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.
> Find more advice for GP registrars in our training section
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?
Quality Improvement Activity Entry
?An audit of oral emergency contraception (EC) – are women issued with Levonelle or ellaOne by the practice receiving information about long-acting reversible contraception (LARC) within one month of EC prescription?
Brief description of the QIA
?I wanted to audit contraception, specifically looking at whether clinicians offered women issued with oral EC LARC options. During a conversation with the pharmacy technician, I learnt that is is important to educate women who experienced contraceptive failure, or who have ongoing contraceptive needs, about LARC, to increase its uptake and thereby (hopefully) decrease unwanted pregnancies.
After discussion with my trainer, I felt that an audit would be a good QI methodology to assess what our practice currently does, introduce changes if needed, and re-audit to see if practice improves.
What were you trying to accomplish?
I was trying to see if the practice was compliant with NICE guidance CG30 (2005; updated July 2109) that all women given oral emergency hormonal contraception (EC) by the practice receive information about LARC within one month of EC prescription.
To set the standard for my audit, I discussed it at a governance meeting. The practice nurses and doctors advised me to set a lower initial audit standard (50% of women, not all). 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. By agreement, 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 team 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 and check if our practice had changed.
How will we know that a change is an improvement?
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.
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.
How have you engaged with others? ?
I presented my findings to the practice at the Govenance Meeting. 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.
- Attach a patient information leaflet (PILs) to their econsult or text it to their mobile using the Gov.UK notify service.
- Repeat this audit in four months.
What changes have taken place?
- The team now know about the EC template, how easy it is to use, and how to print, email, or text the LARC patient information leaflet to patients.
- The pharmacy technician has the search for EC set up and is able to re-run it at regular intervals.
Reflection: what will I maintain, improve or stop?
The idea for this audit was planted 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. Having not written a script for ellaOne before, EC was a learning need for me. After I read the NICE guidance, I wasn’t sure whether our patients get a good service, in line with NICE guidance, when consulting for EC. My trainer, the Family Planning trained doctor in our practice, suggested audit as a methodology for comparing actual practice with ‘ideal’ practice. I have undertaken audit before, but I need to maintain and improve my audit skills as this is a common QI methodology in GP.
I need to improve my data collection skills. I could speak to the pharmacy technician and ask her to show me how she constructs the search.
I need to stop assuming that everyone uses IT, inluding templates, well. The clinicians were genuinely interested in looking at the template and seeing how easy it is to attach PILs to an econsult or gov.uk notify service.
Clinical experience groups (max 2) :
- Clinical problems not linked to a specific clinical experience group.
Capabilities that this entry provides evidence for (you can only add 3 capabilities)
- Maintaining performance, learning and teaching
- Working with colleagues and in teams
- Organisation, management and leadership
Well done on developing the idea that sprang from a conversation with the pharmacy technician, which prompted you to read the Nice guidelines. I’m glad that you chose audit as your QI methodology. You have completed your first data collection. I look forward to the full-cycle audit after your 2nd data collection. The practice really enjoyed your demonstration of the IT. You walked us through the gov.uk notify service really well
Click here to find out how this audit would be assessed
- 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.
- What is a QIA reflective learning log entry?
- Simon, C. Audit in primary care. Innovait 2008; 4: 274-9.
- Benjamin, A. Audit: how to do it in practice. BMJ 2008; 336: 1241.