Advanced Clinical Audit Assessment - Healthcare Practices

This assignment assesses understanding of clinical audit principles within a healthcare context. It defines clinical audit and research, differentiating their characteristics and providing examples. The assignment explores the relationship between clinical audit and clinical governance, highlighting its role in improving healthcare quality. It examines the benefits of clinical audit for organizations and healthcare staff, including improved care and training. The assessment includes defining audit criteria and standards, critiquing examples, and calculating sample sizes for audit data. Furthermore, it requires the development of a documentation audit, including criteria and standards to assess the quality and accuracy of patient information. The assignment emphasizes the practical application of clinical audit to enhance healthcare practices.

CLINICAL AUDIT SUPPORT CENTRE
ADVANCED CLINICAL AUDIT – OCN ASSESSMENT
Name: ____________________________________________________
Organisation: ____________________________________________________
Email: ____________________________________________________
Course Date: ____________________________________________________
Please complete the following assessment template if you would like to gain
accreditation for the Advanced Clinical Audit training course that you have attended
today. Please complete all answers as fully as possible and ensure that you conform to
the guideline word count in response to each question. To be eligible for the relevant
qualification you must submit your assignment via this template, fully complete
the personal details section above and ensure that the assignment is typed (no
handwritten assignments will be accepted). Please see the associated CASC ‘Open
College Network Accreditation – Guidance Notes’ for more information.
If you use or directly quote from external information sources you will need to
reference these fully within your answers. It is acceptable to use either the Harvard or
Vancouver style referencing systems. Can we also recommend that you
spell/grammar check your work and that you format the document appropriately?
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1.1a Define clinical audit
Clinical audit is primarily a quality improvement practice of the various treatments provided
by the healthcare department. Clinical auditing helps the healthcare institution to improve
their treatment techniques, make sure that the practices are according to the standards of
care and the quality is maintained.
1.1b Define research
Research is defined as a method to validate a hypothesis through the collection of
various genuine data and analysing the collected following the existing methodologies to
create new ideas and concepts.
1.1c Select three characteristics of clinical audit and research
Clinical audit characteristics:
1. Compares the standards along
with the prevailing practices of
care giving
2. Clinical audit is practice based
Research characteristics:
1. Analyses and collects data to
validate a hypothesis
2. Research is started for the first
time by the researchers on a
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3. Aims to improve the current
healthcare process
selected topic
3. Aims to create new ideas and
theories
1.1d Review the brief case studies provided and determine if they are examples of
clinical audit or research (see attached sheet ‘Supporting information for
question 1.1d) Give reasoning for your answers (guideline 200 words each).
Project 1:- Clinical Audit
The first case study is about the treatment plan adopted by the hospital to treat his
condition of thyrotoxicosis. The patient had to go through several stages of treatment
and was shifted between primary care to secondary care several times. The project
aims to determine the standards of treatment that is provided to the patient. Clinical
auditing is a part of the clinical governance as it maintains the quality of the
treatment.The clinical audit in these projects also aims to test the transparency
between the patient and the doctors to understand that the patient is receiving an
informed course of treatment and has agreed to it (Yoon, 2018). Other aspects which
are to be determined in the project are the standards of diagnosis of thyrotoxicosis,
standards regarding the period of treatment, standards of the biochemical tests and so
on. The clinical audit aims to provide various suggestions to improve the standards of
quality and increase the efficiency and the effectiveness of the services.
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Project 2: Clinical research
The second case study deals with some samples collected by the local GP from some
of his patients. He happened to find a systematic pattern in the samples after
employing methods of clinical management on them. The case study can be inferred
as clinical research based because the beginning of the every research starts with the
collection of relevant and important data from reliable sources. The research then
precedes following a set of methodologies in these cases the clinical management
framework to conclude some theories. Some of the outcomes that are expected from
the research are- systematic representation of the data collected by the GP,
introducing improved thyroid care systems to the local people, spreading awareness
regarding the disease, creating a set a guidelines for the local medical intuitions to
follow for the treatment. The aims of the study are expected to be reached using a
systematic research technique while using authentic scientific information based on
certain set objectives.
1.2 Explain how clinical audit relates to the wider clinical governance agenda
(guideline 100-200 words)
Clinical governance is the framework to deliver high quality, effective and safe
healthcare by the various medical institutions. It helps to test and maintain the
standards of quality of treatment maintain the guidelines of treatment for the disease
and so on (Zingg et al., 2015). Clinical audit is directly related to clinical governance
as it also helps to analyse the quality of the treatment provided to the patient. Clinical
governance has seven pillars:
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1. Patient involvement
2. Risk management
3. Clinical audit
4. Staffing and staff management
5. Training
6. Clinical effectiveness
7. Clinical information
Clinical audit plays some role in each of the seven pillars of clinical governance
(Mark et al., 2015). Clinical audit is responsible for checking the involvement of the
patient in the treatment course. It checks how much the patient is informed about the
course and how much choices are provided. The clinical Audit suggests innovative
methods to proceed with the treatment course keeping up with the quality(Ashley et
al., 2014). Clinical audit also measures the performance of the staff and runs an
analysis on their working techniques. Clinical audit keeps in check the effectiveness
of the various treatment processes used in the hospital and suggests new methods to
upgrade them.
2.1 List and provide examples of the clinical audit obligations for the organisation
that you currently work in (guideline 100-200 words)
Clinical Audit is one of the most important control techniques to improve the quality
of healthcare provided by the organisation. The following obligations are followed in
my organisation:
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 The care giving systems are according to the standards of the care quality
commission (Van Zwanenberg and Edwards, 2018)
 The clinical audit advocates safe care through maintaining the care quality
commission standards
 The quality of the treatments are monitored using the outcome 16 of the care
quality commission standards and the health act(2009)
 The various financial documents of the hospital are audited following the
NHS Standard Contract
 Record keeping and maintaining those records are also followed under the
clinical audit obligations.
 The clinical audit governance helps the hospital to identify the risk factors and
help in managing them by suggesting improved methods of treatment.
2.2 Assess the actual/potential benefits of clinical audit and explain why it is
important that clinical audit is carried out by healthcare staff. If you have
previously taken part in clinical audit projects you may wish to reflect upon
past experiences and identify how clinical audit has led to changes and
improved patient care (guideline 300-500 words)
The benefits of clinical audit:
1. Improved care: Clinical audit is an important method to improve the methods
of patient care from time to time. It helps to understand the various flaws in
the treatment courses and makes recommendations accordingly to improve the
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methods of treatment by increasing their effectiveness.
2. Current techniques: clinical audit helps to measure the various clinical
methods in practice and helps the staffs to improvise those methods or
introduce new techniques to the system. The new techniques are always in
accordance to the NICE Guidance, World Health Organisation Advice etc
(Boyle and Keep, 2018).
3. Improved training: the training practices of the organisation can be improved
through enhancing different attributes of the people. The staffs have to use
their project management skills, motivating skills and team management skills
during the assessments.
4. Support revalidation: in every five years, the doctors should be encouraged to
take part in a clinical audit to understand and evaluate their quality of services
provided to the patients. The nurses should also take part in clinical auditing to
meet the expectations of the patients.
5. Quality documentation: the clinical auditing helps the hospital to maintain
quality documentation because the documents of the hospital are reviwed by
the CQC and the NHS in public interest. This helps to create a quality image
of the hospital.
The clinical audit is done among the staff by dividing them in small groups. During
the process, their problem solving techniques are emphasised and observed. Later,
their behaviours are analysed and suggestions are provided (Price, Murphy-Jones and
Edwards, 2018). Clinical audit helps the staff members to access new techniques and
information about the diseases and their treatment processes. the standards of care
provided by them also improves when they are aware of the various standards of care.
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3.1 Provide a clear definition of clinical audit criteria and standards and supply a
suitable example (guideline 100-200 words)
The clinical Audit criteria are the scientifically developed statements which are used
to develop the various healthcare decisions takes by the healthcare institutions. Some
of the clinical audit criteria are:
1. Written statements should be provided (Dugo et al., 2015)
2. The audit should be performed based on real evidence
3. The staff of the hospital should comply to the audit
4. The audit should be performed in a fair and in transparent manner
The clinical audit standards are the measuring techniques of the performance of the
entire medical institution by complying with the criterion. Some of the clinical
standards are:
1. The results should be written in percentages
2. The audit should be evidence based
3. The staff should accept the benefits of the audit
4. The improvements of the audit should be achievable (Pozo‐Rodríguez et
al., 2015)
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3.2 Critique the following examples and determine whether they represent well-
written and accurate criteria and standards. Provide reasoning for your
answers. If you feel that the criteria and standards could be improved you
may wish to devise what you consider to be a more appropriate criteria and
standard for measuring care (guideline 100 words for each)
1. Diabetic patients should have their feet and eyes checked annually (100%)
The given criterion is not good criteria as it does not have any contradicting statement
to compare its main topic. The statement is a mere suggestion from the doctor to the
patient. Good criteria should include a comparative statement.
2. The front sheet of the patient record should include the following information:
Patient name, NHS number, date of birth, patient’s address (100%)
This statement is a good criterion as collection of important information such as
personal details are very important in maintain records in the hospital. This would help
the doctors to search for the records later and compare with them in future.
3. Patients over 65 should be offered an influenza vaccination annually (100%)
The given statement is also an example of good criteria as it is based on a valid
rationale. The statement mentions that the patient is of 65 years and needs to be
vaccinated annually, thus stating the origin of the standard.
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3.3 It is important to ensure that clinical audit data is representative of the wider
population being audited.
Working on a confidence level of 95% (+/-5%) please provide an accurate
sample size needed for audit data collection for the patient populations below:
PATIENT POPULATION AUDIT DATA COLLECTION
SAMPLE
50 45
300 169
1000 278
10000 370
3.4a Please devise a simple documentation audit that could be used to assess the
quality and accuracy of patient information. In the first instance you are
required to research, develop and write a minimum of ten appropriate criteria
and standards that could be used to assess documentation. Please provide
background to the documents that your audit will focus on and list the criteria
and standards. It would also be helpful if you can provide references in
relation to best practice sourced to develop the criteria and standards (e.g.
Royal College of Physicians ‘Generic medical record keeping standards’.
Provide background to documents being audited, e.g. why this area was selected,
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how data is stored (e.g. paper-based/electronically), how data will be accessed,
how criteria and standards have been agreed and devised, etc. (guideline 100-200
words)
Healthcare audit assessing patient information was selected in order to evaluate and
improve care for the patients. This patient information audit will measure current
practice against a set or desired standards. Patient information on admission
process forms a key aspect in enhancing and provides primary data to facilitate
treatment process. Wrongful patient information often leads to poor outcomes. The
data being utilized in the section are stored via electronic health records with main
servers serving various access points at the facility.
The data will be assessed using accuracy, inclusion criteria, sample size, time prior,
and data sources and data analysis tools. The data must meet the set criteria and
conduct based on the set standards. The sample selection for this process will entail
a population size of 1000 patients having 954% confidence level; the sample size
will select 378 sample respondents from the patient population. Data will be
collected using combined forms of clinical notes and telephone interviews among
the respondents.
Please list your criteria and standards in the table below. If there are more than ten
criteria/standards please add to the table provided. To assist you, an example has been
given.
No Criterion Standard Source
1 Records will be written in black ink
only
100% Trust policy
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2 Data collection process telephone and
clinical notes
NHS
3 Data privacy 100% Royal college of
Nurses
4 Patient able to narrate medical
condition
50% Royal college of
Nurses
5 Above 18 years 100% NICE
6 Individual patient assessment 100% Medical records
7 Ability to recall past diagnosis 100% Medical files
8 Diagnosis 100% NICE
9 Number of patient visits 100% Royal college of
Nurses
10 Frequency of hospital visits 100% Generic medical
record keeping
standards
3.4b Please devise a suitable data collection form that could be used to carry out the
documentation audit that you have developed. The form should be user-
friendly and well constructed. The form should contain no patient identifiable
data and all criteria and standards must be covered via this document.
*Please note – for sections 3.3 and 3.4 you may want to submit an existing
documentation audit and/or supply these as separate electronic attachments.
On completion of your assignment:
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