Table 3

Guiding principles for clinical audit.[4]

Stage
Recommendations
Addressed within Cochrane Review?

Preparing for audit
Securing stake-holder interest and involvement (e.g. professionals, patients or carers)
No

Selection of appropriate topic, according to whether:


• Topic concerned is of high cost, volume, or risk to staff or users
No

• Evidence of a serious quality problem
Yes: effects greater if low baseline

• Good evidence available to inform quality standards
No

• Amenability of problem to change
No

• Potential for involvement in a national audit project
No

• Topic is pertinent to national policy initiatives
No

• Topic is a priority for the organisation
No

Clear definition of purpose of audit, e.g. to improve or ensure the quality of care
No

Provision of necessary support structures, i.e.


• Structured audit programme (committee structure, feedback mechanisms, and regular audit meetings)
No

• Sufficient funding (audit staff, time of clinical staff, data collection, feedback)
No

Identification of skills and people needed to carry out the audit
No
Selecting criteria
Definition of criteria (structure, process and outcome)
No

Validity and potential to lead to improvements in care


• Evidence based
No

• Related to important aspects of care
No

• Measurable
Yes (implicitly)
Measuring level of performance
Planning data collection


• Definition of user group (and exceptions)
Can't tell

• Definition of healthcare professionals involved
Yes (implicitly)

• Definition of time period over which criteria apply
Yes (implicitly)
Making improvements
Identification of barriers to change
No

Implementing change


• Establishing the right environment (at individual, team and organisational levels)
No

• Considering external relationships (e.g. with patients or other agencies)
No

• Use of other supporting interventions (e.g. educational outreach, reminders) and / or multifaceted interventions
Yes: not supported by evidence
Sustaining improvement
Monitoring and evaluating changes, e.g. continuing audit cycle, use of performance indicators
No

• Appropriate organisational development (e.g. cultural change, adequate training)
No

• Use of existing strategic, organisational or clinical frameworks
No

• Leadership
No

Foy et al. BMC Health Services Research 2005 5:50   doi:10.1186/1472-6963-5-50