Journal of Pakistan Association of Dermatologists 2012;22 (4):358-362.

Review Article
Clinical audit: A simplified approach
Mansoor Dilnawaz, Hina Mazhar, Zafar Iqbal Shaikh

Department of Dermatology, Military Hospital (MH), Rawalpindi

Abstract A clinical audit measures practice against standards and performance. Unlike research which poses
the question, “what is the right thing to do?” clinical audit asks are we doing the right thing in the
right way? An approach for understanding a clinical audit is provided. A basic clinical audit
example of a case note audit is presented. A simplified template to help the beginners is included.

Key words
Clinical audit.

Introduction and steps of clinical audit We should determine what we are trying to
measure and define gold standards. The next
Audit is a key component of clinical stage is about setting the standards. Criteria are
governance, which aims to ensure that the those aspects of care that we wish to examine.
patients receive high standard and best quality Standards are the pre-stated or implicit levels
care.1,2 It is important that health professionals of success that we wish to achieve. The
are given protected and adequate time to standards are based on the local, national or
perform clinical audit.4,5,6,7 Clinical audit runs international guidelines. They should be
in a cycle and aims to bring about incremental relevant to our practice. A couple of example
improvement in health care. Guidelines and of the sources includes National Institute of
standards are set according to perceived Clinical Excellence (NICE) and the British
importance and performance is then measured Association of Dermatologists (B.A.D) web
against these standards.8,9,10. sites. When setting the standards remember the
acronym SMART – Specific, Measurable,
A clinical audit is NOT the same as research. Achievable, Relevant and Theoretically sound
There are differences (Table 1). – based on current research.

A clinical audit usually starts by discussion at Next, methodology should be defined. Who
an audit team meeting discussing possible will be involved? Who will collect and analyse
topics and prioritising them according to data? What will be the sample size? What
perceived importance applicable to the about the feedback of findings – to whom and
practice. The golden rule is we should only how? When will the project begin and end?
ever audit our own practice. If for some reason
we need to gather data about the practice of The audits and the data collection can be
others, then we should involve them in the prospective or retrospective (Table 2)
audit and obtain their permission.11
Address for correspondence The audit once completed is presented at a
Dr. Mansoor Dilnawaz meeting and recommendations are made with
Consultant Dermatologist regards to deficiencies found and to identify
Department of Dermatology
Military Hospital (MH), Rawalpindi areas for improvement. The implementation of
Email: [email protected] the changes cannot be over emphasized - What
Ph: +92 342 421 0568

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Journal of Pakistan Association of Dermatologists 2012;22 (4):358-362.

Table 1 Difference between audit and research.

Research Audit
Generates new knowledge Knowledge being used to the best effect
Is initiated by the researchers Usually led by the service providers
Is theory driver (hypothesis based) Is practice based (standard based)
Is often a one-off study Is an ongoing process
Large scale, prolonged periods Usually less so
Lot of statistical analysis Not much analysis
May involve allocating service users randomly to different Never so
treatment groups
May involve administration of placebo Never so
Requires approval from ethical committee No such approval needed

Table 2 Data collection.

Categories Retrospective Prospective
Definition Data collected by looking back Data collected from this point onwards,
over your practice starting at a future date
When to use When looking at what has been Data currently unavailable
happening in a chosen topic area Data of poor quality
Advantages Can be faster Avoids using poor quality data.
Provides a baseline Allows design of a clear and concise
data collection sheet
Disadvantages Past service users do not benefit Provides no baseline for audit.
Can be time-consuming since a no of
individuals needed to collect data

Clinical Audit Cycle

1. Select
8. Re-audit
topic

2. Agree
7. Implement
standards of
change
best practice
Action Planning

6. Make 3. Define
recommendations Audit methodology

4. Pilot
5. Analysis and
and data
Reporting
collection

Figure 1 Clinical audit cycle.

needs to change? How change could be will be monitored and by whom to achieve the
achieved – what actions need to be taken? desired outcome and then re-auditing to see if
Who needs to take these actions? When will the desired outcome(s) has been achieved.
the proposed actions begin? How these actions

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Journal of Pakistan Association of Dermatologists 2012;22 (4):358-362.

A summary of the stages of clinical audit are 1. Clinical effectiveness This means
presented in the form of audit cycle (Figure 1) ensuring that everything we do is
designed to provide the best outcomes
Discussion for patients i.e. “doing the right thing
to the right person at the right time in
Clinical audit in simple words means are we the right place”. In practice this means
doing the right thing in the right way? This is an evidence based approach, changing
achieved by measuring our practice and practice if current practice is shown
performance against standards. Doing regular inadequate, developing and
clinical audits is essential. Audits improve implementing new protocols and
patient care, identify and promote good guidelines, conducting research to
practice, lead to improvement in service develop evidence, CPD, maintaining
delivery, demonstrate to others that our service log books, time management, seeking
is effective, provide opportunities for help where required, patient
education and training and encourages satisfaction surveys, adequate
teamwork. The overarching aim of clinical consultation time, information leaflets
audit is to improve service user outcomes by etc.
improving professional practice and the 2. Clinical audit The aim of the audit
general quality of services delivered.12 process is to ensure that clinical
practice is continuously monitored
There are three main types of clinical audit: and that deficiencies in relation to set
standards of care are remedied.15
1. Structure (what we need). This 3. Risk management This involves
includes staffing and facilities. having robust systems in place to
2. Process (what we do). The examples understand, monitor and minimise the
are checklists, protocols, guidelines, risks to patients and staff and to learn
record keeping, waiting times, from mistakes. When things go wrong
trainee’s attendance and treatment. in the delivery of care, doctors and
3. Outcome (what we expect) for other clinical staff should feel safe
example satisfaction surveys. admitting it and be able to learn and
share what they have learnt. In simple
Clinical Governance
terms this means to identify, assess,
prioritise and prevent risk.16
A clinical audit is an integral part and key
Examples of risk management
component of clinical governance.13 Clinical
include: complying with protocols,
Governance is an umbrella term which
learning from mistakes and near-
encompasses a range of activities in which
misses, reporting any significant
clinicians should become involved in order to
adverse events via incident forms,
maintain and improve the quality of the care
looking closely at complaints,
they provide to patients and to ensure full
promoting a blame-free culture.
accountability of the system to patients.14
4. Education and training This means
enabling staff to be competent in
There are basically seven pillars of clinical
doing their jobs and to develop their
governance:
skills so that they are up to date. This
involves attending courses and
conferences – CPD activities, taking

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Table 3 Clinical audit template.

Project title Name of the audit
Specialty Name
Professor/HOD Name
Project Lead(s) Name(s)
Staff members involved Names
Date of presentation Date
Rationale Background/Reason for the selected topic
Objective(s) Insert
Project type Structure, process or outcome
Basis of proposal Local, National, International guidelines
Criteria Insert
Standard(s) Insert
Sample source Insert
Sample size Insert
Data collection/ analysis Retrospective/ Prospective
Results Insert
Recommendations/ Insert
Areas for improvement
RE-AUDIT Date/ Time frame

Table 4 Case notes audit example.

Project title Case notes audit
Re-Audit
Specialty Dermatology
Professor/HOD Dr. Zafar Iqbal Shaikh
Project lead(s) Dr. Mansoor Dilnawaz
Staff members involved Dr. Hina Mazhar
Date of presentation 5 October 2012
Rationale Meticulous record keeping is an integral part of patient care
Objective(s) 1- To assess the quality of patient record
2- To seek incremental improvement
Project type Process
Basis of proposal Local guidelines
Criteria The case notes should contain the relevant demographic and clinical details of
the patients
Sample source Case notes from the dermatology ward at Military Hospital, Rawalpindi
Sample size 10 case notes selected at random
Data collection/analysis Dr. Mansoor Dilnawaz, Dr. Hina Mazhar
Standard(s) 1. Is there:
a. A hand written record?
b. Is the clinician identified?
c. Is it legible?
2. Is patient identified on each page (name, personal number, age,
disease)?
3. Is there clear diagnosis or clinical problem?
4. Is there a clear management plan?
Results 1 2 3 4 5 6 7 8 9 10
1a
1b
1c
2
3
4
Recommendations/areas for 1- All the case notes had hand written, legible record of the patients with clear
improvement diagnosis and management plan
2- To continue with maintaining good patient record
Re-audit 6 months

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Journal of Pakistan Association of Dermatologists 2012;22 (4):358-362.

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