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icaJJWma1, 298,1021-23.

Audit for a Purpose FOCUS

Sarah Cook Penny Spreadbury

mf- Clinical audit. quality.

Summuy This mc le argues that to be succeeshrl clinical audit needs to hewaQtplicitanduselulpurpcsalhisCkrthegeneralpurpose deudlt. and for.achsp&ficdinlcal audit proie*. -and podthm views about cllnicel audit are compared with the Omcial poky mat the pupose d clinical adit is to Imptcm, patient care. It Is 8uggesW that to be purposetul. each clinical audit pmjec4 needsObeds%rtybamedandconcemissuesthatareimportant totha POOW who am Qoingtocarry cut the audit. The audit also nmdslosddrssl iwuea about quality, such aseffectiveness and eflldency. It ba$oagomSad t ha td lnkh wed toown the audii p~ocegl IfthwamlDbecanmmedtoeInlng~ own practice and ldenwylng any dedclenciea The choice of audit topic and analyrle d dsts crhould therefore be controlled by the cllnlcians. This bad6 lo dlscumbn d posdbk conffict betwe%n managers, pmhming agmc4mend dlnlchns OHT the choke d audit topica It hmndudrdthlt carehrl negotiaNon may be required to ensure Mal W tOpic b perceived aa purpowtul by clinicians.

Introduction The authors have frequently heard themselves saying ta workshop participants:

'If you do not have a clear purpose for your clinical audit project, don't bother, you are probably just wasting your time and about to give up anyway.'

"his opinion has arisen from the lessons learnt from running workshops on clinical audit and evaluating eight clinical audit projects. The experiences of some clinical audit groups who had become stuck, lost, disillusioned, or even positively averse to the mention of audit, were compared with the experience of staff who had become fired with enthusiasm by their audit activities. The purposefulness of clinical audit projects appeared to be an important contributory factor to the success of the audit. This view is reinforced by studies such as the national survey of chairpersons of medical audit committees carried out by the Research Unit, Royal College of Physicians:

'There were concerns about the clarity of [audit's] objectives . . . and the need to build up clinicians' enthusiasm for and commitment to the audit programme' (Walshe and Cobs, 1993, p 23).

Purpose of Clinical Audit in General Staff groups have reported a wide variety of purposes for clinical audit. One view is that clinical audit is a tool for management to spy on clinical staff and that the purpose is to get information in order to cut services and demote or even dismiss staff. Another view is that there is no purpose and that clinical audit activity creates an unnecessary additional burden of paperwork €or clinicians who are already drowning in a sea of paper. These clinicians wish they were left alone to get on with treating the patients. In contrast audit groups who have successfully used clinical audit to examine and change their service for the benefit of their client, have spoken with pride and commitment of the usefulness of the clinical audit process. Those with these more positive expectations of audit have described the purpose of clinical audit as primarily ‘to improve their service’ (Cook and Spreadbury, 1994, p11). The improvements to services concern qualities such as effectiveness, equity, access, acceptability to users, appro- priateness, communication, continuity and efficiency (Firth-Cozens, 1993). Focusing the purpose of clinical audit on improving services to patients is coherent with Government suggestions that successful audit ‘develops a culture of continuing evaluation and improvement of clinical effectiveness’ (DOH, 1994, p 7) and that ‘clinical audit provides an opportunity for professionals who provide healthcare services to work together to set standards for services to patients, to measure their actual practices against the standards, and to make improvements in services as indicated’ (NHS Training Directorate, 1994, p 42).

The disparity between the negative views of some clinicians and Government policy is of concern, especially when clinicians are contracted to carry out clinical audit as part of service agreements. It may be that the following factors have hamp- ered agreement about the purpose of clinical audit. First, health professionals may argue that evaluation and improvement of services have always been an integral part of professional practice, therefore clinical audit serves no additional purpose. Margaret McGarry (1988) points out that ‘striving for excellence is probably inherent in most physiotherapists’ (p 6) but staff may be prevented from carrying out desired improvements because of deficiencies in resources. The second factor may be that although the official definition of clinical audit emphasises ‘systematically looking at the procedures used for diagnosis, care and treatment, examining how associated resources are used and investigating the effect care has on the outcome and quality of life for the patient’ (DOH, 1993, p 41, there is no point in doing this unless changes are implemented.

Staf€ can be deterred by experiencing audit projects that do not have a clear mason why they are carried out (Crombie and Davies, 1992) and then do not result in benefits for patients or clients. A third factor may be that individuals or p u p a of staff are hesitant to believe the Department of Health‘s promotion of quality assurance and clinical audit initiatives. Doubts are held about whether a process that arose from manufacturing industry CHHCRU, 1991) is really effective when applied to public services. This understandable scepticism can be welcomed with an invitation to try a small clinical audit project and evaluate its results - provided the project has a clear, epecific and agreed purpose.

The Purpose of a Specific Clinical Audit Project It is not possible for one audit project to investigate and improve everything about a service Each project needs to have a defined purpose that concerns a limited and focused area of clinical practice. Physiotherapists in Hull community teams for people with learning disability were involved in a foeused audit, the purpose of which was to strengthen their multi-professional team work (Allen, 1994, p63). A result of this audit was the development and audit of a collaborative care plan. Another issue concerning the specific purpose of an audit project is whether the staff group is committed to that purpose If the audit topic does not appear to have an urgent and important purpose clinicians won give up because they are much too pressured with other demands to waste their time on something that does not eeem important. It has been suggested that a topic is important if ‘it involves a high volume of patients . . . especially high cost, or. . . addreaeea practices or procedures known to be of high risk to patients’ (Walshe, 1993, p 11). An example is a multi- disciplinary audit carried out by the elderly services at St James University Hospital, Leeds (1993). The purpose was described as ‘to establish guidelines to assist with the discharge planning process,. The discharge of patients was Been as an important process and the audit was aimed at improving the effectiveness, appropriateness, timeliness and completeness of their patient discharge planning information. Walshe also points out that all staff need to be in support of the audit project: ‘A lone voice among clinicians may be right, but he or she needs to get their colleagues signed up to the audit project before it starts’ (Walshe, 1993, p 12). An audit project may also need to compete with demands on staff time such as pressure by some NHS trusts to increase the volume of patient contacts In this

pmssurised environment staff are likely to be motivated by an audit that aims to maintain high quslity services by gaining evidence of effective- ness, or finding ways of improving efficiency. Outcome measures are needed to provide evidence of effectiveness and for physiotherapists to ‘undertake a purpowfd and valuable clinical audit that will promote and develop quality standards of patient care’ (Maweon, 1993, p 762). The Wessex Region Physiotherapy Audit Project is an example of a project that focused on outcomes as well as process. The aim was ‘to establish levels of physio- therapy input in relation to the achievement of measurable functional outcomes for specific conditions’ (Barnard, 1993, p 766).

This article has argued that clinical audit needs to have an explicit and useful purpose in general and for each specific audit pmject. It has also been suggested that for clinicians to adopt purposeful audit into their routine practice, they need to have ownership of and commitment to the purpose of their audit activities. How can this ownership and commitment be engendered if the choice of audit topic is not in the control of the audit group who are going to carry out the audit? Managers of provider units and commissioning or purchasing agencies such as District health authorities may request that clinicians audit particular aspects of their service. If there is agreement between clinicians and these other bodies on the most useful purpose of their next audit, then presumably this will add weight to the importance of the invest- igation and the recommendations that arise fmm the study. If there is not agreement about the purpoeefulness of a suggested audit topic, the commitment of the staff may be compromised. Commitment is vital because clinical audit relies on a group of peers being willing to examine their practice honestly and identify gaps or deficiencies, and enthusiastically to generate and implement solutions to problems. One of the differences may be about whether the purpose of audit is to improve clinical care or to monitor the quality ofclinical care within service contracts (Doyle, 1994). Marketing strategies, competitive tendering and performance related pay are likely to inhibit staff from examining and revealing the d&icita in their services. In the future as users, managers and purchasers become increasingly interested in clinical audit, it may be that the purpose of individual audit projects needs to be carefully negotiated with those staff whose commitment is required.

Conclusion In the context of clinical practice the authors have proposed that to be purposeful, a clinical audit projed needs a clear aim and objective that is agreed and owned by those people carrying out the

audit. It has been proposed that clinical audit needs to be viewed as useful and needed for the work of the clinician. It is concluded that clarity of purpose imbues clinical audit with meaning, direction, intention, and importance, and will therefore result in real improvements being made for the benefit of the uaers of our services.

Funding The Trent Region Occupational Therapy Clinical Audit and Outcomes Project has been funded by the Regional Health Authority.

Authors Sarah Cook MEd DipCOTand Penny Spreadbury DipCOT MBA job share a post as research and development workers for the Trent Region Occupational Therapy Clinical Audit and Outcomes Project. In addition, Sarah works as a senior lecturer at Sheffield Hallam University, and Penny works as a tutor for Nottingham University.

Addmss for Cortwspndence Ms S Cook, School of Health and Community Studies, Sheffield Hallam University, Collegiate Campus, Sheffield S10 26P.

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