Billy Boland: Clinical audit is not dead

billy_bolandWhile Quality Improvement (QI) is enjoying a surge in popularity in health services, it can also suffer from an image problem. I’ve been told that it’s a fad, a management trend, and not evidenced based. I generally don’t quite get what these objections are about. Often in medicine when we come up against problems, these are rooted in issues of communication. Sometimes I wonder if objections are borne out of that. The Quality Improvement field is filled with jargon and differing branding and methodologies. I think they can be confusing and alienating. It takes a bit of work to get under the skin of what QI is all about. At its heart though, is the simple mission found in its name—it’s about improving the quality of care.

Think then of what can often get overlooked as the poor cousin of quality improvement: clinical audit. If QI is the slick, new, sexy end of service development, then clinical audit can seem old fashioned, a fuddy duddy. In the world of health providers it can get ensconced with regulation and “assurance”—the province of bean counters and distant from the front line. In a rapidly changing world that thrives on innovation, “just” doing audit can seem trivial and out of touch.

It’s perceived relevance can suffer through endless cycles of audits where change doesn’t occur. Annual audits can generate significant activity for clinicians with actions planned, only to discover that when re-audit happens again the next year, little has changed. It is easy to see how monumental effort for little gain can be demotivating. People can become disconnected.

That is why the current clinical audit awareness week is so important. It seeks to put clinical audit in the spotlight and celebrate the positive difference it can make. We need to re-assert why clinical audit is a good thing, shout about the value that it adds for patients, and show that change is possible. Clinicians need to be helped to understand that Quality Improvement and Clinical Audit aren’t necessarily separate things. They can be two sides of the same coin. High quality clinical audit can lead to high quality improvement if it is done right.

Both rely on measurement to assess change, and both broadly use a Plan, Do, Study, Act cycle to get their work done. For me, the key is in the action planning. After a large scale piece of data collection for audit, I’ve often found people feel chuffed to get there, relieved that their hard work has paid off. And they can think they’re done—action planning can be a bit of an afterthought. In my experience, when a piece of work is focused on action planning and improvement, people place more emphasis on making change. Action planning becomes the journey, and data collection serves a purpose. QI can help with action planning as it promotes “rapid experimentation,” or PDSA cycles in quick succession. This can encourage people to stay engaged rather than wait for the annual audit wheel to turn around until next year.

In both Clinical Audit and QI we need to celebrate having a consistent and methodical approach to looking at problems in clinical practice and committing to making positive contributions. QI and clinical audit can support each other and both work towards the same goal: improving patient care. What could be sexier than that?

Billy Boland is a consultant psychiatrist and associate medical director for quality and safety at Hertfordshire Partnership University NHS Foundation Trust. You can follow him on Twitter @originalbboland.

Competing interests: I am vice chair of the general adult psychiatry faculty at the Royal College of Psychiatrists.

  • Carl Walker

    Excellent blog – important to remember that clinical audit is actually a quality improvement process (as defined by NICE in 2002) and the clinical audit community have been using clinical audit awareness week to remind people of this. As you say its all about improving patient care in a systematic way – knowing how you are doing and then gaining knowledge about the effectiveness of your interventions / changes made to seek improvement in (ultimately) patient centred outcomes.