Clinical Audit

It is evident that GPs are investing a lot of time and effort into undertaking an audit, sometimes under challenging circumstances or where little opportunity for audit appears to exist. However, we still receive queries about what constitutes an audit. Some key pointers are included below to guide you:

In essence, a 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".

Clinical audit is recognised as having three elements:

• Measurement – measuring a specific element of clinical practice
• Comparison – comparing results with the recognised standard
• Evaluation – reflecting on outcome of audit and where indicated, changing practice accordingly

It is common that when undertaking an audit, doctors leave out the following key steps so be mindful to include these:

• Comparing your activity against a guideline
• Carrying out a re-audit

Should there come a time that the Medical Council starts requesting copies of the evidence of the CPD activities you record it will be expecting that your audits satisfy the above steps. Please refer to the audit toolkit and sample audits on the PCS webpage, which are there to practically demonstrate the audit cycle.

Yes, there is a short guide to audit and a wide selection of sample audits available in our Audit Section to assist you.

An audit involves taking a standard and comparing your current practice against that standard. Audit assumes that standards, guidelines or evidence exists, and asks: "Are we doing what we should be doing?"

You can carry out a clinical or practice-based audit and there are examples of these on the audit webpage to assist you.

You could also choose to undertake a patient survey to meet your audit requirement once in a 5 year cycle.

If you require further assistance in relation to your audit, please Contact Us.

No specific guidance has been given on this by the Medical Council. However, it is likely that in the event of scrutiny of compliance with the requirements of professional competence, you should be able to demonstrate that you have measured your audit activity against a reasonably up-to-date guideline or protocol.

Given that no specific guidance has been given, it is reasonable to assume (until directed otherwise by the Medical Council) that if the initial audit fulfilled the recommended time requirements in that year, the re-audit could be conducted the following year in full/part fulfilment (depending on size) of that year's requirements. However, it is unlikely that it will be acceptable to continue repeating the same audit each year. Another suggestion is that you have a five-year cycle of audits with each of five audit topics completed once in a five-year cycle.

The Medical Council has recommended 12 hours in the year as a guidance, however, it is not specified that it must be prolonged over the year and depending on the topic chosen may be done over a condensed period (e.g. 3 months). The amount of time spent doing the audit is self-recorded and regulated at this time.

Source: ICGP Director of Research

Read an example of how you can carry out peer observations for your clinical audit (PDF, 119KB)

When carrying out your audit, it is advisable to check if you are following the audit cycle as set out in each of our samples.

The key elements of a full audit cycle are:

• Initial measurement – measuring a specific element (or elements) of your practice
• Comparison – comparing the results with the recognised standard/guideline
• Evaluation – reflecting on the outcome of the above and where indicated, changing your practice accordingly
• Post-change measurement – re-measure the same element(s) to establish the level of improvement.

There is no minimum or maximum number of patients stipulated, however your sample should include current/recent patients. The purpose of audit is improved patient care through application of recognised standards and ongoing efforts to sustain this change. If you can show that you have considered the clinical management of patients with reference to an agreed standard, you have already conducted an audit. However the current recommendations of the Medical Council are that you should spend one hour per month on audit activity.

If you can extract data easily from your practice management software system for your audit, it is feasible that you could conduct your audit on all relevant patients (e.g. all with COPD or all with Diabetes etc.), however, if not, you can conduct your audit on a sample of relevant patients. There is no specific guideline on the numbers, however, since you will be basing decisions and changes on the findings of the audit, you should ensure that the sample is of sufficient size and selected in an appropriate manner so that the findings are valid and reliable.

It depends on the activity chosen but in general the recommendation is that one hour activity per month should be assigned to audit.

Firstly, you should ensure that this is truly an audit and therefore there is a comparison to an existing guideline (e.g. the methadone treatment guidelines and the LARC protocols) and that criteria have been stated against which practice is being measured.

Audits such as these are externally administered and hence much of the work is taken out of the process for you as the criteria, standard and data collection tool is already created for you. However, when data is leaving the practice for external use/publication, you should ensure that the appropriate ethical approval is in place. The key issues in using these audits for your professional competence requirements are that you must have access to your own data and you must develop an action plan for your practice based on these results, which you implement and then re-audit (the quality improvement activity and re-audit aspects are not always part of such external audits). As these audits are usually quiet extensive, you may wish not to consider all of the criteria used in the full external audit in terms of your action plan and re-audit.

Source: ICGP Director of Research

Audit is a quality improvement exercise and involves reflection on your practice - whatever that constitutes. I am sure you have guidelines with regard to how you carry out your work/duties and you should take the guidelines, which related to an aspect of your work, and use them for your audit. The Medical Council has stated that the following are included in acceptable audits:

Measurement of individual compliance with guidelines/protocols.

• Skills analysis.
• Department/practice audit.
• Directly Observed Procedures (DOPS).
• Evaluation of individual risk incidents/complaints.
• Patient satisfaction.
• Self assessment.
• Peer review.
• Work Site Visits (Occupational Medicine).

Source: ICGP Director of Research

The Medical Council have agreed to consider this issue further. However, they have stated that the practitioner should audit their own clinical activity whenever this is undertaken, even if only for short periods during the year.

Audit is a quality improvement exercise and involves reflection on your practice - whatever that constitutes. If you do not currently see patients, perhaps there are other activities you are involved in on which you could carry out an audit. The Medical Council has stated that the following are acceptable audits:

• Measurement of individual compliance with guidelines/protocols.
• Skills analysis.
• Department/practice audit.
• Directly Observed Procedures (DOPS).
• Evaluation of individual risk incidents/complaints.
• Patient satisfaction.
• Self assessment.
• Peer review.
• Work Site Visits (Occupational Medicine).

If you do see patients, even if this is only occasionally, you can design the audit to adapt to your consultations. For example, if you are seeing patients during the flu season, you could complete an audit on the flu vaccination guidelines - you could ask relevant patients as they attend if they have had the flu vaccination during the last flu season (data collection 1), offer the vaccination if relevant (action plan is opportunistic targeting) and record whether or not they had the vaccination during the current flu season (data collection 2/re-audit).

Alternatively, you could approach the practice you used to work in and ask them if you can join their audit or have access to conduct your own audit in their practice. In this instance, the relevant confidentiality, ethical and data protection requirements should be adhered to.

Source: ICGP Director of Research

Yes, the Irish College of GPs has developed tools to enable doctors to complete HIQA's Safer Better Healthcare Standards and these include audit options, quality improvement plans and a patient satisfaction survey.

This poses different challenges. In order to overcome the difficulty of having very few patients it may be necessary to undertake a number of re-audit cycles of a number of criteria. You could consider starting with an audit on the management of an acute rather than a chronic illness e.g., antibiotic or analgesic prescribing, management of an acute sore throat etc.

You can design the audit to adapt to your consultations. For example, if you are seeing patients during the flu season, you could complete an audit on the flu vaccination guidelines - you could ask relevant patients as they attend if they have had the flu vaccination during the last flu season (data collection 1), offer the vaccination if relevant (action plan is opportunistic targeting) and record whether or not they had the vaccination during the current flu season (data collection 2/re-audit).

Alternatively, you could approach the practice in which you are conducting the locum work and ask them if you can join their audit or have access to conduct your own audit in their practice. In all instances, the relevant confidentiality, ethical and data protection requirements should be adhered to.

Read more information for locum doctors on meeting their annual PCS requirements

Source: ICGP Director of Research

Yes. Audit is about improvement. You should be changing or improving things as a result of your audit. After you have implemented your action plan, you should re-audit to review your position in terms of your (new) target.

One of the most common errors when carrying out an audit is omitting to go back and do a re-audit. This is an essential step as part of the audit process. In essence, an audit cannot be considered as complete if the re-audit has not been undertaken. Depending on the nature of your audit, it may not be feasible for you to carry out your re-audit in the same PCS year. In this case it is fine to go back and do it at a later date but it is important that this is done. Audit is about quality improvement so it makes sense to review and check if the changes you have put in place as a result of the audit have been effective. Remember, doing a re-audit does not constitute an audit in itself and hence does not qualify as your audit for the subsequent PCS year.

The main aim of the audit is to test whether you are doing what you should be doing by comparing yourself to a guideline. Therefore, audits come in many shapes and sizes and are all valuable. If your audit was conducted over the whole year then you should record your audit in the year that most of the work was completed. For example, if your audit started in May 2022 and was completed at the end of April 2023 but you just had a few loose ends to finish up, then you should record your audit as competed by 30 April 2023.

If you recorded your audit as completed for a date after 30 April 2023, it will display in the PCS year 2023-2024, and your statement will indicate that you had not completed an audit for the 2022-2023 year when you actually did. If this applies to you then you can change your audit completed date using the edit function next to the activity in your ePortfolio and the audit will then display in the relevant year. Please Contact Us if you need assistance with this.

Practice audits do not have to be clinically focused but can be a quality improvement exercise applying the principles of audit. The audit should reflect your practice, which means your work and how you practice, the patients you see or the non-clinical role you are involved in, eg. educator, mentor or board member. If you work part-time in a clinical role and part-time as an educator, you can audit either of these work practices. However, you should ensure that all your audits do not concentrate on one aspect only. Likewise, if you don't see patients at all, then your audit should reflect the work that you are involved in, eg. educator, medico-legal, researcher, etc. Even if you are in full-time clinical practice you can undertake an audit of your data management processes.

Read through our sample audits as these will assist you in understanding the principles of audit and make adaptation easier. Please Contact Us if you have any questions.

Doctors may need to take leave from practice for a number of reasons. This is understandable – life happens and achieving CPD is sometimes not feasible. However, it is important that you try to make up extra CPD when you return to practice. Here are some suggestions:

• If getting out and about is an issue, online learning offers a good opportunity to achieve CPD whenever suits you without having to travel. There is a range of e-learning modules available on the education section of this website. These can all be accessed free of charge to College members.
   
• If you are short on internal credits, a patient survey may be a good option. It is also a useful means of getting valuable feedback from the patients' perspective which could
  help identify areas for improvement.
   
• You could also consider undertaking a quality improvement project such as a review of record-keeping, updating practice software or carrying out a review of health and safety standards in the practice.

The audit report or any information requested will not be such that it will compromise patient confidentiality as patients would not be identified in same. However, the records you keep must be capable of substantiating the audit. National data protection requirements will be adhered to during the validation process.

Further information related to confidentiality and data protection issues 

Source: ICGP Director of Research

No. None of the activity you include on your ePortfolio should include patient identifiers. Your clinical audit should only include de-identified patient data.

If you do not attach a report to your audit on your ePortfolio, please add a summary in the description box when adding your audit activity as this may be required in the event that you are randomly selected for verification by the Irish College of GPs.

Clinical audit is recognised as having three elements:

1. Measurement - measuring a specific element of clinical practice.
2. Comparison - comparing results with the recognised standard (in circumstances where comparison is possible).
3. Evaluation - reflecting on outcome of audit and changing practice accordingly.

Examples of acceptable clinical audit include:

• Measurement of individual compliance with guidelines protocols (one per year).
• Double reading.
• Simulator training (ACLS, etc).
• Skills analysis.
• Department/practice audit.
• Directly Observed Procedures (DOPS).
• Individual Practice review.
• Evaluation of individual risk incidents/complaints.
• Patient satisfaction.
• Self assessment.
• Peer review.
• Work Site Visits (Occupational Medicine).

It is recognised that audit structures in Ireland will change over coming years and practitioners will be able to measure outcomes as determined by National Treatment Programmes currently being developed by National Directorate of Clinical Strategy and Programmes.

Source of information: Medical Council

Audit is a quality improvement process that follows a systematic review and evaluation of activities against research-based standards. An audit is a continuous process of aiming to improve patient care and practice excellence.

The audit requirements for the PCS are as follows:

• Choose an audit topic
• Agree and review standards
• Collect data
• Compare data with standards
• Implement changes
• Re-audit: close the loop and continue the cycle as appropriate

Write and retain a copy of the audit report for each clinical audit you take part in. This is the official record of what was done and as such can be revisited for ongoing review. The re-audit forms an essential part of the audit. After change has been implemented, the practice audit cycle is completed by repeating the process to examine whether the implemented changes were effective or not. A comprehensive toolkit and template examples of a clinical audit are available here to assist you in constructing and conducting your audit.

he purpose of audit is to act as a mechanism for you to reflect on your practice and to document improvements as a result. In an audit, you are asking 'Am I doing what I am supposed to be doing?", and therefore it assumes that standards, guidelines or evidence exists. (This is in comparison to research which asks "What should we be doing?").

We advise that you start your clinical audit as soon as possible into the PCS year. This is to allow yourself enough time to complete all steps of the audit and carry out your re-audit in advance of 30 April. You should be engaging in your audit activity throughout the year.

If you are daunted by the thought of starting an audit or uncertain what topic to pick, please visit our Audit Resources section where we have a selection of sample audit topics and information and guidelines for carrying out an audit in your practice. We will also be providing a National Audit which should be available to access in September.

Remember: When your audit is complete, tick the 'audit complete' box before saving in order for it to show on your Statement of Participation.

See "Clinical Disease Coding and Classification: An Overview for General Practitioners" in Appendix 2 of our Audit Toolkit (PDF, 1.4MB).

See "Clinical Disease Coding and Classification: An Overview for General Practitioners" in Appendix 2 of our Audit Toolkit (PDF, 1.4MB)

The GPIT group have provided step-by-step instructions on how to carry out an audit using the GP practice management software systems.

You can engage in an audit with other GPs (e.g. other members of your practice, local colleagues) if you wish to do so. In this instance, all GPs taking part in the audit should be actively engaged in the process and should fulfil their individual time requirements (12 hours per annum). Each GP should record the audit individually to their own ePortfolio. Group audits may present an opportunity to form a local audit group and to have meetings to discuss analysis/results.

Please note that if the audit data is leaving the practice or will be published, and therefore is not only being used for internal practice purposes, ethical approval should be obtained.

In response to GP demand, the Irish College of GPs have created sample audits that identify the relevant guidelines, suggest criteria and outline the data as needed. 

Source: ICGP Director of Research