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How To Improve The Audit Process?
Harish V Kurup, *Andy McMurtrie, &Steve Sarasin.

*Specialist Registrar in Orthopaedics, Gwynedd district hospital Bangor, North Wales LL57 2PW
&Specialist Registrar in Orthopaedics, Gwynedd district hospitalBangor, North Wales LL57 2PW


Address for Correspondence

Harish V Kurup
Specialist Registrar in Orthopaedics
Gwynedd district hospital
Bangor, North Wales LL57 2PW
Phone: +44 1248384384


Clinical audit is mandatory in the NHS (National Health Service) in UK and mostly carried out by junior medical staff as part of their training. However there has been growing concern over whether this fulfils its intended purpose. One of the important pitfalls in successful completion of an audit is poor loop closure. This in turn fails to measure the change in local practice and contributes to failure of the system. We audited all audits carried out in our orthopaedic department in the past 5 years to identify the flaws in the system. We found poor loop closure (5%) and failure to change practice based on audit (26%) as the major pitfalls in system. We recommend that junior doctors should be encouraged to do a re-audit and close an existing loop before starting a new topic and that progress on all audits should be discussed in the following meeting. We also suggest periodic audit of the audit process by individual departments.

Keywords: Clinical audit, training, orthopaedics.

J.Orthopaedics 2006;3(4)e5


The definition of clinical audit as endorsed by NICE (National Institute of Clinical Excellence, United Kingdom) is that ‘Clinical audit is a quality improvement process that seeks to improve the patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structures, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual team, or service level and further monitoring is used to confirm improvement in healthcare delivery'. It states that a clinical audit must include a review date and identify the individual or individuals responsible for their implementation. It also recommends that 90% of audits with an action plan should be re-audited.

Participation in clinical audit is mandatory for all clinical staff in the NHS in United Kingdom (McCarthy, 1997). This is intended to improve the junior doctor's concept about the process of audit and its relevance in clinical practice. This is important part of their training curriculum, so as to establish its importance in clinical practice (Currie, 1998).  Whether this serves its intended purpose is debatable. Johnston et al (2000) in a study of 145 clinicians found that only 24% changed their practice based on the results of an audit. Junior doctors understand the relevance of clinical audit but are not allocated appropriate study periods for carrying out these audits (McCarthy, 1997). Clinical audit is a cycle of events leading to change in practice depending on the findings and their relevance. Completion of audit cycle is the final step in the process and this is usually poor among participants (Lough, 1995).

Auditing the audit process itself improves the process by identifying pitfalls in the cycle (Tabandeh, 1995). We audited the audit projects done in our present department to get insight into how this system could be improved.

Materials and methods

All orthopaedic audits carried out in our hospital from 1999 to 2004 were reviewed retrospectively. We looked at the audit topics, leads, whether the audit was completed and presented, whether the audit loop was closed and whether this has changed the local practice. The database maintained by the clinical audit department was used to extract the data into a structured data collection form. Where data was found to be inadequate, attempts were made to contact audit leads to get more details. The data was transferred to Microsoft Excel for analysis.


38 audits were done from 1999 to 2004 in our department. We found a recent increase in the number of audits (10 in 2004 compared to 2 in 2001). 54 % of audits were done by Senior House Officers and 32 % by registrars (86 % of total number being done by junior doctors). Most (47 %) audits looked at trauma related topics, investigations such as radiography were reviewed in 16 % and 11 % looked at administrative issues like case note completion. 11 % of audits were not completed and in all of them the reason was that the audit lead had left the hospital to join another one during the project. In only 5% audit loop was closed by doing a re-audit.

We reviewed the current local practice to see whether the suggestions from these audits were being followed. The audits had successfully changed local practice in 18 % and in another 16% the change was only partial; only some of the recommendations were being followed. 26 % of the audit projects had failed to change the practice. The rest of the audits were either still active or it was too early to assess outcome. The most popular topic was fractured neck of femur (18%) followed by Fractures of distal radius (13 %) and record keeping (10%). 3 of the audits were converted to a regional or national presentation.


Audit consumes a lot of manpower in terms of working hours. Most audits are done by junior doctors as part of their training. This consumes part of their working hours or some make use of outside of work hours to do audit depending on the pressure on them to complete the audit. Most audits require review of case notes and audit department usually pays for this. Some orthopaedic audits may need collection of x-ray packets as well. Most hospitals have an audit meeting once every 2, 3 or 6 months. The completed audit projects are presented at this meeting and discussed. The need for change in practice is usually considered here but may not reach a consensus and some units do allocate the responsibility to a consultant. The next audit meeting usually does not discuss this topic again and unless someone does a re-audit at a later date it is impossible to find out whether the practice has changed at all. The whole process repeats at every meeting and the attendance at these meetings is usually monitored as well. Most hospitals cancel all elective work for audit meetings and this improves attendance at these meetings (McCarthy, 1997). In one study, 41 % clinicians felt that audit consumes resources that could be better used on patient care (Smith, 1992). We had a similar feeling when we found that 26% of the audits failed to change the local practice. The authors have worked in different NHS hospitals and have been part of many audits during our career. With our experience from different hospitals, we knew that this was endemic in NHS; but this should be considered as anecdotal evidence only.

It is important to complete audit cycle by doing re-audit. We found that only 5% of orthopaedic audits were re-audited in our department. This compromises the fundamental principle of audit and thereby clinical effectiveness. Most audits are undertaken by junior doctors who are keen to start an audit as soon as they start a substantive six month training post. The topics are either chosen by them or allocated to by their consultant. In an attempt to project themselves forward, they rarely take up a re-audit nor are they advised to do one. Most junior doctors in Orthopaedics do one or two audit projects during a 6 month appointment. We feel that the process may be strengthened by allocating re-audits to junior doctors along with new topics.

Audit is a form of retrospective research for most units. This allows them to do a retrospective study without the hassle of going through the lengthy process of ethics committee approval. This seems to be the norm and usually reflects in the conversion rate of these audits to regional or national presentations. This conversion rate was low in our department (8%).This possibly can be improved by doing a re-audit and proving that evidence from audit had improved local practice. This should make the findings relevant to a broader group than the respective department. This generally varies between departments and is generally higher in university hospitals.


We make the following recommendations based on our findings:

  1. Junior doctors should be encouraged to do re-audits along with new projects.

  2. Audits should identify the person responsible for the planned change and the progress made should be discussed in the following meeting.

  3. Every department should audit its own audits periodically to review changing practice and identify defects in the system.


  1. Currie IS, Paterson-Brown S. (1998) Clinical audit; who is auditing who? Scott Med J. 43(6):185-8.
  2. Johnston G, Davies HT, Crombie IK. (2000) Improving care or professional advantage? What makes clinicians do audit and how well do they fare? Health Bull (Edinb). 58(4):276-85.
  3. Lough JR, Mckay J, Murray TS. (1995) Audit: trainers' and trainees' attitudes and experiences. Med Educ. 29(1):85-90.
  4. McCarthy MJ, Byrne GJ. (1997) Surgical audit: the junior doctors' viewpoint.J R Coll Surg Edinb. 42(5):317-8.Principles for Best Practice in Clinical Audit. NICE. (2002) Radcliffe Medical Press.
  5. Smith HE, Russell GI, Frew AJ, et al. (1992) Medical audit: the differing perspectives of managers and clinicians. J R Coll Physicians Lond. 26(2):177-80.
  6. Tabandeh H, Thompson GM. (1995) Auditing ophthalmology audits. Eye. 9:1-5.


This is a peer reviewed paper 

Please cite as : Harish V Kurup: How to improve the audit process?

J.Orthopaedics 2006;3(4)e5







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