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Clinical Audit

A Clinical Audit is a quality improvement process used in healthcare to systematically review and improve patient care. It involves comparing current practice against established standards or guidelines, identifying areas where care could be improved, and implementing changes to enhance outcomes.

In simple terms, Clinical Audit asks the question:

"How are we performing against set standards of care?"

Constantly improving

The NHS uses clinical audit as a key tool to improve the quality, safety, and effectiveness of care. It helps ensure that patients receive care based on the best available evidence and that services are being delivered consistently and appropriately.

Why do we "do" Clinical Audit?

We "do" Clinical Audit in order to know what is happening in a service; what is working well and where areas could be improved, and the results can help us highlight potential concerns.

Where do the standards we use come from?

The standards can come from local policies as well as national guidance like those from the National Institute for Clinical and Healthcare Excellence (NICE).

How can you involve patients and the public with audits and evaluations?

A simple way is to ask them to describe their experiences or opinions. This usually starts with surveys but can include interviews and focus groups.

How do we know which projects to carry out?

We work with a network of leads and meetings across our trust. There are some national projects that we must do, whilst others are identified by our commissioners, trust wide oversight groups or specific services. We also carry our annual planning exercises with each division.

Examples of Clinical Audits

We participate in a wide range of national clinical audits, including mental health, falls, diabetes, and cardiac and pulmonary rehabilitation.

We also complete a range of trust-wide audits, including infection control, medicines management, documentation, safeguarding, accessible information, the Baby Friendly Initiative, end of life care, NEWS2, nutrition, and resuscitation.

Our local audits cover topics such as documentation standards, transitions of care, prescribing practice, complications from interventions, referral quality, and quality of testing.

Discharge summaries audit (Older People’s Inpatient Mental Health)

We reviewed 52 discharge summaries. Most clearly stated the reason for admission, medical history, and resuscitation status. Two areas needed attention: documenting mental capacity assessments and recording diagnosis. Short-term plans include targeted training and peer review; longer-term actions include templates with mandatory fields and quality monitoring on a dashboard. This should improve the clarity and safety of handovers to primary care.

Perinatal & Infant Mental Health

A staff survey, a patient experience survey, and a review of 90 records were combined to understand how well the service identified and supported perinatal and infant mental health. Staff generally had the right skills, but training access was uneven across areas. One locality benefited from a dedicated lead and targeted funding, while others did not. Use of assessment tools varied, and mental health checks were less consistently completed at the new-birth visit or the later Health Review. Most service users fed back positively, but some did not feel fully listened to, suggesting the feedback form may be too complex. A single training offer will be created for all areas, and the patient feedback mechanism will be redesigned.

NEWS2 (National Early Warning Score)

Twice a year, we review how consistently staff use the NEWS2 early warning score across all inpatient areas. NEWS2 helps ensure that people who are more unwell receive timely observations. Our results show improvement, but recorded use is still less consistent than we expect. Using Quality Improvement methods, we found we could improve the use of paperwork in one service and the electronic observations system in others. We will also update the audit tool so it properly records exceptions (for example, when a patient declines).