Blog: In for the long haul

Published: 29 Feb 2024

Taking an effective and sustainable approach to clinical audit

Vicky Patel, Chair, National Quality Improvement (incl. Clinical Audit) Network (N-QI-CAN)

“Any commissioner or provider of health and care has a duty to review and monitor the quality of the services delivered, making improvements, where appropriate, that are sustainable. The clinical audit community fully supports this responsibility, and there are a number of exemplar projects that have made a difference to patient care and outcomes that take sustainability into consideration. However, this comes with challenges, and these need addressing if we are to enable teams to strengthen and future-proof our systems. Here, we outline some considerations and approaches that could support you in overcoming these challenges…

Firstly, there’s the sheer volume of clinical audits that health and care organisations are eligible to participate in, in order to review, monitor and improve health and care. This highlights resource issues that, if not understood and addressed, can impact on the ability to be both effective and sustainable. Then, even once resources are in place, there are a number of other considerations to take into account…

Clinical audit topic selection is based upon the health and care priorities for our nations at a national level, and for our local communities at a local level. Patients and service users should be involved to bring a ‘lived experience voice’ to the topics for inclusion but, most importantly, they should inform the metrics for measurement. They can provide the ‘what matters to me’ that we need to embed into our decision-making, to improve and further strengthen health and care. But, once we know what the clinical audit programme should include, how do we ensure that it delivers on what it sets out to achieve effectively?

Principles of Best Practice

For many years the clinical audit community has promoted Preparation and Planning as the most important stage to take time to get right. The other stages will be more easily achieved if we have planned and prepared for the right data being collected in the right way at the right time – and then validated, triangulated and translated for the right audience(s), to inform timely decision making. For example, we need to ensure that the workforce has the capability and capacity to implement an improvement plan and evidence the impact. We also need to plan for measuring over time, to ensure the improvements implemented have sustained impact.

The National Quality Improvement (incl. Clinical Audit) Network (N-QI-CAN) encourages health and care staff to not see each clinical audit as an additional workload or task, but to find ways to embed the activity as business as usual. Make a pledge to undertake a Quality Improvement (QI) project after reviewing the processes for participating in each clinical audit in your programme. This supports a focus on reducing the data burden and releasing resources for taking action for improvement as well as evidencing the impact on improving patient and service user outcomes. Also, don’t forget to share your learning with each other, celebrating success. With most organisations experiencing a high number of projects on their programme, this could all feel like an overwhelming task, but take it one step at a time. Focus first on the highest priority section of your programme. Follow the ‘Do One Thing’ approach, start with Just One Clinical Audit and consider the following top tips:

  • When planning, don’t start at the beginning. Identify where the vision is going to take you and where the journey will end. If this is a national audit, agree where the priority fits within the local picture. Clarify the drivers both nationally and locally. Buy-in at all levels is key.  Link the clinical audit topic to the wider QI plans and work streams within your own organisation and across the system. If the QI function is not part of your team, protect some time with those colleagues and align the clinical audit to patient pathways and other QI workstreams, to ensure the wider improvement plan includes the clinical audit and a move towards continuous measurement. Additionally, ensure that any further QI as a direct result of the clinical audit measurement, is taken forward collaboratively with all relevant stakeholders.
  • Build your team and supporters. Identify and engage an individual who will be the ‘Clinical Champion’ for the clinical audit. In addition, identify and include leadership roles for those who will be the decision makers. They need to sponsor the project, committing to actively reviewing the outcomes and resourcing actions needed to improve. There will also be further individuals who will need to undertake QI projects as part of training programmes, curriculums, revalidation, appraisals and Personal Development Plans.  Implement local processes to involve and engage them in improvement work that matters, and which is a priority for the organisation and local system.
  • Embed data identification, collection, validation and submission into everyday practice. Implement processes to ensure that all eligible audit or QI cases are identified for inclusion, to ensure a valid review of the selected population. Build in a validation process to confirm that the data for submission is accurate. Confirm which roles will take responsibility, and ensure deadlines are made known and committed to. Then, map the dataset and work with your Informatics team to automate the extraction of metrics from existing systems, working to add further fields to collect data where they don’t currently exist. Consider building forms and reports within Electronic Patient Records (EPRs) to prospectively collect the data that can be extracted electronically, where these don’t already exist. Leave any metrics remaining that may have to be collected prospectively at the point of contact or retrospectively from case notes. For organisations not yet on EPRs, consider designing an electronic form to collect the data and use software with queries set up to analyse the data automatically. Confirm the skills required to collect and interpret the information. You will need to establish the project team based upon capability as well as capacity.
  • Plan and agree both the timeline and process for review of data and actions for improvement, moving to a proactive rather than reactive approach. Forward plan the clinical audit timeline of data submission as well as publication releases of data and reports. Agree in advance the forums where the data will be reviewed and discussed with the right level of roles to inform decision making for QI plans. Plan in wider triangulation with data and information, to understand the context and further inform actions required to improve. Make contact with relevant partner organisations within the local system and agree how to take forward a QI plan across the system that improves both health and care along the Patient and Service User pathway. This should support effective and efficient access of data and reports, to inform decision making and enable timely action on improvements.
  • Evidence the impact. Identify at the start what measurement needs to be built in, to evidence the impact of any changes made. For a number of national clinical audits that continuously collect and present data over time, this is already incorporated into the design of the audit – but there may still be measures you want monitoring in more real time locally. For local audits and those that are not continuously measuring and monitoring, consider what available metrics you can access to evidence the impact. Where these are not already available, take action to build this in. Ensure that there is a focus on timely identification of unwarranted variations, continuous decision-making and an improvement journey; not just on one point in time.

Clinical audit agreement processes

So, to bring this full circle, we should go back to the beginning and urge you to consider these two questions when potential audit topics are identified:

  • Why this topic?
  • Why now?

Determine the real driver behind the selection, and who is driving it. Is there an urgency to measure and improve now? Make informed decisions on a truly prioritised clinical audit programme. Place additional emphasis on sustainability in terms of cost, efficiency and environment, while still achieving the best possible outcomes, keeping patients safe and providing the best experience for each individual patient at the time of need. Consider utilising Clinical Audit as a tool for measuring the impact of adopting technologies that can release efficiencies in the system while improving health outcomes and experience for patients and service users.

This model of thinking and action-taking aligns with the NHS IMPACT strategy. It links clinical audit with wider Quality Improvement while automating data where possible, to free up resources to influence improvements that are sustainable across the pathway. In summary, a clinical audit should be sufficiently resourced to ensure both efficiency (in relation to undertaking the project) and effectiveness (in relation to delivering on its purpose). In other words, for sustained improvements to be achieved, clinical audit resources must be available throughout all stages. Furthermore, taking the time to effectively plan and prepare each clinical audit to measure health and care that address all the domains of quality – effectiveness, safety, experience (responsive and person-centred), well led, sustainably resourced and equitable – alongside data-driven discussions and decision-making on improvement plans, will contribute to future-proofing our healthcare system.

To conclude, it is imperative that we work collaboratively across our systems to implement sustainable improvements, measuring over time to evidence the impact of any change in practice or service. If we focus on ensuring sustainability, any changes made will be embedded in practice and support the achievement of all domains of quality, both now and into the future.


National Quality Improvement (Incl. Clinical Audit) Network (N-QI-CAN)

N-QI-CAN is a professional network of colleagues undertaking clinical audit and other healthcare improvement work across England, which was founded in 2000 (originally as the National Audit Governance Group). They have over 1000 active members from more than 500 organisations that provide care to patients in the NHS and hospices, which are organised across twelve regional networks.

To find out more, visit the N-QI-CAN website.”

More like this

This article is one of a number of articles written for CORNERSTONE, HQIP’s free publication, designed to support Quality Improvement. This article was featured in the 2024 edition, which features other articles on patient engagement, benchmarking, and the using health data to influence change (among other topics).

For more information, go to