By Priyanka Adatia, Foundation Dentist

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A clinical audit consists of measuring the performance of an activity or process, against well-defined standards set on principles of evidence-based dentistry to identify changes needed to improve the quality of care. Audits can be carried out routinely or in response to a significant even that has occurred.

Some audits are mandatory to complete - the Care Quality Commission (CQC) advises regular audits on:

  1. 1.

    Infection Decontamination and Control

  2. 2.

    Radiography

  3. 3.

    Accessibility1

Audits topics can be based on local need - it is important that audits are tailored to individual practices to maximise effectiveness which is why it is useful to take all staff viewpoints onboard when deciding on what audit topics should be performed.

Audit topics should be SMART:2

Specific

There should be a clearly defined objective detailing:

  • Who is leading it? Are the supporting staff?

  • When - what time frame is this occurring over?

  • Where is it limited to this practice? Are there other practices involved?

Measurable

It should be possible to measure the goal to know when it has been achieved via time, numbers, quality and quantity etc.

Achievable

Have awareness of the skills/resources needed to attain the goal - do you have the training/knowledge/access to courses to facilitate the move towards improvement?

Realistic

It may be unrealistic to have an expectation of 100% for certain goals.

Timely

There should be a timeline at which it is expected the goal will be achieved.

Audits topics can be based on local need - it is important that audits are tailored to individual practices to maximise effectiveness

How do audits related to clinical governance?

HEE defines Clinical Governance (CG) as 'A system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish'.3 What this translates to is:

  1. 1.

    Audits are a quality assurance process

  2. 2.

    Designed to ensure standards of care are maintained

  3. 3.

    Designed to ensure standards of care are improved

  4. 4.

    Allows the NHS to be accountable to the public.

CG is formed by seven instrumental pillars, of which Audits form an integral part. The pillars are often denoted by the mnemonic PIRATES:4

  • Patient and public involvement

  • Information and IT

  • Risk Management

  • Audit & Peer review

  • Training and Education

  • Clinical Effectiveness

  • Staff management

Audits are facilitated via the 'Audit Cycle' which is made up of six stages - diagrammatically represented in Figure 1. These stages are:5

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Fig. 1 A flowchart representing the stages of the Audit Cycle

  1. 1.

    Identify the issues - Audits are carried out locally in a practice or hospital department. Therefore, to ensure effectiveness, it is useful to consult the team about ideas they have for an audit topic - these should fit the SMART objectives - what are you looking to achieve?

  2. 2.

    Define the standards - The 'gold standard' for the chosen objective is what will be used to compare findings against i.e. NICE Guidance on the Extraction of Wisdom teeth - ideally it would be a national or published recommendation, alternatively it may be a locally agreed criterion.

  3. 3.

    Define methodology and collect data - How is the sample going to be chosen; will the data be collected prospectively or retrospectively; what is the sample size; is it only your patients or practice-wide; are other practices involved; how is selection bias going to be mitigated?

  4. 4.

    Data analysis and comparing of standards - Calculate the degree to which the agreed 'gold standard' is met - this should be expressed as a percentage.

  5. 5.

    Identify issues and implement change - Assess if there is a problem with meeting the standard - undertake Root Cause Analysis via either 'Fish-bone' analysis shown in Figure 2 or 'Five Whys' principle, shown in Figure 3.6 Decide on what changes need to be made i.e. via a practice meeting, followed by a modality to train/learn from the findings - this may be a CPD course/an external lecture. Staff members can record their learning needs in their Personal Development Plan (PDP).

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    Fig. 2 An example of how the Fishbone/Ishikawa Diagram is used for root cause analysis

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    Fig. 3 The use of the 5 Whys technique to perform root cause analysis

  6. 6.

    Re-audit - An audit is only thought to be complete once you have 'closed the loop'. Re-auditing allows you to compare new-found practice following implementation of changes, against the gold standards - there should be an expected improvement attainment rate as set out by the SMART goal.

    An audit is a process which compares clinical practice against set standards. Research aims to create new knowledge that can be used to develop new standards of care

How is an audit different to research?

An audit is a process which compares clinical practice against set standards. Research aims to create new knowledge that can be used to develop new standards of care. Therefore research helps establish best practice whilst audit checks that best practice is being applied in practice. The benefits and limitations of audits are shown in Table 1.

Table 1 A table listing the benefits and limitations of clinical audits
Full size table

Summary

Audits are an instrumental tool in maintaining a high standard of care towards patients and are utilised in multiple industries to maintain and improve public care. Performing an audit in your undergraduate years may be a prudent idea especially if you are considering applying for DCT/further postgraduate qualifications where audits are desirable criteria.