How to perform a perfect audit

Careful planning should make the audit process efficient and painless, says Dr Kate Roberts-Lewis.

LEARNING POINTS

How to get the most from audits

  • Choose a topic that interests you and has potential for improvement.
  • Keep it simple - don't have too many criteria.
  • Plan carefully, involve the whole team, share the work.
  • Make changes specific and sustainable, and involve the team in identifying them.
  • Complete the cycle, and feed back to the team what progress has been made.

WHY AUDIT?
Currently, to pass summative assessment in order to practise as a GP.

With the dawn of the new MRCGP this will change, but audit is unlikely to disappear from the GP registrar radar, and rightly so. Doctors and practices are responsible for keeping knowledge and service provision moving with the times. To make changes, and therefore progress, the current situation needs to be assessed, and areas in need of improvement identified.

This is where audit comes in. Evidence of the ability to perform audit and effect successful change will be helpful, or indeed essential, for appraisal and revalidation.

WHAT TO AUDIT
Planning what to audit is important, both to avoid wasting your time, and to make the process of doing the audit more rewarding. Key considerations include the following.

Is there need for change? If requirements are being met effectively already, then your audit is unlikely to have a significant impact on improving service provision. Is improvement possible? If the area you plan to assess is one where expert opinion gives no clear consensus of the best management, then it is unlikely that a unified approach will be successfully introduced.

You should be interested in your subject because you will be spending precious time on it.

Also, consider the complexity, because it will be easier to keep track of things, and make targeted changes, if the area chosen is not too big.

For example, auditing the whole of 'epilepsy management' could be very time consuming, whereas auditing whether patients with epilepsy have had their medications reviewed is more manageable.

In addition, making too many changes at once tends to overload the team, meaning that fewer changes are effectively adopted.

STRUCTURE OF THE AUDIT
An audit should involve one full cycle as shown in the diagram. For summative assessment, write it up using the pass criteria as headings.

Involve the team from the planning stage. Other people may be able and willing to help you with the workload, but you will also find they will be more likely to make changes if they feel they have been consulted and involved in the process of identifying need for change.

Choosing a title can help you focus your audit. Phrase it as a question, for example 'Have all our patients with epilepsy had a medication review within the past year?'

The criterion is a statement of gold standard practice toward which your audit will aim to move the existing situation. It should be based on high-quality evidence, which should be quoted when presenting the audit. In the example used here it might be 'all patients with epilepsy should have a yearly medication review', which is based upon NICE guidance. One or two criteria should be sufficient per audit.

The standard is the percentage of patients whose care you and the practice reasonably expect should meet the criterion. For example, if it is known that 5 per cent of patients with epilepsy in the population opt out of attending medication reviews despite all encouragement, then you might set the standard at 95 per cent. The standard should be based where possible on factual information, and where this is not available on consensus opinion from members of the practice team.

THE PROCESS
Collect data about the current situation by searching the computer records for Read codes. However, some audit subjects may demand a different approach, which may be more time consuming. Compare your data with the standard set.

Involve the team in identifying what you can realistically change to improve the service provision. If the changes are too many or too complex, people will not adopt them. The aim is to make changes that will have a sustained benefit. For example, asking all doctors as a one-off to call their patients with epilepsy for review will have a great effect by second data collection, but is unlikely to be sustained the following year. Better then to have a yearly computer-generated reminder for each patient with epilepsy.

Your second data collection should occur once sufficient time has passed for the changes to come into effect. Ensure the methods from the first data collection are replicated to eliminate any bias.

Your discussion will examine how effective your changes have been, the reasons for this and whether they can be sustained or improved. You should identify other related audit areas and tips for performing the same audit in the future.

All is not lost if the changes made little difference or even made the situation worse, but it is important to identify why, and to suggest how the practice moves forward.

Feed back the results to the team, presenting the data clearly with graphs and tables. Reference other work that you've looked at while planning and performing your audit.

- Dr Roberts-Lewis is a GP registrar in Bristol

REFERENCE
Stokes T, Shaw E J, Juarez-Garcia A, Camosso-Stefinovic J, Baker R. Clinical Guidelines and Evidence Review for the Epilepsies: diagnosis and management of the epilepsies in adults and children in primary and secondary care. London: Royal College of General Practitioners, 2004. (Available to download from: www.nice.org.uk).

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