The concept of clinical audit often raises various misconceptions. The use of the term "audit" leads many to believe that this process is an investigation conducted when a case or problem arises. However, this activity is actually a quality improvement process carried out by healthcare professionals.
Through this audit, healthcare units can systematically improve their services by evaluating practices and their compliance with existing standards. Thus, audit results can serve as a tool to drive continuous improvement.
What is a Clinical Audit?
Clinical audit is an improvement in the quality of clinical services and output Patients are assessed through a systematic review of services involving clear criteria and implementation of changes. The audit review covers the diagnostic and therapeutic processes, the use of hospital resources, and output or quality of life from the patient.
Unlike other types of audits, clinical audits are conducted by clinicians such as doctors, nurses, or other clinical support personnel. Hospital activities involve a variety of equipment, procedures, and terminology that may not be fully understood by the general public.
Thus, the implementation of the audit by experienced clinicians in their field will be able to support the effectiveness and efficiency of its implementation.
See also: Medical Audit: Types, Scope, Benefits, and Examples of Implementation
Objectives of Implementing Clinical Audits
- Improving patient quality and safety – achieved through identifying weaknesses in care, ways to minimize errors, and reduce risks to patients.
- Comparing standards – compare actual practice with medical guidelines and standards to find areas of deviation.
- Achieving best practices – promote good practices and identify areas of excellence to be replicated or become references, guidelines or operational standards for other units.
- Resource efficiency – ensuring that resources are used effectively and cost-effectively.
- Learning and education – audit results can be a means of planning ongoing training and professional development for medical staff.
- Accountability – demonstrate service effectiveness to stakeholders and ensure services run as expected.
Stages of Clinical Audit Implementation
Clinical audits in hospitals involve three parts, namely (1) the medical committee, nursing committee, and other health worker groups whose job is to determine the audit topic and coordinate the audit process, (2) the team Ad hoc clinical audits whose job is to conduct analysis and prepare improvement plans, and (3) audit assistants whose job is to search for and process data. Furthermore, clinical audits are carried out in the following stages.
1. Determining the Topic
Topic determination is carried out through a coordination meeting of the Medical Committee, Nursing Committee, other Clinical Services Committees, and management representatives. Topics can be determined based on routine hospital data, such as patient satisfaction data, observations of the service delivery process, morning report, reports of unexpected events, and input from various parties.
Hospitals are advised to conduct clinical audits covering three to four topics per year. The following are examples of topics that can be used.
- Clinical audit of typhoid fever management in adults
- Clinical audit of dengue fever management in children
- Tonsillectomy clinical audit
2. Determining the Background, Purpose, and Targets of the Topic
After the Medical Committee determines the topic, a Hospital Director's Decree is issued. Then the team ad hoc formed and the selection of members is adjusted to the selected topic, namely health workers providing related clinical services.
Tim ad hoc is responsible for establishing the background, objectives, and targets (steps to achieve the overall goal) of the clinical audit. These are formulated as a guide to ensure the audit team shares a shared vision and mission.
3. Determine the Criteria
In the third stage, the team ad hoc Develop audit criteria. Audit criteria are evidence that patients have received optimal and maximum care. At this stage, auditors focus on assessing the appropriateness of clinical service processes and outcomes. This allows them to provide recommendations for improvement.
The determination of criteria in clinical audits must be guided by the National Guidelines for Medical Practice (PNPK), Clinical Practice Guidelines (PPK), Clinical Pathway, algorithms, protocols, and standing order.
4. Preparation of Audit Instruments
Tim ad hoc Develop audit guidelines, data collection forms, establish audit populations and samples, and sampling methods. Audit guidelines include audit criteria, data collection instructions, and exceptions. Forms can be simple and printed.
Regarding the population, the audit team can use patients who received services within a year prior to the audit. A sufficient sample size ranges from 30 to 100. Simple random sampling can be used as the sampling method.
5. Collecting Service Data
Service data collection is carried out by audit assistants. The data collection method is retrospective or uses data from medical records. The following are the data collection steps.
- Take the medical records that are audit samples, study them and find out their suitability, whether every criterion in the audit guidelines has been fulfilled in the medical records.
- Determine the conformity of audit results to the criteria.
- Write the audit results in code form.
- Separate medical records containing deviations for re-evaluation by the team. ad hoc.
6. Analyzing Data Through Comparison
Analysis by the team ad hoc aims to calculate the general level of compliance, identify patterns of deviation, and identify the causes of deviation.
This analysis was conducted using descriptive statistical tools and quality tools such as Root Caused Analysis (RCA) or Fishbone Diagram (Ishikawa). Audit results can be presented in tabular or graphical form to illustrate the level of conformity for each criterion more clearly.
7. Establish and Implement Changes
Determining changes that include corrective action plans or follow-up plans is carried out by other departments. However, at this stage, the team ad hoc propose change plans and monitor their implementation.
The change plan referred to in this context includes the problem, action plan, implementation of the action, and the deadline for completing the action.
8. Conduct a Re-Audit
Re-audits are conducted to determine whether improvements have occurred after the proposed change plan. This process is carried out using criteria and sample sizes that are the same or close to the previous sample size.
9. Preparation of Audit and Re-Audit Reports
The audit report is prepared collaboratively by the three audit departments involved, each with its own assigned duties. The audit and re-audit reports are prepared in separate reports, following a specified format.
Clinical Audit Example
- Determination of audit topics: administration of antibiotics to patients with respiratory tract infections due to high antibiotic use and the risk of resistance.
- Establishing standards or criteria: National Antibiotic Therapy Guidelines and hospital SOPs, such as antibiotics are given according to indications and doses and duration according to guidelines.
- Data collection: The audit assistant reviewed the medical records of 30 inpatients, noted the doctor's prescriptions, and the results of supporting laboratory tests.
- Analysis and comparison: tim ad hoc analyzed and showed that 70% of prescriptions were in accordance with standards and 30% of cases showed a longer duration of antibiotic consumption than recommended.
- Identification of findings: tim ad hoc found discrepancies in the duration of antibiotic therapy and a lack of re-evaluation of therapy after laboratory results came out.
- Recommendations for improvement: The auditor recommended strengthening physician education regarding antibiotic evaluation and implementing antibiotic evaluation reminders in the electronic medical record system.
- Implementation of corrective actions: Clinic management conducted a short training on rational antibiotic use and added a therapy evaluation reminder feature.
- Re-audit: The clinical audit team conducted a re-audit and found compliance had increased to 90% and antibiotic use was more rational.
- Conclusion: Clinical audits have been proven to help improve the quality of services using the therapy evaluation reminder feature.
Closing
Clinical audits are not just an evaluation tool, but rather an important effort to ensure that healthcare practices are carried out correctly, safely, and in accordance with guidelines.
Given that healthcare services directly impact human safety, healthcare units need to conduct continuous evaluation and improvement. Through clinical audits, gaps can be identified and addressed to improve service quality.
In order for the audit process to run optimally, health units not only need support from independent personnel, but also the right technology. Audithink audit application can be the right solution to help make the audit process faster, more accurate, and more monitored. From risk assessments and template-based audit programs to automated reporting. Schedule a demo now or contact our team for further consultation.
