In the first article on audit write-ups, we covered the theory of audit and important aspects of the write up – what was done in the audit, what was learnt from doing the audit and how your practice will change having done this learning.
This second article covers how the audit log entries are assessed and discusses the typical comments given by trainers. The feedback should inform you of what you have done well and should provide suggestions that may be useful to you when you do another audit so that your auditing practice improves incrementally.
In the first article, the trainee audited oral emergency contraception (EC). She asked a specific question: ‘Are women issued with Levonelle or ellaOne by the practice receiving information about LARC within one month of EC prescription?’
How audit is assessed
After reading her log entry, I understood why she asked this question; how she gathered the data to answer the question; how she analysed the data; what conclusions she made about the acceptability of level of service being provided; and what actions the practice agreed to help improve standards.
My feedback to the trainee would include a comment on how well this reflection demonstrated her knowledge of audit principles and how her write-up is a succinct presentation of her findings and recommendations. I also agree that her newly-discovered learning needs around EC prescriptions, QOF and computer searches for auditing are important issues and need to be written up as a PDP.
My feedback about audit includes certain specific comments aimed at meeting annual review of competence progression (ARCP) criteria. The ARCP expects trainees to be able to conduct a clinical audit.
Being a General Practitioner, learning outcome 1.5.2 states: ‘Audit is just one example of quality improvement activity and the curriculum does require trainees to have skills in auditing the quality of care.’
By the final ARCP, the panel expects to see at least one completed audit, where the second cycle of data gathering is analysed and discussed. Therefore, I would tell to this trainee that I look forward to seeing her second entry in four months’ time after her second set of data analysis, with the audit written up in a eight-point format, which includes:
- Reason for the audit
- Criterion or criteria to be measured
- Standard(s) set
- Preparation and planning
- Results and date of data collection one
- Description of change(s) implemented
- Results and date of data collection two
The RCGP provides detailed guidance and examples, which you can access here.
The audit topic
The example audit that was undertaken fulfils a need for the practice. This audit helped the practice understand how it could improve its level of EC care by discussing LARC more systematically with a 'hooked' and interested group.
It also helped the trainee address her learning needs about Levonelle and ellaOne, which was a bonus. Had the trainee chosen a topic that was not a priority for the practice, I would have fed-back that audit is a clinical governance activity, aiming at improving standards of patient care, not a research activity.
In research we ask 'what is the right thing to do?' whereas in audit we ask ‘are we doing the right thing in the right way?’
This audit is linked to the trainee's personal development plan (PDP). The trainee had some learning needs about prescribing EC, understanding QOF and undertaking computerised searches on prescriptions. I would now expect to see a linked PDP which tells me how she became aware of these learning needs and how she intends to address them.
The trainee is able to describe accepted best practice in her audit topic. Preferably information about best practice is from a literature search and the trainee cites multiple sources. In this learning log, there is room for improvement. The trainee cited QOF 2016 and NICE CG30 (2005). She demonstrates an acceptable understanding of current recommendations but would have scored more highly had she summarised key aspects of the clinical topic, citing several literature sources.
This example shows where this is done well.
In this example, the criterion could be better worded. The RCGP advises writing the criterion as 'what should happen' and 'who tells us to do this'. Following this advice, the trainee would be better off writing 'all women prescribed oral EC should receive information about LARC within one month of EC prescription (QOF 2016)'.
Presenting your findings
The trainee compares her findings with best practice and presents her findings to the practice team, but she does not provide further details of how she presented the information. It would be good to know if data was presented using graphs in a PowerPoint presentation or if a handout was created.
Had she used charts, I would have commented on whether the most appropriate method to present the data was used, for example were pie charts used to show proportions and bar charts used for easy comparison between different clinicians or time periods. Some trainees upload a copy of their PowerPoint presentation, practice minutes, or their handout to the log entry.
It is always good to read some reflection on how the presentation went. I usually encourage trainees to collect feedback on the presentation and to reflect, in a separate log entry, on their IT and presentation skills. Bristol Hospital provides an excellent guide to audit presentation.
The changes the practice agrees to should be documented. Recommendations should be SMART (Specific, Measurable, Achievable, Realistic, Timely). Some trainees construct a clinical audit action plan, using HQIP templates.
If a new protocol is written, then it too could be uploaded. If a teaching package was delivered to help bring about change, then the trainee could reflect on this in a separate entry or she could attach her teaching handout.
Excellent reflective logs would also tell me what this trainee would do differently if she repeated the audit; what small specific actions she would take to make the auditing process easier or more effective. She could review her audit methodology and comment on processes that need fine-tuning before her second data collection.
- 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.
- Postgraduate Deanery for Kent, Surrey and Sussex. A guide to completing the e-portfolio learning log.
- Health Quality Improvement Partnership. Template for clinical audit.
- For an example of a well written audit, see: McElveen, H. Clinical audit: Polycystic ovarian syndrome. Innovait 2013; 6: 731-4