What is audit?
Audit measures practice against standards and helps us to answer the question ‘are we doing the right thing in the right way?’ It is about understanding practice so we can change it if needed, to improve the quality of care for patients.
Trainers marking a trainee's audit are looking for evidence of preparation; correct selection of criteria; evidence of knowing how to measure performance levels; and the ability to motivate practice change so sustainable improvements are made.
As with all forms of structured reflection, the audit write up includes:
- A narrative (what I did in my audit),
- Learning (what I learnt from doing this audit) and
- Change (what will I do differently in future to improve my practice and also to improve my future auditing).
An example audit log entry
Read through the learning log entry below on an audit of emergency contraception. As you read through, ask yourself the following questions:
- Is the topic a priority for the organisation?
- Is there good evidence from systematic reviews or national guidelines to inform standards?
- Do I understand why this standard (level of care) was chosen?
- Do I understand how the data was collected, manually or by computer?
- Was the data compared to the standard? If standards were not met, were reasons for this identified?
- Were audit findings presented and discussed with the team? How were results presented; were graphs/ PowerPoint used?
- What recommendations for change were agreed?
- Was the audit repeated to see if the recommendations brought about an improvement in practice?
Learning log (Audit)
An audit of oral emergency contraception (EC)– are women issued with Levonelle or ellaOne by the practice receiving information about LARC within one month of EC prescription?
What was the subject and aims of the audit?
The subject of the audit was contraception, specifically looking at offering women issued with oral EC LARC options. The aim is to educate this group of women who experienced contraceptive failure or who have ongoing contraceptive needs about LARC, to increase its uptake and thereby (hopefully) decrease unwanted pregnancies.
The criterion is: 90% of women given oral emergency hormonal contraception (EC) by the practice in the last year have received information about LARC within one month of EC prescription.
I obtained this criterion from the QOF (2016) which is based on NICE guidance CG30 (2005).
After discussion with the practice nurses and doctors, I set the standard at 50% of women given oral emergency hormonal contraception (EC) by the practice in the last four months should have received information about LARC within one month of the EC prescription.
The reason for this lower percentage is because clinicians may not be documenting the fact that they counsel about LARC. While the GP partner and two nurses who have an interest in family planning know about the templates and Read Codes, the wider practice has not discussed contraception in a clinical meeting in the last two years and are perhaps not as up to date.
When I discussed standards with the team, they believed that the lower standard of 50% is still acceptable practice. I also shortened the time frame to four months so that I can re-audit in four months, during my placement.
The pharmacy technician conducted a dispensing search on 3 Feb in the following manner:
- ST – searches and reports
- PS – prescription statistics
- Select A – collect prescription information
- Select D – list issues of an individual item between specified dates. She searched for the last 4 months.
The search identified 16 women. On checking each record manually, I found:
- 10 patients did not have a record of LARC being discussed.
- Six (38%) were offered LARC. We fail to meet our standard of 50%.
- Of the six, one returned for depo and two for Mirena.
What led to this particular subject being chosen?
During my induction, when I sat in with the pharmacy technician, she mentioned that she noticed that the number of prescriptions for Levonelle and ellaOne had increased. At a recent practice meeting, the practice manager discussed the QOF points available for contraception and advised that there was room for improvement.
I am new to primary care and am sure to be asked by patients for EC. Having not written a script for ellaOne before, EC is a learning need for me. By undertaking an audit on EC, I want to increase my knowledge about EC and also to assess whether our patients get a good service, in line with NICE guidance, when consulting for EC.
What did you learn?
I learnt that we documented the offer of LARC to only 38% of women issued with EC and that there is room for improvement. Either we are not making the offer or we are not documenting the offer in the notes.
What will you do differently in future?
In my presentation of findings to the practice, we discussed:
- Use the presentation for EC as an opportunity to discuss LARC.
- Document the offer of LARC (tick the box on the EC template)
- Book the patient an appointment for LARC with the family planning trained clinician before they leave or signpost them to the Family Planning clinic.
- Repeat this audit in four months.
What further learning needs did you identify?
- I do not know how to construct the computer search myself.
- Could I administer depo provera at the same appointment as issuing oral EC?
How and when will you address these?
- I could speak to the pharmacy technician and ask her to show me how she constructs the search. I could speak to the practice manager about searches and QOF in the tutorial on practice management next month.
- I need to read more about when depo could be safely administered either online (Faculty of Family planning guidance) or consult Guillebaud's book.
- Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP was published in January 2016.
- Simon, C. Audit in primary care. Innovait 2008; 4: 274-9.
- Benjamin, A. Audit: how to do it in practice. BMJ 2008; 336: 1241.