How to Audit and Adjust Your Patient Care Standards

A clinical audit is a systematic process where a medical facility goes through several stages to ensure it is using best practices. In the audit, the facility measures its care standards against established standards, takes action to improve care where needed, and then monitors the care to make sure the best practices are maintained.

There are five main stages that comprise a clinical audit:

Identifying problems.

There are a number of different ways of doing this. The most readily apparent is looking at areas where problems have been encountered in clinical practice. Another method is comparing how things are done at the facility to national standards or guidelines, or where there is hard evidence of what works and what does not.

Other possibilities for identifying problems include suggestions from patients and the public of areas that need to be looked at. Finally, other possibilities include places in the facility that experience high volume, deal with high risk patients, or where there is high cost.

Defining criteria and standards.

Look at what you want to accomplish as a result of the audit – what its purpose is, or what should happen as a result. These criteria are generally expressed as statements or tasks upon which the audit will focus.

The purpose of the criteria is to define what is being measured. They deal with aspects of care that can be measured objectively. The outcomes will then be compared to standards, which define an optimal level of patient care.

Collecting data.

Naturally, before any data can be collected, the facility needs to determine what data will correspond to the criteria being measured. The facility needs to determine what patients will be included in the study, as well as which healthcare personnel, and a time period over which the study will take place.

The size of the sample has to be large enough to be statistically valid, but not so large that it becomes impractical.

Comparing the data collected with the criteria and standards.

In this stage of the audit, the facility is analyzing the data to see if it meets the criteria and standards for performance. The facility is looking at how well the standards were met, and if not, why they were not met.

Where the standards were not met all of the time, theoretically there would be room for improvement.

Making changes.

After the results have been determined, the facility needs to put an action plan in place to make improvements. The plan includes recommendations as to what needs to be done. Each recommendation needs to be clear and precise and should include information about who is to implement the recommendation, as well as a time frame for accomplishing it.

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