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Introduction and Contents

Background and Responsibilities

Audit Lead and Audit Manager

Facilitators and Programme

Resources and Topic

Audit Cycle and References

Appendix 1

Appendix 2

Appendix 3

Appendix 4

Appendix 5

Appendix 6

Appendix 7

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A Practical Handbook for Clinical Audit

Guidance published by the Clinical Governance Support Team March 2005

Practical Clinical Audit Handbook pdf icon PDF (601KB)


This handbook has been developed with the intention of improving clinical audit at a local level and is designed for use in acute trusts, primary care trusts (PCTs), ambulance trusts and mental health trusts. There are many different models for clinical audit which work well at a local level and the handbook documents the range of models which are applicable and where possible gives examples of good practice. The handbook is designed to give advice and guidance to those organisations where local clinical audit is proving difficult to embed within the trust and to improve its integration into clinical governance.
This is an evolutionary document and updates, in particular examples of good practice with contact details, will be added regularly to the web site.

The handbook has been endorsed by the Healthcare Commission, National Institute for Clinical Excellence (NICE), the Clinical Governance Support Team (CGST) and the National Audit and Governance Group (NAGG).

I am indebted to all those who have assisted in the development of this handbook in particular Martin Ferris, Emma Challans, Stephen Ashmore, Tracy Johnson, Richard Kuczyc and Jane Hartley from the National Audit and Governance Group (NAGG), Mark Noterman form the Department of Health, Andrew Singfield from the Clinical Governance Support Team (CGST) and Claire Morrell from the Royal College of Nursing.
My particular thanks to all members of NAGG who have given their time and enthusiasm during the evolution of this document.

Graham Copeland -- Clinical Audit Development Director

1. Background
2. Strategic Health Authorities and trust responsibilities for clinical audit
  2.1 Strategic Health Authority responsibilities
2.2 - 2.3 Trust Chief executive and Medical Director responsibilities
2.4 2.6 Clinical Governance Lead responsibilities
3. The clinical audit lead
  3.1 3.2 Clinical audit lead
3.3 3.4 Developing a Clinical audit/effectiveness committee and linkages to clinical governance
3.5 Apportioning time to clinical audit lead function
4. The clinical audit manager
  4.1 4.2 Types of clinical audit manager
4.3 4.4 Types of clinical audit department (acute trusts)
4.5 Types of clinical audit department (PCTs , ambulance trusts and Mental Health trusts)
4.6 4.7 Linkages to other aspects of clinical governance
4.8 4.9 Responsibilities to facilitators and training
5. The clinical audit facilitators
  5.1 Responsibilities
5.2 - 5.5 Types of facilitators
5.6 Information technology and facilitators
6. The clinical audit programme
  6.1 Responsibilities
6.2 - 6.3 Clinical audit priorities and choice of topics
6.4 - 6.6 Types of clinical audit (prospective vs retrospective)
6.7 - 6.8 Types of clinical audit (multi-service and multi-professional)
6.9 Patients and clinical audit
6.10 - 6.11 Individual clinical audit leads for national and local audits
7. Resources for clinical audit
  7.1 7.2 Clinical audit budget
7.3 7.5 Time spent on clinical audit
7.6 Clinical audit and appraisal
7.7 Clinical audit and managers
8. Developing a local audit topic
  8.1 8.2 Local audit design
8.3 8.4 Use of guidelines
8.5 Clinical audit vs Research
8.6 8.10 Audit sample size
8.11 8.13 Audit of outcomes
8.14 Confidential enquires and CNST
9. Completing the audit cycle (action planning and re-audit)
  9.1 Action plans
9.2 9.3 Process improvement and outcome assessment in action planning
9.4 Refining the audit process
9.5 9.6 Re-audit
9.7 Dissemination of results
10. References

11. Appendices
  1. Criteria for good local clinical audit
  2. Assessment tool prior to instigating a clinical audit
  3. Assessment tool to ascertain the appropriateness of an audit project
  4. Definitions of research vs audit
  5. Self assessment tool for clinical audit departments
  6. Tool to monitor compliance with NICE guidance and technology appraisals
  7. Patient Involvement

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