ISSN 0972-978X 

  About COAA








Medical Audit

Dr. Anwar Marthya
Senior Lecturer in Orthopaedics
Medical College Calicut

Addresses for Correspondence

Dr. Anwar Marthya
Senior Lecturer in Orthopaedics
Medical College Calicut

JJ.Orthopaedics 2005;2(2)e1



Medical audit is currently the subject of much talk as demonstrated by its high profile throughout the medical literature.  The Royal College of Physicians of London now seeks evidence of sound medical audit as a condition for the recognition of higher training.  It is also important for allocation of funds given by health authorities.  Despite all the words that have been written and spoken about audit, it is not a new concept.   The word audit is of Latin derivation and means ‘hearing’.  It dates back to biblical times when it was customary for a landowner to ask his steward to give an account of the way in which his property was being put to use.  One of the earliest examples of medical audit goes back to 1912 when the American College of Surgeons required applicants for fellowships to submit 50 records for inspection.   The poor response to this request led to a proper procedure for keeping records being devised. 

With an expansion in the variety of health care services, there is now a need to look more critically at the effectiveness of these services.  Audit is now generally seen to be a necessary requirement for quality health care.   It is now seen as the norm rather than the exception.   Audit is fast becoming a fact of professional life.  Outside pressure have also been instrumental in creating the present environment for audit.  The relationship between the medical profession and the general public has changed over recent years.   Actions now have to be justified and the professions are now more aware of the need for maintaining high standards of care.    

Despite so much having been written about audit, people still differ in their understanding of what it is.   Audit is about taking note of what we do, learning from it and changing if necessary.   Medical audit is the improvement in the quality of care through standard setting, peer review, implementation of change and re-evaluation.   Audit is about looking at what you are doing with a view to arriving at acceptable guidelines and evaluating the outcome.  Although there is no perfect definition of audit, there is general agreement about its key components.

Components of an Audit:

  • Expectation: These can be your colleagues’ expectations or your patients’ expectations.  These expectations regarding performance, whether individual or collective, have to be clearly stated.

  • Enquiry: The next stage requires the desire and ability to enquire in a skilful and objective fashion into specific areas of your practice.

  • Evaluation: Without proper evaluation, the issue of enquiry is meaningless.   This stage involves the critical analysis of the information resulting from the enquiry which may result in the decision to implement change.

  • Education:  This stage results from the experiences gained during the three previous stages.   You are educating yourself to continue to enhance care.

  • Enhancement: The aim of the entire process is the enhancement of care and a fuller understanding for the patient and providers of what is going on.   Enhancement includes efficiency, effectiveness and esteem


What can Audit Measure?

There are three main constituents of care which can be measured by audit are frequently referred to as 1)structure, 2)process and 3)outcome.   

  • Structure is the resources and personnel available to you.  The quantity and types of resources which are available to you are 1) the number of staff 2) the use of specialized equipment 3) the availability of beds.

  • Process is what happens in your practice/hospital unit? It is about the delivery of care to a select group of patients.   1)referrals to hospital 2) clinical investigations  3)procedures done  4)the quality of clinical notes

  • Outcome is the results of your care. It measures the effectiveness of the care given to a particular group of patients.  The audit can assess how many patients had returned to work three months after Posterior Lumbar Interbody fusion for segmental instability of spine.

The type of audit used will depend on the aim of your audit and what you are trying to measure.


Audit Vs Research:

Is audit the same as research?  The boundaries between audit and research are not clear-cut.  Indeed audit and research have much in common.   They both share a rigorous approach to methodology.   Whether you are involved with research or audit it is important to recognize and adhere to the strict disciplines within each.  Audit aims to review current practice by using existing knowledge and to improve patient care in the practice/hospital setting.   It is based on current information about standards of care.


Criteria Vs Standard:

Two important words in audit are Criteria and Standard.  Audit criteria are general statements about the delivery of patient care.  They focus on those aspects that can be used to assess the quality of such care.  From criteria you can develop standards applicable to your own practice or hospital unit.   The standard is the proportion of time you feel that the criteria can be fulfilled to ensure quality of care.  Examples are, 



Children under 2 years should be immunized against polio

90% of 2 years olds are immunized against polio

Penicillin sensitivity must be marked in red color on the clinical notes

100% of patients sensitive to penicillin are marked on red color on clinical notes

Reduction of infection after THR

Infection reduced to less than 5% after THR


Audit Cycle:


What is the desired level of Performance?


Implement possible change


What actually happens
in the hospital unit




There are different methods of arriving at suitable standards.  Those involved in audit have to decide on the level of care which they consider desirable.   The standard can be derived as follows,

  • consulting the relevant literature and specialist textbooks

  • based on evidence from your own experimental work and observations

  • you can actively develop your own standards

A combination of the three above seems to be the best solution for most audits.  It is also be beneficial to examine closely the practice or unit performance before agreeing on standards.  The educational aspects of audit are highlighted by this method as it can lead to useful exchanges of ideas, information and opinions within the group.  There will be times when the level of standard will be easy to decide upon, i.e. 100%; as in case of 100% of patients sensitive to penicillin are marked on red color on clinical notes.  In many cases this maximum standard may be very difficult to obtain.  Ensure that your standards are realistic and practical.  A minimal standard is simply the minimal acceptable level for the proper care of the patient to be maintained.  With the highest realistic standard, you are trying to achieve the best possible standard of care.


Audit Team:

There are no simple answers about the numbers and type of personnel that should participate in audit.  The emphasis is on the health care team with the key aim of enhancing patient care.  The level of teamwork and the way in which groups function together are of considerable importance in setting up audit projects.   

The patients are an integral part of a number of audit exercises.  It is important that they are informed of what is happening and encouraged to give their feedback.  Doctors will make up the majority of audit participants.  Ward sisters, hospital pharmacists, medical secretaries and community nurses are some examples of likely participants.  For audit to succeed, definite commitment is needed by senior doctor staff.   Many specialties require interdisciplinary collaboration and a fundamental principle of audit should be to encourage the development of multidisciplinary audit procedures.  Involving health care professionals other than doctors in audit is considered valuable to audit process and to the improvements of education and communication. 

While it is feasible for individuals to carry out audit on their own it is more beneficial to work within a group.  Ideas and methods can be shared about an audit project and this can remove the feeling of isolation that can occur in daily practice.  Bringing people together to look constructively at aspects of clinical care can enhance the delivery of care to patients. 

Once the participants of the audit team are successfully identified, you should identify the various responsibilities of each member.   The group should consider carefully the specific jobs that demand attention.   Try to ensure that each person feels comfortable in their role.   The tasks of keeping the minutes of the meetings, task of keeping the group informed about what is happening, the task of data collection, the task of analysis etc should be entrusted to the participants and should be executed meticulously.   The importance of communication in the audit process cannot be overestimated.   It is essential to have good communication within the group to maintain sensitivity and cohesion.   This encourages an atmosphere to develop where ideas and opinions are aired freely.  Regular feedback about progress is an essential component of any audit project.


For Successful Audit:

To get commitment to the audit each person should feel involved and have a sense of ownership.   They should also feel confident that they have the support of an audit group.  Involvement in audit should be encouraged from the start.   At the initial meeting each participants should be made to feel that they have an important role to play.  Clarify their roles early in the proceedings.  Support for individuals within the group should be available at all times.  If group support is perceived then it will encourage greater enthusiasm and create a positive attitude towards the exercise.

References And Reading:


1)Shaw CD and Costain DW. Guidelines for medical audit.  BMJ, 1989, 229:498-499.
2) Medical Audit.  Working Paper 6. London, HMSO, 1989.
3) Hopkins A. Measuring the Quality of Medical Care.  Royal College of Physicians, London, 1990
4) Baker R. The future of general practice.  Audit and standards in new general practice. BMJ 1991, 303:32-34.
5) The Royal College of Physicians.  Medical Audit: A First Report.  London, Royal College of Physicians, 1989.

 This is a peer reviewed paper 

Please cite as :
Anwar Marthya: Medical Audit
J.Orthopaedics 2005;2(2)e1






Arthrocon 2011

Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.