Audit

Process of collecting data against a set of standards, in an attempt to improve compliance with those standards. But often ineffective – especially when no changes made (“closing audit loop”) to improve performance. And slow – by the time you’ve collected the data and summarized it, you’ve wasted time that could be been used to improve things you’ve already seen going wrong.

Often just turns into criticism, with intervention being no more than “perform better”. And then just induces resistance.

Cochrane review of audits in general found median 4.3% improvement with compliance, which isn’t much, but potentially more with incremental gains and repeated audit. And potentially scalable. And about a quarter achieve nothing.

Audit chain only as strong as weakest link – awareness of standards, reliability of processes, feedback.  All aspects of programmed should be designed with a focus on desired change in behaviour, and barriers should be anticipated.

Checklist for doing audit well –

  • Can you recommend actions consistent with established goals and priorities
  • Actions that are under audience’s control?
  • Actions that are specific
  • Can you provide multiple data points as feedback ASAP – and as often as frequency allows
  • Individual as well as general feedback if possible
  • Can you provide comparators that reinforce desired behaviour change
  • Format of feedback – link visuals with summary message, multiple methods, minimize distractions.
  • Actionable plan along with feedback
  • Address barriers
  • Short, actionable message with optional detail
  • Realistic goals.
  • Address credibility. 
  • Anticipate defensive reactions
  • Construct feedback through social interaction

Feedback to clinicians, who all think they’re great, requires careful thought.  Trying to improve already high performance may be a waste of effort, there is a ceiling for most things where organisation close to max capacity.

Patients and the public often surprised by the extent of variation.  They express frustration at difficulties in routinely measuring less technical aspects of care, such as consultation skills and patient centredness.  Patients are an untapped force for change which audit could learn to harness.

[ Revitalising audit, BMJ 2020;368:m213]

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