Audit is Dead - Long Live Audit

Dr Jane Youde is a geriatrician at University Hospital of Derby and Burton NHS Foundation Trust and is Clinical Director for the RCP’s National Audit and Accreditation Programme. She tweets @JaneYoude

We’re all occasionally tempted to consider ourselves immune to the ageing process. I am a consultant of more than 20 years, yet I can’t help but think of myself as a peer to the new consultants and junior staff I work with.  

Occasionally I am reminded of the differences, even the divide, between us.

Recently, a younger colleague made a comment suggesting enthusiastically that audit was a dying art and would soon no longer be needed, to be replaced by Quality Improvement (QI) methods. Should I have peered over my glasses and indicated their mistake?

I held my counsel and reflected later on this enthusiasm for QI compared to audit. I had just been appointed Clinical Director for Audit and Accreditation at the RCP - was this post no longer needed? Was audit a dying area of our cherished clinical practice?

I’d like to think that my much younger colleague trained when audit was already embedded in clinical practice and not a new pillar of governance as it was when I achieved my consultant post. I have been involved with the care of older people with falls and syncope for over 20 years now and have seen first-hand how the RCP’s hip fracture audit has transformed care for tens of thousands of patients. It has helped to halve the number of deaths from hip fractures and we are seen as world leaders in this field. That’s something the UK should be proud of.

Orthogeriatrics is now an established sub-specialty of the geriatric curriculum and there are specialist groups for all of the specialties involved in caring for these patients. These improvements have been driven by the audit and it can be easy to assume that all patients have access to the same high quality, timely hip fracture services, delivering all the agreed standards of care.

However, thanks to audits, we know that this is not always the case. Audit data can and does continue to drive improvements in our patients’ care.

So what’s the difference then between audit and QI? Should it matter?

My simplistic way of understanding this is that audit looks at everyday clinical care, comparing it against standards set using national or international evidence-based guidance. This can happen continuously or at time intervals.

The results can guide the teams involved to look at areas of their care that need to be improved, which is where Quality Improvement comes in: staff can then use QI methods to monitor how changes are improving care over shorter periods of time. QI uses different systematic methods to improve patient safety and effectiveness of care by designing, testing and implementing changes in care and monitoring their impact using continuous live data. One of the current challenges of QI as I see it is maintaining the improvement, which is where audit and accreditation are important.

So, I think it’s fair to say audit is not dead, and QI has not replaced it. Instead, QI is building on the world-leading standards that audit continues to set. They are similar and offer complementary ways of improving clinical standards. They should be used in parallel – not one or the other – and, recognising that challenges lie ahead in both, in the rush to evolve both audit and QI, we should not forget the patients whose care we strive to improve.