.

„Taking part in an audit can be both an intimidating and an uplifting experience,“ said Dr. Birgit Ertl-Wagner, from the Institute of Clinical Radiology University of Munich in Germany. “On the one hand, it is frightening that someone is examining me, someone is looking at my affairs, and someone could blame me. On the other hand, it is postive that I can learn from the audit, I can see the improvement, my patients and employees are safer, and I am doing everything possible to continuously improve my practice.“

For internal audits, she had the following tips: Plan them well ahead (for the entire year); notify the auditors and audited parties well in advance about the time, place, and topic; conduct them at the workplace with a co-auditor; prepare the audits thoroughly; avoid yes/no or suggestive questions; and aim for a relaxed professional atmosphere.

Her other tips are to have a checklist of questions ready, consider indicators that can be quantified (especially key indicators), consider legal requirements, consider risk management, look for continuous improvement, and prepare a written report with action items.

For further reading, Adam recommends the EC Guidelines on Clinical Audit (for radiological procedures) from November 2009, which is a comprehensive guide with suggested methodology for clinical audit, including an external auditing process for all ionizing radiation procedures. She also directed attendees towards “Clinical audit-ESR perspective,” published in the January 2010 edition of Insights into Imaging.

Note: a version of this article appeared in the 2010 ECR Today newspaper.