How do I implement a clinical audit in my practice?

Why audit matters in private practice

Clinical audit is a quality improvement cycle. You measure care against agreed standards, take action to close the gaps, and measure again. That is how the Healthcare Quality Improvement Partnership (HQIP) describes it in its best practice guidance.

In private general practice there are three practical reasons to do it:

• The CQC. In England, regulation 17 requires CQC-registered providers to assess, monitor and improve the quality and safety of their services. The CQC’s guidance on the regulation refers specifically to regular audits.
• Appraisal and revalidation. The RCGP says GPs are expected to take part in quality improvement activity that relates to their practice at least once in each five-year revalidation cycle, and appraisal should cover your whole scope of practice. Your private work counts.
• Safety. Without a practice team around you, audit is one of the few ways to find out whether what you think happens is what actually happens.

The audit cycle, step by step

1. Choose a topic. Pick something where the risk is high, the activity is frequent, or you already suspect a problem. Keep the question narrow enough to answer.
2. Set the standard. Write one to three criteria, each with a target. For example: “100% of patients prescribed methotrexate have blood monitoring recorded within the interval recommended in the BNF.” Say where each standard comes from.
3. Decide the sample. Define who is included, the time period and how many records. For a small service, all eligible patients over six or twelve months is often manageable.
4. Collect the data. Run a search if your record system allows it, or use a simple data collection form. Record exceptions and the reasons for them.
5. Compare with the standard. Work out the percentage meeting each criterion and look at the cases that did not, because the reasons tell you what to change.
6. Agree and make changes. Change the system, not just your resolve. Examples are a template, a recall, a checklist, a new step in a protocol or training for staff.
7. Re-audit. Repeat the same measurement after the changes have had time to work, often three to six months later. If the target still is not met, go round again.
8. Write it up. A one-page summary is enough: topic, standards, results of both rounds, changes made and next steps. Keep it for your appraisal portfolio and CQC evidence.

Topics that suit a private GP service

Topic	Example standard	Source of the standard
Monitoring of high-risk medicines	Monitoring up to date before each further supply	BNF, product licence, shared care protocols
Antibiotic prescribing for sore throat or respiratory infection	Prescribing in line with NICE guidance, with the decision tool score recorded	NICE antimicrobial prescribing guidelines
Letters to NHS GPs	Letter sent within an agreed number of working days when diagnosis or medicines change, or refusal of consent recorded	Your own policy, GMC guidance on sharing information
Test results	Every result reviewed, actioned and communicated to the patient within an agreed time	Your results policy
Remote consultations	Identity check and safeguarding questions recorded before prescribing	Your remote consulting policy, GMC remote prescribing guidance
HRT reviews	Annual review documented, including risks and benefits discussed	NICE menopause guidance
Minor surgery	Histology sent and result acted on for every excision, and consent recorded	Your minor surgery protocol

Nationally developed prescribing safety indicators, such as those from the PINCER programme, give ready-made criteria for hazardous prescribing and monitoring. Researchers have promoted them as an audit tool for general practice.

Getting the data

The quality of your records decides how easy audit is. If diagnoses, medicines and tests are coded, for example in SNOMED CT, you can search for every eligible patient in minutes. Free-text notes mean reading each record by hand, and you will miss people. When choosing or reviewing a record system, check whether you can search by code, date and medicine, export results and save searches to re-run. See how to choose a record system.

Clinical audit of your own service’s records by your own clinical team is part of running the service. Anonymise the data before sharing results outside the team, for example with an appraiser.

Common pitfalls

• No re-audit. A single round of data collection is not a completed audit.
• Vague standards. “Good documentation” cannot be measured. “Allergy status recorded” can.
• Too big. Twenty criteria across a thousand records will not get finished.
• Blaming individuals. Findings should lead to changes in systems.
• Confusing audit with research. Audit measures against existing standards and does not go to a research ethics committee, although ethical and data protection principles still apply. If you are testing something new or allocating patients to different care, it may be research. HQIP publishes a guide to telling them apart.

In Wales, Scotland and Northern Ireland

Regulation 17 and the CQC apply in England only. The audit cycle above works in every nation, but the legal hook is different:

• Wales: Healthcare Inspectorate Wales (HIW) inspects independent clinics against the Independent Health Care (Wales) Regulations 2011 and the National Minimum Standards for Independent Health Care Services in Wales. Regulation 19 requires systems to regularly assess and monitor the quality of your service, and to make changes in response to incident analysis and the conclusions of clinical audits. HIW can ask for a written annual return on how you do this, due within 28 days of the request. Standard 6 of the national minimum standards covers taking part in quality improvement activities, and it gives clinical audit as an example.
• Scotland: Healthcare Improvement Scotland (HIS) regulates independent clinics, including private GP services. Under regulation 13 of the Healthcare Improvement Scotland (Requirements as to Independent Health Care Services) Regulations 2011, you must make sure your care is of an appropriate quality, review it with input from service users, and record the review in writing for HIS and service users.
• Northern Ireland: RQIA registers and inspects independent clinics. Regulation 17 of the Independent Health Care Regulations (Northern Ireland) 2005 requires a system for reviewing the quality of treatment at appropriate intervals, a report of each review sent to RQIA and made available to patients, and arrangements for learning from adverse incidents. RQIA’s provider guidance for private doctor services lists routine audits, including clinical audits, with actions put into practice, as examples of evidence.

Appraisal and revalidation are run by the GMC across the UK, so the quality improvement expectation for your appraisal is the same wherever you work. Check your own regulator’s current guidance for any reporting it expects.

Where audit fits

Audit is one part of clinical governance, alongside significant event review, complaints, patient feedback and training. See what is clinical governance? For ideas on what to audit first, the risk areas in preventing clinical errors are a good place to start.