Undertaking a clinical audit project: a step-by-step guide docx

7
Step-by-step guide
Undertaking a clinical audit project:Undertaking a clinical audit project:
Undertaking a clinical audit project:Undertaking a clinical audit project:
Undertaking a clinical audit project:
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GUIDEGUIDE
GUIDEGUIDE
GUIDE
This chapter provides a practical ‘step-by-step guide’ for carrying out a clinical audit project. The
10 stages in the clinical audit cycle are described together with the various activities for their
completion. In order to demonstrate how each stage can be translated into practice, a ‘running’
example is provided of a clinical audit, which is shown in a shaded box and abbreviated to
“Clinical audit on preparing families for assessment”. The example is of a clinical audit project
on:
‘The preparation of families, by a multi-disciplinary team, for
their initial assessment appointment at a child and family
psychiatry department’
This is a fictitious example aimed to help clarify the clinical audit process and is not intended
as an ‘ideal recipe’.
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CLINICALCLINICAL
CLINICALCLINICAL
CLINICAL

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UDITUDIT
UDIT



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CLE
The conventional way of presenting the clinical audit process is as a ‘cycle’. The clinical audit
cycle used in this book (see Fig. 2.1) has 10 key stages, each of which will be described in this
chapter.
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Clinical audit cycleClinical audit cycle
Clinical audit cycleClinical audit cycle
Clinical audit cycle
ClinicalClinical
ClinicalClinical
Clinical
auditaudit
auditaudit
audit
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Select topicSelect topic
Select topicSelect topic
Select topic
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88
8
Set/review standardsSet/review standards
Set/review standardsSet/review standards
Set/review standards
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5
Collect dataCollect data
Collect dataCollect data
Collect data
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4

Design auditDesign audit
Design auditDesign audit
Design audit
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eview literatureeview literature
eview literatureeview literature
eview literature
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1010
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ee
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-audit-audit
-audit-audit
-audit
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Change practiceChange practice
Change practice

66
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6
Analyse dataAnalyse data
Analyse dataAnalyse data
Analyse data
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7
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eed back findingseed back findings
eed back findingseed back findings
eed back findings
➤
➤
➤
➤
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➤
➤
➤
➤
➤
33
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Set standardsSet standards
Set standardsSet standards

Set standards
99
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9
Set/review standardsSet/review standards
Set/review standardsSet/review standards
Set/review standards
8
After completing all of the stages of the clinical audit process, the cycle should be repeated
to assess whether changes in practice have resulted in standards being met. Clinical audits
should involve more than one circuit of the cycle:
“In terms of how many times you might complete the audit cycle, two consecutive
loops are generally seen as being enough” (Firth-Cozens, 1993).
With the model presented as a circle it appears as if you could continue to audit the same
topic forever. For this reason, some people prefer to present the clinical audit process as a spiral
of repeating cycles (Goodwin et al, 1996).
In order for the ‘audit loop to be closed’, changes in practice should be implemented and
then re-audited to ascertain whether improvements in service delivery have occurred as a result.
Unfortunately, these stages of the cycle are often omitted in clinical audit projects.
9
Step-by-step guide
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The first decision to be made when embarking on a clinical audit project is: “What do you want
to know about the service you are providing?”
AREAS FOR AUDIT
As already mentioned, there are numerous topics which are suitable and relevant for clinical
audit. The Venn diagram in Figure 2.2 shows some possible clinical audit topics in CAMHS using
the Donabedian (1966) classification system of structure, process and outcome.
ACTIVITIES FOR SELECTING A TOPIC
To choose an appropriate topic for a clinical audit project, the following activities may be helpful:
(a) At an audit team meeting, discuss possible topics and prioritise according to perceived
importance.
(b) Consult with any other relevant stakeholders (not on the audit team) about proposed topics.
(c) Evaluate the topics according to the criteria outlined below.

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. 2.2. 2.2
. 2.2. 2.2
. 2.2
Examples of clinical audit projects in child and adolescent mental health servicesExamples of clinical audit projects in child and adolescent mental health services
Examples of clinical audit projects in child and adolescent mental health servicesExamples of clinical audit projects in child and adolescent mental health services
Examples of clinical audit projects in child and adolescent mental health services
••
••
•
Availability ofAvailability of
Availability ofAvailability of
Availability of
assessmentassessment
assessmentassessment
assessment
toolstools
toolstools
tools
••
••
•
Quality of facilitiesQuality of facilities
Quality of facilitiesQuality of facilities
Quality of facilities

available (e.gavailable (e.g
available (e.gavailable (e.g
available (e.g
. size of. size of
. size of. size of
. size of
consultation room)consultation room)
consultation room)consultation room)
consultation room)
••
••
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Accessibility ofAccessibility of
Accessibility ofAccessibility of
Accessibility of
service forservice for
service forservice for
service for
disableddisabled
disableddisabled
disabled
individualsindividuals
individualsindividuals
individuals
••
••
•
Adequacy ofAdequacy of
Adequacy ofAdequacy of
Adequacy of

informationinformation
informationinformation
information
on referralon referral
on referralon referral
on referral
••
••
•
Timing and contentTiming and content
Timing and contentTiming and content
Timing and content
of letters sent toof letters sent to
of letters sent toof letters sent to
of letters sent to
GPGP
GPGP
GP
s/referrerss/referrers
s/referrerss/referrers
s/referrers
••
••
•
Appropriateness ofAppropriateness of
Appropriateness ofAppropriateness of
Appropriateness of
assessmentassessment
assessmentassessment
assessment

proceduresprocedures
proceduresprocedures
procedures
••
••
•
CommunicationCommunication
CommunicationCommunication
Communication
with patients atwith patients at
with patients atwith patients at
with patients at
first appointmentfirst appointment
first appointmentfirst appointment
first appointment
••
••
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Number of childrenNumber of children
Number of childrenNumber of children
Number of children
rere
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re
-referred-referred
-referred-referred
-referred
••
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WW
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eight increase andeight increase and
eight increase andeight increase and
eight increase and
stability in youngstability in young
stability in youngstability in young
stability in young
people with anorexiapeople with anorexia
people with anorexiapeople with anorexia
people with anorexia
after interventionafter intervention
after interventionafter intervention
after intervention
••
••
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Degree ofDegree of
Degree ofDegree of
Degree of
improvement inimprovement in
improvement inimprovement in
improvement in
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as a result ofas a result of
as a result of

interventionintervention
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••
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of artof art
of art
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therapist withtherapist with
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in in-patientin in-patient
in in-patient
unitunit
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••
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Input ofInput of
Input of

psychiatrist withpsychiatrist with
psychiatrist withpsychiatrist with
psychiatrist with
emergencyemergency
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admissions ofadmissions of
admissions of
adolescents toadolescents to
adolescents toadolescents to
adolescents to
A&E followngA&E followng
A&E followngA&E followng
A&E followng
self-harmself-harm
self-harmself-harm
self-harm
STRUCTURE PROCESS
OUTCOME
10
CRITERIA FOR SELECTING A TOPIC
It is advisable to choose a topic for your clinical audit project which encompasses as many of
the following as possible:
• It is of concern to service users and has potential to improve service user ‘outcomes’.
• It is important and of interest to you and members of your team.
• It is of clinical concern (e.g. an acknowledged variation in clinical practice, high-risk
procedures, complex management).
• It is financially important (either very common and/or very expensive).
• It is of local and/or national importance (e.g. a Department of Health initiative).

• It is practically viable (e.g. can be measured and you will be able to implement change or
effect the implementation of change).
• There is new research evidence available on the topic.
• It is ideally supported by good research.
In general, the golden rule is that you should only ever audit your own practice. If, for some
reason, you wish to gather data about the practice of others, then you should (a) involve them in
the clinical audit project and (b) obtain their permission.
CLINICAL AUDIT OBJECTIVES
Having decided on the topic area it is helpful to clearly define your clinical audit objectives, that
is


why you are doing the audit and what you are hoping to achieve as a result. This will facilitate
the setting of standards and development of data collection methods at a later stage.
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ASSESSMENT
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Clinical audit topic
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reparation of families for initial multi-professional assessment appointment at a child and family psychiatryreparation of families for initial multi-professional assessment appointment at a child and family psychiatry
reparation of families for initial multi-professional assessment appointment at a child and family psychiatryreparation of families for initial multi-professional assessment appointment at a child and family psychiatry
reparation of families for initial multi-professional assessment appointment at a child and family psychiatry
department.department.
department.department.
department.
Type of clinical audit
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rocess.rocess.
rocess.rocess.

rocess.
Objectives
(a)(a)
(a)(a)
(a)
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o confirm whether parents/carers are sent an information leaflet prior to assessment appointment.o confirm whether parents/carers are sent an information leaflet prior to assessment appointment.
o confirm whether parents/carers are sent an information leaflet prior to assessment appointment.o confirm whether parents/carers are sent an information leaflet prior to assessment appointment.
o confirm whether parents/carers are sent an information leaflet prior to assessment appointment.
(b)(b)
(b)(b)
(b)
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o confirm whether the parents/carers receive a telephone call from a member of the team prior to theiro confirm whether the parents/carers receive a telephone call from a member of the team prior to their
o confirm whether the parents/carers receive a telephone call from a member of the team prior to theiro confirm whether the parents/carers receive a telephone call from a member of the team prior to their
o confirm whether the parents/carers receive a telephone call from a member of the team prior to their
assessment appointment.assessment appointment.
assessment appointment.assessment appointment.
assessment appointment.
(c)(c)
(c)(c)
(c)
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o determine whether the parents/carers feel adequately prepared for assessment as a result of theo determine whether the parents/carers feel adequately prepared for assessment as a result of the

o determine whether the parents/carers feel adequately prepared for assessment as a result of theo determine whether the parents/carers feel adequately prepared for assessment as a result of the
o determine whether the parents/carers feel adequately prepared for assessment as a result of the
leaflet and telephone call.leaflet and telephone call.
leaflet and telephone call.leaflet and telephone call.
leaflet and telephone call.
11
Step-by-step guide
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2.1 2.1
2.1 2.1
2.1
Useful information sourcesUseful information sources
Useful information sourcesUseful information sources
Useful information sources
SOURCESOURCE
SOURCESOURCE
SOURCE
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Databases
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sychLit, EmbasesychLit, Embase
sychLit, EmbasesychLit, Embase
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Local and professional librariesLocal and professional libraries
Local and professional librariesLocal and professional libraries
Local and professional libraries
Royal College of NursingRoyal College of Nursing
Royal College of NursingRoyal College of Nursing
Royal College of Nursing
, Royal College of, Royal College of
, Royal College of, Royal College of
, Royal College of
PP
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sychiatristssychiatrists
sychiatristssychiatrists
sychiatrists
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P
rofessional organisationsrofessional organisations
rofessional organisationsrofessional organisations
rofessional organisations
King’s FKing’s F
King’s FKing’s F
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undund
undund
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National audit databasesNational audit databases
National audit databasesNational audit databases
National audit databases
National Centre for Clinical AuditNational Centre for Clinical Audit
National Centre for Clinical AuditNational Centre for Clinical Audit
National Centre for Clinical Audit
Synthesised researchSynthesised research
Synthesised researchSynthesised research
Synthesised research
Cochrane LibraryCochrane Library
Cochrane LibraryCochrane Library
Cochrane Library
, Centre for Evidence, Centre for Evidence
, Centre for Evidence, Centre for Evidence
, Centre for Evidence
-Based-Based
-Based-Based
-Based
Mental HealthMental Health
Mental HealthMental Health

Mental Health
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EVIEWEVIEW
EVIEWEVIEW
EVIEW



LITERALITERA
LITERALITERA
LITERA
TURETURE
TURETURE
TURE
REASONS FOR REVIEWING LITERATURE
There are a number of reasons why it is important to review the relevant literature at this early

stage in the clinical audit cycle:
• to find out whether there are any recommended national standards on which to base the
standards you are setting
• to find out about any previous audits which have been conducted on your specific topic to
help you in both designing the method of data collection and setting standards
• to find out whether there have been any guidelines or research on the topic which can
help to define what constitutes good-quality care in order to set standards.
WHERE TO SEARCH FOR LITERATURE
You may find the information sources listed in Table 2.1 useful when searching for relevant
literature. See ‘Clinical audit resources’ for further information about organisations.
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THE IMPORTANCE OF SETTING STANDARDS
Standards play an important role in the clinical audit process. Developing standards facilitates
discussion among staff about a particular aspect of care and inspires some reading of the
relevant literature. Comparing current practice against standards can highlight problems which
may otherwise have remained unrecognised. Standards may help to motivate changes in practice
by revealing gaps between the quality of current practice and the desired level of care provision.
HOW TO SET STANDARDS
Setting standards usually involves a number of stages as shown in Figure 2.3. When trying to
develop standards it is worth considering the following points:
• Standards which are applicable to your specific service should be set and should be
agreed by all relevant staff participating in the clinical audit.
• Where possible, standards should be based on the best available evidence regarding
good practice.
• The development of standards will usually involve a combination of clinical experience and
a review of the available evidence. In CAMHS there are very few national guidelines regarding
clinical practice and there is limited robust research on certain topic areas. Standards
often, therefore, must be based on the clinical experience of the service providers. On
such occasions you may find it helpful to pose the following question to colleagues:
“If a member of your family was to receive this service what do you think would be

an acceptable standard?”
• In some circumstances, using clinical audit to observe your current practice may help to
generate standards (see ‘When to set standards’ p. 14)
WHERE STANDARDS COME FROM
Standards may be based on one, or any combination, of the following:
• National guidance or standards (e.g. Patients’ Charter).
• College or professional organisation guidelines.
• Laws (e.g. Mental Health Act 1983).
• Previously agreed local guidelines/protocols (e.g. through consultation with commissioners).
• Standards used locally by colleagues or competitors (e.g. your neighboring trust, ward, etc.).
• Research evidence (from which standards can be developed).
• Literature review of other clinical audits which have published their standards/results.
• Current knowledge from clinical experience.
• Current practice (observe and assess current practice).
UNDERSTANDING STANDARDS
A standard is:
“a statement which outlines an objective with guidance for its achievement given in
a form of criteria sets which specify required resources, activities and predicted
outcomes” (Royal College of Nursing, 1990).
13
Step-by-step guide
(Criterion – in brackets)
95% of (children referred to the department will be seen by a member
of the team within two weeks of the referral being received)
Target
Yardstick – in italic
➤
➤
➤

Standard = criterion + target
(Statement of what is being measured) + (Y(Statement of what is being measured) + (Y
(Statement of what is being measured) + (Y(Statement of what is being measured) + (Y
(Statement of what is being measured) + (Y
ardstick)ardstick)
ardstick)ardstick)
ardstick)
(% to be achieved)(% to be achieved)
(% to be achieved)(% to be achieved)
(% to be achieved)
(measurement boundary)(measurement boundary)
(measurement boundary)(measurement boundary)
(measurement boundary)
➤
➤
➤
All standard statements should contain a criterion and a target, as shown below.
A criterion:
• forms the main body of the standard
• is a clear and precise statement of care
• uses words/phrases which mean that it is measurable
• indicates the boundaries of the measurement (e.g. a time frame and who it involves)
known as a yardstick.
A target:
• is expressed as a percentage and defines the level of performance considered acceptable,
in relation to the chosen criterion.
Below is an example of a standard statement about response times which contains all of the
necessary components.
SETTING TARGETS

Targets should be set at realistic and attainable levels, while not being set too low. When setting
targets the following factors should be considered:
• clinical importance
• practicability
• acceptability.
In the above example the target is set at 95%. A target of 100% would be unrealistic since
there are inevitably some cases which will not be seen within two weeks for reasons that cannot
be prevented (e.g. the family goes on holiday).
Sometimes it may be possible, prior to the clinical audit being conducted, to identify
circumstances when it would acceptable for a criteria not to be met. In this situation it may be
more sensible to set a target of


100% with
defined exceptions. defined exceptions.
defined exceptions. defined exceptions.
defined exceptions. An example is shown below.
For 100% of adolescents attending the therapy group, a letter will be sent to their GP
prior to attending their first group session explaining why the adolescent has been
asked to attend and over what time period.
ExceptionsExceptions
ExceptionsExceptions
Exceptions Cases when consent to contact the GP is denied by the client.
14
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2.2 2.2
2.2 2.2
2.2
The purposes of setting standards at Stage 3 and Stage 9The purposes of setting standards at Stage 3 and Stage 9
The purposes of setting standards at Stage 3 and Stage 9The purposes of setting standards at Stage 3 and Stage 9
The purposes of setting standards at Stage 3 and Stage 9
STST
STST
ST
ANDAND
ANDAND
AND
ARDS SET AARDS SET A
ARDS SET AARDS SET A
ARDS SET A
T STT ST
T STT ST
T ST
AGE 3AGE 3
AGE 3AGE 3
AGE 3
STST
STST
ST
ANDAND
ANDAND
AND
ARDS SET AARDS SET A
ARDS SET AARDS SET A
ARDS SET A

T STT ST
T STT ST
T ST
AGE 9AGE 9
AGE 9AGE 9
AGE 9
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o:o:
o:o:
o:
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o:o:
o:o:
o:
••
••
•
measure whether the standards have been metmeasure whether the standards have been met
measure whether the standards have been metmeasure whether the standards have been met
measure whether the standards have been met
••
••
•
describe the current situationdescribe the current situation
describe the current situationdescribe the current situation
describe the current situation

••
••
•
identify some reasons for standards not being metidentify some reasons for standards not being met
identify some reasons for standards not being metidentify some reasons for standards not being met
identify some reasons for standards not being met
••
••
•
contribute to setting standardscontribute to setting standards
contribute to setting standardscontribute to setting standards
contribute to setting standards
••
••
•
examine whether standards need alteringexamine whether standards need altering
examine whether standards need alteringexamine whether standards need altering
examine whether standards need altering
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ARING



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AMILIESAMILIES
AMILIES



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FOR



ASSESSMENTASSESSMENT
ASSESSMENTASSESSMENT
ASSESSMENT
SS
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S
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3 – S 3 – S
3 – S 3 – S
3 – S

ETET
ETET
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STST
STST
ST
ANDAND
ANDAND
AND
ARDSARDS
ARDSARDS
ARDS
Standards set
(a)(a)
(a)(a)
(a)
100% of parents/carers will be sent an information leaflet by the team administrator no later than100% of parents/carers will be sent an information leaflet by the team administrator no later than
100% of parents/carers will be sent an information leaflet by the team administrator no later than100% of parents/carers will be sent an information leaflet by the team administrator no later than
100% of parents/carers will be sent an information leaflet by the team administrator no later than
two weeks before they have their assessment appointment.two weeks before they have their assessment appointment.
two weeks before they have their assessment appointment.two weeks before they have their assessment appointment.
two weeks before they have their assessment appointment.
(b)(b)
(b)(b)
(b)
95% of parents/carers will receive a phone call from a member of the team 2–7 days before they have95% of parents/carers will receive a phone call from a member of the team 2–7 days before they have
95% of parents/carers will receive a phone call from a member of the team 2–7 days before they have95% of parents/carers will receive a phone call from a member of the team 2–7 days before they have

95% of parents/carers will receive a phone call from a member of the team 2–7 days before they have
their assessment appointment.their assessment appointment.
their assessment appointment.their assessment appointment.
their assessment appointment.
(c)(c)
(c)(c)
(c)
95% of parents/carers who attend their first assessment appointment will feel adequately prepared as a95% of parents/carers who attend their first assessment appointment will feel adequately prepared as a
95% of parents/carers who attend their first assessment appointment will feel adequately prepared as a95% of parents/carers who attend their first assessment appointment will feel adequately prepared as a
95% of parents/carers who attend their first assessment appointment will feel adequately prepared as a
result of the information they have been given.result of the information they have been given.
result of the information they have been given.result of the information they have been given.
result of the information they have been given.
DEVELOPING GOOD STANDARDS
When writing your standards try to remember that they should always be SMART:
Specific – clear, understandable
Measurable
Achievable
Relevant – to the aims of the audit
Theoretically sound – based on current research.
WHEN TO SET STANDARDS
On our clinical audit cycle (Fig. 2.1) there are two places where standards can be set:
• before designing the audit and collecting the data (Stage 3) and
• after feeding back the results of the audit study (Stage 9).
Standards should be set as early as possible in the audit process, ideally before assessing
your practice. As already mentioned, however, this may not always be possible. In such
circumstances, the results of the audit should be used to inform the development of standards.
The reasons for setting standards at Stage 3 and at Stage 9 are outlined in Table 2.2.
15
Step-by-step guide

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. 2.3. 2.3
. 2.3. 2.3
. 2.3
How to set standardsHow to set standards
How to set standardsHow to set standards
How to set standards
Search for relevantSearch for relevant
Search for relevantSearch for relevant
Search for relevant
existing researchexisting research
existing researchexisting research
existing research
Able to reach consensus?Able to reach consensus?
Able to reach consensus?Able to reach consensus?
Able to reach consensus?
WRITE ‘SMARWRITE ‘SMAR
WRITE ‘SMARWRITE ‘SMAR
WRITE ‘SMAR
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STST
STST
ST

ANDAND
ANDAND
AND
ARDARD
ARDARD
ARD
STST
STST
ST
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TEMENTSTEMENTS
TEMENTSTEMENTS
TEMENTS
Search for existingSearch for existing
Search for existingSearch for existing
Search for existing
standardsstandards
standardsstandards
standards
Search for clinicalSearch for clinical
Search for clinicalSearch for clinical
Search for clinical
experience withinexperience within
experience withinexperience within
experience within
and/or outside teamand/or outside team
and/or outside teamand/or outside team
and/or outside team

Discuss with team, adapt if necessaryDiscuss with team, adapt if necessary
Discuss with team, adapt if necessaryDiscuss with team, adapt if necessary
Discuss with team, adapt if necessary


.
Able to reach consensus?Able to reach consensus?
Able to reach consensus?Able to reach consensus?
Able to reach consensus?
Discuss with team and base standards onDiscuss with team and base standards on
Discuss with team and base standards onDiscuss with team and base standards on
Discuss with team and base standards on
research findings and clinical experience.research findings and clinical experience.
research findings and clinical experience.research findings and clinical experience.
research findings and clinical experience.
Able to reach consensus?Able to reach consensus?
Able to reach consensus?Able to reach consensus?
Able to reach consensus?
OBSERVE PRAOBSERVE PRA
OBSERVE PRAOBSERVE PRA
OBSERVE PRA
CTICECTICE
CTICECTICE
CTICE
Discuss with team.Discuss with team.
Discuss with team.Discuss with team.
Discuss with team.
Agree!Agree!
Agree!Agree!
Agree!

NONENONE
NONENONE
NONE
➤
YESYES
YESYES
YES
➤
NONO
NONO
NO
➤
➤
➤
YESYES
YESYES
YES
➤
YESYES
YESYES
YES
➤
NONENONE
NONENONE
NONE
➤
YESYES
YESYES
YES
➤

YESYES
YESYES
YES
➤
➤
➤
YESYES
YESYES
YES
➤
NONO
NONO
NO
➤
NONO
NONO
NO
➤
16
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE

GE
4 – D 4 – D
4 – D 4 – D
4 – D
ESIGNESIGN
ESIGNESIGN
ESIGN



AA
AA
A
UDITUDIT
UDITUDIT
UDIT
When designing a clinical audit project you will need to address the following questions:
• Who will be involved?
• How will the project be carried out?
• Data collection: what information?
what type to data?
how should the data be collected?
how can reliability and validity be ensured?
how can the collection method be piloted?
• Sample: what size?
how should the sample be selected?
• Data analysis: who will analyse the data?
how will the data be analysed?
• Feedback of findings – to whom and how?
• When will the project begin and end?

WHO TO INVOLVE IN THE CLINICAL AUDIT PROJECT
As many of the key stakeholders as possible should be involved in designing the audit (see
‘Who should be involved in the clinical audit?’ p. 4).
HOW TO DO THE CLINICAL AUDIT PROJECT
(A) DATA COLLECTION
By conducting stages 1–3 in the clinical audit cycle, the type of information you will require for
the project will become increasingly evident. Most data collected for clinical audit are quantitative.
It can also be useful to collect some qualitative data to increase understanding of complex
areas (e.g. service users’ views). More time tends to be required for the analysis of qualitative
data than quantitative data.
When undertaking a clinical audit project, people often decide to collect a range of data
which they feel could be of clinical importance, although not strictly relevant to the objectives of
the audit (e.g. demographic data). This may prove useful, but will clearly increase the time and
costs required to complete the project.
Clinical audit data can be collected retrospectively or prospectively. Table 2.3 outlines the
differences between these two methods and some of the advantages and disadvantages of
each.
Data may be collected using any number of research methods. The most appropriate method
for your project will depend on a number of factors such as the available time, budget and data
sources. Examples of different data collection strategies at are shown in Table 2.4.
There is no one ‘correct way’ of collecting data for a clinical audit
project
As with research, clinical audit information needs to be collected in a way that it is both valid
and reliable.
••
••
•
VV
VV
V

alidity = alidity =
alidity = alidity =
alidity = the degree to which you are measuring what you are supposed to be
measuring.
••
••
•
RR
RR
R
eliabilityeliability
eliabilityeliability
eliability = the degree to which you are consistently measuring what you want to
measure (e.g. the same data would be collected by a different person, or by the same
person at a different point in time).
17
Step-by-step guide
TT
TT
T
ABLEABLE
ABLEABLE
ABLE
2.3 2.3
2.3 2.3
2.3
The differences between retrospective and prospective data collectionThe differences between retrospective and prospective data collection
The differences between retrospective and prospective data collectionThe differences between retrospective and prospective data collection
The differences between retrospective and prospective data collection
RETROSPECTIVERETROSPECTIVE

RETROSPECTIVERETROSPECTIVE
RETROSPECTIVE
PROSPECTIVEPROSPECTIVE
PROSPECTIVEPROSPECTIVE
PROSPECTIVE
DEFINITIONDEFINITION
DEFINITIONDEFINITION
DEFINITION
Data collected by looking backData collected by looking back
Data collected by looking backData collected by looking back
Data collected by looking back
Data collected from this point onwards, orData collected from this point onwards, or
Data collected from this point onwards, orData collected from this point onwards, or
Data collected from this point onwards, or
over your practiceover your practice
over your practiceover your practice
over your practice
starting at a future datestarting at a future date
starting at a future datestarting at a future date
starting at a future date
WHEN TWHEN T
WHEN TWHEN T
WHEN T
O USEO USE
O USEO USE
O USE
When looking at what has beenWhen looking at what has been
When looking at what has beenWhen looking at what has been
When looking at what has been
When data are currently unavailable (i.e. hasWhen data are currently unavailable (i.e. has

When data are currently unavailable (i.e. hasWhen data are currently unavailable (i.e. has
When data are currently unavailable (i.e. has
happening in a chosen topic areahappening in a chosen topic area
happening in a chosen topic areahappening in a chosen topic area
happening in a chosen topic area
not been recorded as part of daily practice)not been recorded as part of daily practice)
not been recorded as part of daily practice)not been recorded as part of daily practice)
not been recorded as part of daily practice)
When data are of a very poor quality/incompleteWhen data are of a very poor quality/incomplete
When data are of a very poor quality/incompleteWhen data are of a very poor quality/incomplete
When data are of a very poor quality/incomplete
and it is therefore not possible to auditand it is therefore not possible to audit
and it is therefore not possible to auditand it is therefore not possible to audit
and it is therefore not possible to audit
ADAD
ADAD
AD
VV
VV
V
ANTANT
ANTANT
ANT
AGESAGES
AGESAGES
AGES
Can be fasterCan be faster
Can be fasterCan be faster
Can be faster
AA

AA
A
voids using poorvoids using poor
voids using poorvoids using poor
voids using poor


-
qualityquality
qualityquality
quality
, incomplete data, incomplete data
, incomplete data, incomplete data
, incomplete data
PP
PP
P
rovides a baselinerovides a baseline
rovides a baselinerovides a baseline
rovides a baseline
Allows design of a clear and concise dataAllows design of a clear and concise data
Allows design of a clear and concise dataAllows design of a clear and concise data
Allows design of a clear and concise data
collection sheetcollection sheet
collection sheetcollection sheet
collection sheet
DISADDISAD
DISADDISAD
DISAD
VV

VV
V
ANTANT
ANTANT
ANT
AGESAGES
AGESAGES
AGES
PP
PP
P
ast service users do not benefitast service users do not benefit
ast service users do not benefitast service users do not benefit
ast service users do not benefit
PP
PP
P
rovides no baseline for the auditrovides no baseline for the audit
rovides no baseline for the auditrovides no baseline for the audit
rovides no baseline for the audit
Data may be difficult to collect (e.gData may be difficult to collect (e.g
Data may be difficult to collect (e.gData may be difficult to collect (e.g
Data may be difficult to collect (e.g


.
Can be timeCan be time
Can be timeCan be time
Can be time

-
consuming since a number ofconsuming since a number of
consuming since a number ofconsuming since a number of
consuming since a number of
poorpoor
poorpoor
poor


-
qualityquality
qualityquality
quality
, information missing), information missing)
, information missing), information missing)
, information missing)
individuals must be relied upon to collect theindividuals must be relied upon to collect the
individuals must be relied upon to collect theindividuals must be relied upon to collect the
individuals must be relied upon to collect the
datadata
datadata
data
One way of improving the reliability and validity of your clinical audit project findings is to
ensure that your standards are rigorously developed (i.e. they are clearly defined and measurable).
For example, if one of your standards is that 100% of therapists should explain clearly in the first
10 minutes of a family’s first appointment why the family has been referred and the purpose of
the session, then it will be necessary to decide the components of a clear explanation in order
to design a valid and reliable check-list to be used by the data collector.
The careful selection of an appropriate data collection tool is also important. If, for example,

you used a satisfaction questionnaire designed for parents, to explore the views of children,
then your findings would be invalid. Using established standardised psychometric tools and
check-lists can increase the reliability and validity of your results.
With all clinical audit projects, especially those for which you have designed your own data
collection tool (e.g. an interview schedule), it is advisable to pilot your method prior to beginning
TT
TT
T
ABLEABLE
ABLEABLE
ABLE
2.4 2.4
2.4 2.4
2.4
Examples of data collection methodsExamples of data collection methods
Examples of data collection methodsExamples of data collection methods
Examples of data collection methods
AREA FOR AUDITAREA FOR AUDIT
AREA FOR AUDITAREA FOR AUDIT
AREA FOR AUDIT
EXAMPLES OF SOURCES OF DEXAMPLES OF SOURCES OF D
EXAMPLES OF SOURCES OF DEXAMPLES OF SOURCES OF D
EXAMPLES OF SOURCES OF D
AA
AA
A
TT
TT
T
AA

AA
A
EXAMPLES OF METHODSEXAMPLES OF METHODS
EXAMPLES OF METHODSEXAMPLES OF METHODS
EXAMPLES OF METHODS
STRUCTURESTRUCTURE
STRUCTURESTRUCTURE
STRUCTURE
: Service users’: Service users’
: Service users’: Service users’
: Service users’
Service usersService users
Service usersService users
Service users
Questionnaires or interviewsQuestionnaires or interviews
Questionnaires or interviewsQuestionnaires or interviews
Questionnaires or interviews
satisfaction with facilitiessatisfaction with facilities
satisfaction with facilitiessatisfaction with facilities
satisfaction with facilities
(e.g consultation room)(e.g consultation room)
(e.g consultation room)(e.g consultation room)
(e.g consultation room)
PROCESSPROCESS
PROCESSPROCESS
PROCESS
: W: W
: W: W
: W
aiting times foraiting times for

aiting times foraiting times for
aiting times for
PP
PP
P
atient Administration Systematient Administration System
atient Administration Systematient Administration System
atient Administration System
Use data collection sheet toUse data collection sheet to
Use data collection sheet toUse data collection sheet to
Use data collection sheet to
appointmentsappointments
appointmentsappointments
appointments
(P(P
(P(P
(P
AS)AS)
AS)AS)
AS)
extract information from Pextract information from P
extract information from Pextract information from P
extract information from P
ASAS
ASAS
AS
PROCESSPROCESS
PROCESSPROCESS
PROCESS
: Communictaion: Communictaion

: Communictaion: Communictaion
: Communictaion
Case notesCase notes
Case notesCase notes
Case notes
Use data collection sheet to recordUse data collection sheet to record
Use data collection sheet to recordUse data collection sheet to record
Use data collection sheet to record
with general practitioners/with general practitioners/
with general practitioners/with general practitioners/
with general practitioners/
information from clinical recordsinformation from clinical records
information from clinical recordsinformation from clinical records
information from clinical records
referrersreferrers
referrersreferrers
referrers
regarding correspondenceregarding correspondence
regarding correspondenceregarding correspondence
regarding correspondence
PROCESSPROCESS
PROCESSPROCESS
PROCESS
: Therapeutic: Therapeutic
: Therapeutic: Therapeutic
: Therapeutic
Observation of sessionObservation of session
Observation of sessionObservation of session
Observation of session
Through oneThrough one

Through oneThrough one
Through one
-way miror or video-way miror or video
-way miror or video-way miror or video
-way miror or video
interventionsinterventions
interventionsinterventions
interventions
recordings. Use checkrecordings. Use check
recordings. Use checkrecordings. Use check
recordings. Use check
-list to record-list to record
-list to record-list to record
-list to record
information about interventionsinformation about interventions
information about interventionsinformation about interventions
information about interventions
OUTOUT
OUTOUT
OUT
COMECOME
COMECOME
COME
: Impact of therapeutic: Impact of therapeutic
: Impact of therapeutic: Impact of therapeutic
: Impact of therapeutic
Service user and their familyService user and their family
Service user and their familyService user and their family
Service user and their family
Questionnaires or interviewsQuestionnaires or interviews

Questionnaires or interviewsQuestionnaires or interviews
Questionnaires or interviews
intervention on service userintervention on service user
intervention on service userintervention on service user
intervention on service user
General practitionerGeneral practitioner
General practitionerGeneral practitioner
General practitioner
Out-patient recordsOut-patient records
Out-patient recordsOut-patient records
Out-patient records
Data collection sheet to extractData collection sheet to extract
Data collection sheet to extractData collection sheet to extract
Data collection sheet to extract
information from out-patient recordsinformation from out-patient records
information from out-patient recordsinformation from out-patient records
information from out-patient records
18
TT
TT
T
ABLEABLE
ABLEABLE
ABLE
2.5 2.5
2.5 2.5
2.5
Sampling methodsSampling methods
Sampling methodsSampling methods
Sampling methods

SAMPLING TECHNIQUESAMPLING TECHNIQUE
SAMPLING TECHNIQUESAMPLING TECHNIQUE
SAMPLING TECHNIQUE
DEFINITIONDEFINITION
DEFINITIONDEFINITION
DEFINITION
EXAMPLEEXAMPLE
EXAMPLEEXAMPLE
EXAMPLE
: AUDIT OF A: AUDIT OF A
: AUDIT OF A: AUDIT OF A
: AUDIT OF A
TTENDTTEND
TTENDTTEND
TTEND
ANCEANCE
ANCEANCE
ANCE
RANDOMRANDOM
RANDOMRANDOM
RANDOM
Every member of the population beingEvery member of the population being
Every member of the population beingEvery member of the population being
Every member of the population being
TT
TT
T
otal number of children seen by a teamotal number of children seen by a team
otal number of children seen by a teamotal number of children seen by a team
otal number of children seen by a team

studied has an equal chance of beingstudied has an equal chance of being
studied has an equal chance of beingstudied has an equal chance of being
studied has an equal chance of being
over one year is 400. Each child is assignedover one year is 400. Each child is assigned
over one year is 400. Each child is assignedover one year is 400. Each child is assigned
over one year is 400. Each child is assigned
pickpick
pickpick
pick
eded
eded
ed
a number and a sample of 50 is selecteda number and a sample of 50 is selected
a number and a sample of 50 is selecteda number and a sample of 50 is selected
a number and a sample of 50 is selected
using a random number tableusing a random number table
using a random number tableusing a random number table
using a random number table
SYSTEMASYSTEMA
SYSTEMASYSTEMA
SYSTEMA
TICTIC
TICTIC
TIC
Members of the population are chosenMembers of the population are chosen
Members of the population are chosenMembers of the population are chosen
Members of the population are chosen
Every eighth child (in order of date of firstEvery eighth child (in order of date of first
Every eighth child (in order of date of firstEvery eighth child (in order of date of first
Every eighth child (in order of date of first

in a systematic wayin a systematic way
in a systematic wayin a systematic way
in a systematic way
appointment) is selectedappointment) is selected
appointment) is selectedappointment) is selected
appointment) is selected
STRASTRA
STRASTRA
STRA
TIFIEDTIFIED
TIFIEDTIFIED
TIFIED
The population is split into groups withThe population is split into groups with
The population is split into groups withThe population is split into groups with
The population is split into groups with
Children under the age of five and over theChildren under the age of five and over the
Children under the age of five and over theChildren under the age of five and over the
Children under the age of five and over the
characteristics considered importantcharacteristics considered important
characteristics considered importantcharacteristics considered important
characteristics considered important
age of five are split into two groups. Theage of five are split into two groups. The
age of five are split into two groups. Theage of five are split into two groups. The
age of five are split into two groups. The
to the outcome (e.gto the outcome (e.g
to the outcome (e.gto the outcome (e.g
to the outcome (e.g
. males and females) males and females).
. males and females) males and females).
. males and females).

first group contains 100 and the secondfirst group contains 100 and the second
first group contains 100 and the secondfirst group contains 100 and the second
first group contains 100 and the second
Each relevant subgroup of theEach relevant subgroup of the
Each relevant subgroup of theEach relevant subgroup of the
Each relevant subgroup of the
300. T300. T
300. T300. T
300. T
welve children are randomly selectedwelve children are randomly selected
welve children are randomly selectedwelve children are randomly selected
welve children are randomly selected
population is then randomly orpopulation is then randomly or
population is then randomly orpopulation is then randomly or
population is then randomly or
from group 1, and 38 from group 2.from group 1, and 38 from group 2.
from group 1, and 38 from group 2.from group 1, and 38 from group 2.
from group 1, and 38 from group 2.
systematically sampled in proportionsystematically sampled in proportion
systematically sampled in proportionsystematically sampled in proportion
systematically sampled in proportion
to its size.to its size.
to its size.to its size.
to its size.
CLCL
CLCL
CL
USTERUSTER
USTERUSTER
USTER

Sampling of the group rather thanSampling of the group rather than
Sampling of the group rather thanSampling of the group rather than
Sampling of the group rather than
Attendance is being audited at child andAttendance is being audited at child and
Attendance is being audited at child andAttendance is being audited at child and
Attendance is being audited at child and
individuals. A sample of groups isindividuals. A sample of groups is
individuals. A sample of groups isindividuals. A sample of groups is
individuals. A sample of groups is
family psychiatry departments in London.family psychiatry departments in London.
family psychiatry departments in London.family psychiatry departments in London.
family psychiatry departments in London.
chosen first and then individualschosen first and then individuals
chosen first and then individualschosen first and then individuals
chosen first and then individuals
All of the departments are listed, and 10All of the departments are listed, and 10
All of the departments are listed, and 10All of the departments are listed, and 10
All of the departments are listed, and 10
are takare tak
are takare tak
are tak
en from each of these usingen from each of these using
en from each of these usingen from each of these using
en from each of these using
of the 20 are selected randomlyof the 20 are selected randomly
of the 20 are selected randomlyof the 20 are selected randomly
of the 20 are selected randomly


.

any of the above methods.any of the above methods.
any of the above methods.any of the above methods.
any of the above methods.
Individual cases are then selected from theIndividual cases are then selected from the
Individual cases are then selected from theIndividual cases are then selected from the
Individual cases are then selected from the
10 departments using one of the above10 departments using one of the above
10 departments using one of the above10 departments using one of the above
10 departments using one of the above
sampling methods.sampling methods.
sampling methods.sampling methods.
sampling methods.
the main data collection. This will help to identify any problem areas at an early stage. It should
also ensure that you will be able to meet the original objectives of the clinical audit project from
the data collected, and will reveal whether the tool is both appropriate and usable.
Always conduct a small pilot study
The reliability of data can also be improved by providing appropriate training in data collection
for the person undertaking this task. For qualitative information where subjective assessments
may sometimes be required (for example, rating whether a therapist makes sufficient eye contact
with a family during a session), having one person to collect the data helps maintain consistency.
Most of the time, however, this is unnecessary and/or the time and resources make it an
impractical option.
Where several people are involved in collecting information, liaison and communication are
important. You may even decide you want to include an additional ‘safety measure’ by testing
for interrater reliability, for example by having two individuals separately rating the same therapist
for eye contact, and then comparing their ratings.
(B) THE SAMPLE
For some audits it may be possible to examine all of the relevant cases, where the total number
in the population being studied is small, for example an audit of the outcome of an anger
management group containing 15 adolescents. In most circumstances, however, it will be

necessary to select a


sample from the population.
A sample should be selected which reflects the characteristics of
the population from which it has been drawn
If you select your sample from those cases most easily at hand (e.g. case notes currently in
the office), then your sample is likely to differ systematically from the total population and will
therefore contain bias. To avoid bias, any of the sampling methods outlined in Table 2.5 could be
used.
19
Step-by-step guide
When selecting your sample you should also consider:
• what would be an appropriate sample size
• whether there are any cases which should be excluded from the sample and why
• the time period from which cases will be drawn (e.g. cases seen over past six months =
population being studied)
• how cases will be identified (e.g. a number).
The sample needs to be large enough to be representative of the population you are studying.
Factors which may influence the sample size chosen are listed below.
Practical issues For example, time, audit budget and availability of appropriate cases
Methodology For example, postal surveys tend to have a low response rate so a
reasonably large sample would be required
Size of the study population For example, if you were auditing the assessment procedures used
for children referred with suspected autism, and the total number
referred in one year was 20, then it would not be appropriate to take
a sample of 20% of this population (i.e. four children); if 200 children
were referred to the team, however, then a sample size of 40 could
be acceptable.
(C) DATA ANALYSIS

When designing a clinical audit project it is helpful to discuss and decide how the data you
collect will be analysed and by whom. For more detail about data analysis, see p. 22.
(D) FEEDBACK OF FINDINGS
Ideally, a strategy for feeding findings back to the relevant stakeholders should be developed at
the outset of the clinical audit project. For more information about this see p. 24.
EE
EE
E
XAMPLEXAMPLE
XAMPLEXAMPLE
XAMPLE
: C: C
: C: C
: C
LINICALLINICAL
LINICALLINICAL
LINICAL



AA
AA
A
UDITUDIT
UDITUDIT
UDIT



ONON

ONON
ON



PREPPREP
PREPPREP
PREP
ARINGARING
ARINGARING
ARING



FF
FF
F
AMILIESAMILIES
AMILIESAMILIES
AMILIES



FORFOR
FORFOR
FOR



ASSESSMENTASSESSMENT

ASSESSMENTASSESSMENT
ASSESSMENT
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
4 – D 4 – D
4 – D 4 – D
4 – D
ESIGNESIGN
ESIGNESIGN
ESIGN



AA
AA
A
UDITUDIT
UDITUDIT
UDIT
TT

TT
T
ype of dataype of data
ype of dataype of data
ype of data
PP
PP
P
rospectiverospective
rospectiverospective
rospective
InformationInformation
InformationInformation
Information
FF
FF
F
amily IDamily ID
amily IDamily ID
amily ID
Date of assessment appointmentDate of assessment appointment
Date of assessment appointmentDate of assessment appointment
Date of assessment appointment
Date information leaflet sentDate information leaflet sent
Date information leaflet sentDate information leaflet sent
Date information leaflet sent
If sent late, reason whyIf sent late, reason why
If sent late, reason whyIf sent late, reason why
If sent late, reason why
Date of phone call and person who made itDate of phone call and person who made it

Date of phone call and person who made itDate of phone call and person who made it
Date of phone call and person who made it
PP
PP
P
arents’/carers’ satisfaction with content of information leafletarents’/carers’ satisfaction with content of information leaflet
arents’/carers’ satisfaction with content of information leafletarents’/carers’ satisfaction with content of information leaflet
arents’/carers’ satisfaction with content of information leaflet
PP
PP
P
arents’/carers’ satisfaction with phone callarents’/carers’ satisfaction with phone call
arents’/carers’ satisfaction with phone callarents’/carers’ satisfaction with phone call
arents’/carers’ satisfaction with phone call
Degree to which parents/carers felt prepared for an assessmentDegree to which parents/carers felt prepared for an assessment
Degree to which parents/carers felt prepared for an assessmentDegree to which parents/carers felt prepared for an assessment
Degree to which parents/carers felt prepared for an assessment
MethodMethod
MethodMethod
Method
(a)(a)
(a)(a)
(a)
CheckCheck
CheckCheck
Check
-list put in all case notes to be completed by administrator-list put in all case notes to be completed by administrator
-list put in all case notes to be completed by administrator-list put in all case notes to be completed by administrator
-list put in all case notes to be completed by administrator
,,

,,
,
regarding date information leaflet was sent, and by clinicians,regarding date information leaflet was sent, and by clinicians,
regarding date information leaflet was sent, and by clinicians,regarding date information leaflet was sent, and by clinicians,
regarding date information leaflet was sent, and by clinicians,
regarding the date of phone callregarding the date of phone call
regarding the date of phone callregarding the date of phone call
regarding the date of phone call
(b)(b)
(b)(b)
(b)
Questionnaire, including LikQuestionnaire, including Lik
Questionnaire, including LikQuestionnaire, including Lik
Questionnaire, including Lik
ert scales and open questions, toert scales and open questions, to
ert scales and open questions, toert scales and open questions, to
ert scales and open questions, to
examine parents’ satisfaction with information given aboutexamine parents’ satisfaction with information given about
examine parents’ satisfaction with information given aboutexamine parents’ satisfaction with information given about
examine parents’ satisfaction with information given about
assessment. Given to all parents who attend assessmentassessment. Given to all parents who attend assessment
assessment. Given to all parents who attend assessmentassessment. Given to all parents who attend assessment
assessment. Given to all parents who attend assessment
appointment to complete after the first sessionappointment to complete after the first session
appointment to complete after the first sessionappointment to complete after the first session
appointment to complete after the first session
SampleSample
SampleSample
Sample
(a)(a)

(a)(a)
(a)
All families who have a first assessment appointment over a sixAll families who have a first assessment appointment over a six
All families who have a first assessment appointment over a sixAll families who have a first assessment appointment over a six
All families who have a first assessment appointment over a six


-
month period (including those who do not attend)month period (including those who do not attend)
month period (including those who do not attend)month period (including those who do not attend)
month period (including those who do not attend)
(b)(b)
(b)(b)
(b)
All families who attend their first assessment appointmentAll families who attend their first assessment appointment
All families who attend their first assessment appointmentAll families who attend their first assessment appointment
All families who attend their first assessment appointment
Time periodTime period
Time periodTime period
Time period
Data collected over sixData collected over six
Data collected over sixData collected over six
Data collected over six
-month period starting from the following month-month period starting from the following month
-month period starting from the following month-month period starting from the following month
-month period starting from the following month
20
WHEN TO DO THE AUDIT
The time period over which the data is collected will depend on your data sources, collection
methods and the numbers required for a representative sample. For some projects you may be

able to collect all of the data in one morning (e.g. retrospective study of attendance rates),
whereas in others the data may need to be obtained over a one-year period. However, in designing
the audit you must consider whether the results of an audit which would take two years to
complete would still be beneficial in improving practice. Over long time periods many changes
to service delivery may occur which could render the results of your project meaningless.
21
Step-by-step guide
EE
EE
E
XAMPLEXAMPLE
XAMPLEXAMPLE
XAMPLE
: C: C
: C: C
: C
LINICALLINICAL
LINICALLINICAL
LINICAL



AA
AA
A
UDITUDIT
UDITUDIT
UDIT

ONON
ONON
ON



PREPPREP
PREPPREP
PREP
ARINGARING
ARINGARING
ARING



FF
FF
F
AMILIESAMILIES
AMILIESAMILIES
AMILIES



FORFOR
FORFOR
FOR

ASSESSMENTASSESSMENT
ASSESSMENTASSESSMENT
ASSESSMENT
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
5 – C 5 – C
5 – C 5 – C
5 – C
OLLECTOLLECT
OLLECTOLLECT
OLLECT



DD
DD
D
AA
AA

A
TT
TT
T
AA
AA
A
Coding system
When parents are askWhen parents are ask
When parents are askWhen parents are ask
When parents are ask
ed what they find most helfpful about the telephone call received prior to theired what they find most helfpful about the telephone call received prior to their
ed what they find most helfpful about the telephone call received prior to theired what they find most helfpful about the telephone call received prior to their
ed what they find most helfpful about the telephone call received prior to their
appointment, responses could fall into the following categories which could then be coded numericallyappointment, responses could fall into the following categories which could then be coded numerically
appointment, responses could fall into the following categories which could then be coded numericallyappointment, responses could fall into the following categories which could then be coded numerically
appointment, responses could fall into the following categories which could then be coded numerically
, as, as
, as, as
, as
shown.shown.
shown.shown.
shown.
RESPONSE CARESPONSE CA
RESPONSE CARESPONSE CA
RESPONSE CA
TEGORYTEGORY
TEGORYTEGORY
TEGORY
CODECODE

CODECODE
CODE
Reassurance receivedReassurance received
Reassurance receivedReassurance received
Reassurance received
11
11
1
Opportunity to ask questionsOpportunity to ask questions
Opportunity to ask questionsOpportunity to ask questions
Opportunity to ask questions
22
22
2
Clarification regarding structure of sessionClarification regarding structure of session
Clarification regarding structure of sessionClarification regarding structure of session
Clarification regarding structure of session
33
33
3
Friendliness of clinican – reduced anxietyFriendliness of clinican – reduced anxiety
Friendliness of clinican – reduced anxietyFriendliness of clinican – reduced anxiety
Friendliness of clinican – reduced anxiety
44
44
4
No responseNo response
No responseNo response
No response
55

55
5
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
5 – C 5 – C
5 – C 5 – C
5 – C
OLLECTOLLECT
OLLECTOLLECT
OLLECT



DD
DD
D
AA
AA
A
TT

TT
T
AA
AA
A
This is the stage at which you collect your data using the method developed and piloted at the
design stage. You will need to address the following issues:
• For each individual included in the sample, ensure that you have an identifier or label (e.g.
a number). Keep a list of the patients’ names and numbers separately from the data in
order to maintain confidentiality.


Clinicians’ anonymity should also be maintained (unless
they have agreed to be named) when sharing the results.
• Develop a way of storing your data. This may involve designing a coding system for your
data. Non-numerical clinical audit information may need to be translated into numbers to
make it more manageable in terms of storage and analysis. A code will also need to be
developed for missing data (see the example below).
• Ensure that your data is stored in such a way that it is both secure and conforms to legal
requirements. For example all personal data on a computer should be “secure from loss or
unauthorised disclosure” (Data Protection Act 1984).
22
SS
SS
S
TT
TT
T
AA
AA

A
GEGE
GEGE
GE
6 – A 6 – A
6 – A 6 – A
6 – A
NALNAL
NALNAL
NAL
YSEYSE
YSEYSE
YSE



DD
DD
D
AA
AA
A
TT
TT
T
AA
AA
A
OBJECTIVES OF DATA ANALYSIS
When analysing your data you will generally want to try to reach conclusions about:

• the general pattern of actual practice
• the degree to which actual practice (results of audit) is meeting the standards set
• those cases for which it is clinically acceptable for the standards not to be met.
METHODS OF DATA ANALYSIS
Analysing audit data does not usually require complex statistical tests, although these may be
necessary in certain situations. Clearly the type of data you have collected will determine the
type of analysis employed. The following approaches may be used in analysing your data.
(A) DESCRIPTIVE STATISTICS
This is where the data are described numerically. You may wish to calculate:
• the frequency of certain events/values occurring (i.e. rates and percentages)
• the mean, and/or the median – the most ‘typical value’ for the data
• the range and/or standard deviation – to show the variability of the individual results.
It is often useful to present descriptive statistics graphically using, for example, bar or pie
charts.
(B) STATISTICAL TESTS
These may be used:
• when conducting an outcome audit, for example comparing ‘before’ and ‘after’ results on
questionnaires to find out whether there has been a statistically significant improvement
in the client symptom scores; or
• when wanting to show whether the results you have obtained can be attributed to chance
variation.
(C) QUALITATIVE ANALYSIS
Where open-ended questions have been asked as part of the clinical audit project, qualitative
data will be obtained. There are a number of ways of analysing qualitative data. It may be possible,
for example, to conduct a content analysis of the major recurring themes and a frequency count
may then be performed.
COMPARING WITH STANDARDS SET
Where standards have been set, the final part of your analysis will entail calculating the percentage
of cases meeting and not meeting each standard.
At the standard-setting and design stages of the clinical audit cycle it may not have been

possible to identify circumstances in which it would be acceptable for cases not to meet a
certain standard. Discussions with colleagues about specific cases may highlight some situations
in which it is considered clinically acceptable for standards not to be met. In these situations,
your results may prove most meaningful if you calculate the following percentages:
• percentage of cases meeting each standard (calculated from whole sample including non-
applicable cases)
23
Step-by-step guide
EE
EE
E
XAMPLEXAMPLE
XAMPLEXAMPLE
XAMPLE
: C: C
: C: C
: C
LINICALLINICAL
LINICALLINICAL
LINICAL



AA
AA
A
UDITUDIT
UDITUDIT
UDIT

ONON
ONON
ON



PREPPREP
PREPPREP
PREP
ARINGARING
ARINGARING
ARING



FF
FF
F
AMILIESAMILIES
AMILIESAMILIES
AMILIES



FORFOR
FORFOR
FOR

ASSESSMENTASSESSMENT
ASSESSMENTASSESSMENT
ASSESSMENT
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
6 – A 6 – A
6 – A 6 – A
6 – A
NALNAL
NALNAL
NAL
YSEYSE
YSEYSE
YSE



DD

DD
D
AA
AA
A
TT
TT
T
AA
AA
A
Data analysis in this case would involve calculating percentages for cases in which the leaflet was sentData analysis in this case would involve calculating percentages for cases in which the leaflet was sent
Data analysis in this case would involve calculating percentages for cases in which the leaflet was sentData analysis in this case would involve calculating percentages for cases in which the leaflet was sent
Data analysis in this case would involve calculating percentages for cases in which the leaflet was sent
within the time specified, phone calls were made within the time specified, etc. Qualitative analysis whichwithin the time specified, phone calls were made within the time specified, etc. Qualitative analysis which
within the time specified, phone calls were made within the time specified, etc. Qualitative analysis whichwithin the time specified, phone calls were made within the time specified, etc. Qualitative analysis which
within the time specified, phone calls were made within the time specified, etc. Qualitative analysis which
involves identifying the major themes could also be employed for the open questions on the satisfactioninvolves identifying the major themes could also be employed for the open questions on the satisfaction
involves identifying the major themes could also be employed for the open questions on the satisfactioninvolves identifying the major themes could also be employed for the open questions on the satisfaction
involves identifying the major themes could also be employed for the open questions on the satisfaction
questionnaire. It may be possible then to calculate the frequency of occurrence of these themes.questionnaire. It may be possible then to calculate the frequency of occurrence of these themes.
questionnaire. It may be possible then to calculate the frequency of occurrence of these themes.questionnaire. It may be possible then to calculate the frequency of occurrence of these themes.
questionnaire. It may be possible then to calculate the frequency of occurrence of these themes.
• percentage of cases not meeting each standard (again including non-applicable cases)
• percentage of cases considered non-applicable (not meeting standards for clinically
acceptable reasons)
• percentage of applicable cases meeting each standard
• percentage of applicable cases not meeting each standard.
Where there is only a small difference between the target set and the percentage of cases
meeting the standards in the clinical audit, it may be difficult to know whether this is just due to

chance. Confidence intervals can be calculated to obtain a more accurate idea of whether there
is a statistically significant difference between your results and the set standards.
24
EE
EE
E
XAMPLEXAMPLE
XAMPLEXAMPLE
XAMPLE
: C: C
: C: C
: C
LINICALLINICAL
LINICALLINICAL
LINICAL



AA
AA
A
UDITUDIT
UDITUDIT
UDIT



ONON
ONON
ON

PREPPREP
PREPPREP
PREP
ARINGARING
ARINGARING
ARING



FF
FF
F
AMILIESAMILIES
AMILIESAMILIES
AMILIES



FORFOR
FORFOR
FOR



ASSESSMENTASSESSMENT
ASSESSMENTASSESSMENT
ASSESSMENT

SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
7 – F 7 – F
7 – F 7 – F
7 – F
EEDEED
EEDEED
EED



BABA
BABA
BA
CKCK
CKCK
CK

FINDINGSFINDINGS
FINDINGSFINDINGS
FINDINGS
Findings would need to be fed-back via written reports and verbal discussions, to:Findings would need to be fed-back via written reports and verbal discussions, to:
Findings would need to be fed-back via written reports and verbal discussions, to:Findings would need to be fed-back via written reports and verbal discussions, to:
Findings would need to be fed-back via written reports and verbal discussions, to:
(a)(a)
(a)(a)
(a)
all clinicians on the team;all clinicians on the team;
all clinicians on the team;all clinicians on the team;
all clinicians on the team;
(b)(b)
(b)(b)
(b)
all team administrators;all team administrators;
all team administrators;all team administrators;
all team administrators;
(c)(c)
(c)(c)
(c)
the team manager; andthe team manager; and
the team manager; andthe team manager; and
the team manager; and
(d)(d)
(d)(d)
(d)
any other relevant stakany other relevant stak
any other relevant stakany other relevant stak
any other relevant stak

eholders.eholders.
eholders.eholders.
eholders.
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
7 – F 7 – F
7 – F 7 – F
7 – F
EEDEED
EEDEED
EED



BABA
BABA
BA
CKCK
CKCK
CK

FINDINGSFINDINGS
FINDINGSFINDINGS
FINDINGS
Communicating your findings to the relevant stakeholders is an important part of the clinical
audit process if it is to have any impact on the quality of the service you are providing.
WHO SHOULD KNOW ABOUT THE FINDINGS
It is important that all of the key stakeholders are made aware of the findings of the project and
are provided with an opportunity to comment on them. This will include those individuals:
• whose practice was examined
• who are on the clinical audit project team
• who would be involved in making changes to improve the particular aspect of care in
question.
Different people may have access to different levels of information. For example clinicians
may know the ‘scores’ of all of the other clinicians if previously agreed, but it may not be
appropriate for commissioners to have access to this level of detail.
DISSEMINATION METHODS
A combination of passive feedback (written information) and active feedback (discussion of
findings) is preferable when communicating the findings of your project.
(A) AUDIT REPORTS (PASSIVE FEEDBACK)
It is important to produce a written record of your clinical audit project, which clearly outlines
how you approached each stage in the clinical audit cycle and the results you obtained (a pro
forma which may be used for this purpose is provided on p. 126). This can then be disseminated
to the relevant people as a way of feeding-back findings. This also ensures that a record of the
study is kept for future external and internal use, for example by individuals wishing to conduct
a similar clinical audit project, or by commissioners requiring evidence that the quality of service
provision is addressed by the department.
(B) DISCUSSION OF RESULTS (ACTIVE FEEDBACK)

Discussing the results of the clinical audit project with key stakeholders is an essential exercise
through which areas of practice which need to be changed can be identified and agreed.
25
Step-by-step guide
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
8 – C 8 – C
8 – C 8 – C
8 – C
HANGEHANGE
HANGEHANGE
HANGE



PRAPRA
PRAPRA
PRA
CTICECTICE
CTICECTICE

CTICE
If the clinical audit results demonstrate that your standards are being achieved, then changes in
practice may not be necessary, since your current practice appears to be effective. However, in
most cases one or more of the standards will not have been met. If standards were not set, you
will still probably have revealed certain areas of practice that need addressing. Changes in practice
may have already occurred simply as a result of doing the audit. Data-gathering itself can lead to
changes in behaviour, as can staff discussions about the topic area and the results of the clinical
audit project. However, to ensure that certain improvements are made and maintained, a more
overt process is required which involves a number of activities, as shown in Figure 2.4.
The following questions should be addressed in discussions with members of the clinical
audit project team, and with other relevant stakeholders. Answers to the questions can then be
used to develop an action plan as shown.
FF
FF
F
IGIG
IGIG
IG


.
2.4 2.4
2.4 2.4
2.4
Implementing change after auditImplementing change after audit
Implementing change after auditImplementing change after audit
Implementing change after audit
What are the problem areas, i.e. what standards are not being met?What are the problem areas, i.e. what standards are not being met?
What are the problem areas, i.e. what standards are not being met?What are the problem areas, i.e. what standards are not being met?
What are the problem areas, i.e. what standards are not being met?

What are the potential causes of the problems (e.gWhat are the potential causes of the problems (e.g
What are the potential causes of the problems (e.gWhat are the potential causes of the problems (e.g
What are the potential causes of the problems (e.g
. lack of resources, inadequate knowledge/. lack of resources, inadequate knowledge/
. lack of resources, inadequate knowledge/. lack of resources, inadequate knowledge/
. lack of resources, inadequate knowledge/
skills, lack of procedures, etc.) and which of these are most likskills, lack of procedures, etc.) and which of these are most lik
skills, lack of procedures, etc.) and which of these are most likskills, lack of procedures, etc.) and which of these are most lik
skills, lack of procedures, etc.) and which of these are most lik
ely?ely?
ely?ely?
ely?
How could these problems be overcome (i.e. ideas for change) and which solutions are mostHow could these problems be overcome (i.e. ideas for change) and which solutions are most
How could these problems be overcome (i.e. ideas for change) and which solutions are mostHow could these problems be overcome (i.e. ideas for change) and which solutions are most
How could these problems be overcome (i.e. ideas for change) and which solutions are most
liklik
liklik
lik
ely to be successful?ely to be successful?
ely to be successful?ely to be successful?
ely to be successful?
Whose support will be needed for change to be implemented?Whose support will be needed for change to be implemented?
Whose support will be needed for change to be implemented?Whose support will be needed for change to be implemented?
Whose support will be needed for change to be implemented?
CLINICAL ACLINICAL A
CLINICAL ACLINICAL A
CLINICAL A
UDIT AUDIT A
UDIT AUDIT A
UDIT A

CTION PLANCTION PLAN
CTION PLANCTION PLAN
CTION PLAN
Develop a clinical audit action plan which specifies:Develop a clinical audit action plan which specifies:
Develop a clinical audit action plan which specifies:Develop a clinical audit action plan which specifies:
Develop a clinical audit action plan which specifies:
••
••
•
what needs to change what needs to change
what needs to change what needs to change
what needs to change
••
••
•
how change could be achieved – what actions need to how change could be achieved – what actions need to
how change could be achieved – what actions need to how change could be achieved – what actions need to
how change could be achieved – what actions need to
taktak
taktak
tak
e placee place
e placee place
e place
••
••
•
who needs to tak who needs to tak
who needs to tak who needs to tak
who needs to tak

e these actionse these actions
e these actionse these actions
e these actions
••
••
•
when the proposed actions will begin when the proposed actions will begin
when the proposed actions will begin when the proposed actions will begin
when the proposed actions will begin
••
••
•
how these actions will be monitored and by whom how these actions will be monitored and by whom
how these actions will be monitored and by whom how these actions will be monitored and by whom
how these actions will be monitored and by whom
••
••
•
how and when to assess whether the actions tak how and when to assess whether the actions tak
how and when to assess whether the actions tak how and when to assess whether the actions tak
how and when to assess whether the actions tak
en haveen have
en haveen have
en have
achieved the desired outcomeachieved the desired outcome
achieved the desired outcomeachieved the desired outcome
achieved the desired outcome
RERE
RERE
RE

-
AA
AA
A
UDITUDIT
UDITUDIT
UDIT
➤
➤ ➤ ➤ ➤
26
EE
EE
E
XAMPLEXAMPLE
XAMPLEXAMPLE
XAMPLE
: C: C
: C: C
: C
LINICALLINICAL
LINICALLINICAL
LINICAL



AA
AA
A

UDITUDIT
UDITUDIT
UDIT



ONON
ONON
ON



PREPPREP
PREPPREP
PREP
ARINGARING
ARINGARING
ARING



FF
FF
F
AMILIESAMILIES
AMILIESAMILIES
AMILIES

FORFOR
FORFOR
FOR



ASSESSMENTASSESSMENT
ASSESSMENTASSESSMENT
ASSESSMENT
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
9 – S 9 – S
9 – S 9 – S
9 – S
ETET
ETET
ET
//
//
/

REVIEWREVIEW
REVIEWREVIEW
REVIEW



STST
STST
ST
ANDAND
ANDAND
AND
ARDSARDS
ARDSARDS
ARDS
Standard one (set at Stage 3)
100% of parents/carers will be sent an information leaflet by the team administrator no later than two weeks100% of parents/carers will be sent an information leaflet by the team administrator no later than two weeks
100% of parents/carers will be sent an information leaflet by the team administrator no later than two weeks100% of parents/carers will be sent an information leaflet by the team administrator no later than two weeks
100% of parents/carers will be sent an information leaflet by the team administrator no later than two weeks
before they have their assessment appointment.before they have their assessment appointment.
before they have their assessment appointment.before they have their assessment appointment.
before they have their assessment appointment.
It may be found that some families are offered an assessment appointment very soon after the referral isIt may be found that some families are offered an assessment appointment very soon after the referral is
It may be found that some families are offered an assessment appointment very soon after the referral isIt may be found that some families are offered an assessment appointment very soon after the referral is
It may be found that some families are offered an assessment appointment very soon after the referral is
received. These families will have to be sent an information leaflet immediatelyreceived. These families will have to be sent an information leaflet immediately
received. These families will have to be sent an information leaflet immediatelyreceived. These families will have to be sent an information leaflet immediately
received. These families will have to be sent an information leaflet immediately
, which they will consequently, which they will consequently
, which they will consequently, which they will consequently

, which they will consequently
receive less than two weeks before their appointment. Standard one may therefore need alteringreceive less than two weeks before their appointment. Standard one may therefore need altering
receive less than two weeks before their appointment. Standard one may therefore need alteringreceive less than two weeks before their appointment. Standard one may therefore need altering
receive less than two weeks before their appointment. Standard one may therefore need altering
, either by, either by
, either by, either by
, either by
reducing the target (e.greducing the target (e.g
reducing the target (e.greducing the target (e.g
reducing the target (e.g
. to 90%) or by specifying non-applicable cases such as those described above to 90%) or by specifying non-applicable cases such as those described above.
. to 90%) or by specifying non-applicable cases such as those described above to 90%) or by specifying non-applicable cases such as those described above.
. to 90%) or by specifying non-applicable cases such as those described above.
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
9 – S 9 – S
9 – S 9 – S
9 – S
ETET
ETET

ET
//
//
/
REVIEWREVIEW
REVIEWREVIEW
REVIEW



STST
STST
ST
ANDAND
ANDAND
AND
ARDSARDS
ARDSARDS
ARDS
As part of the feedback discussions it will be important to consider ‘standards’. At this stage
you may be either setting standards for the first time or reviewing the standards already set and
used for the clinical audit project.
USING CLINICAL AUDIT RESULTS TO SET STANDARDS
The results of your clinical audit project can be used to set some standards for your particular
service. If, for example, you found that letters were being sent to general practitioners after the
first assessment appointment for 80% of cases, you may decide to set a target of 90% to work
towards. You may also decide to establish a precise time period over which these letters must
be sent and clearly specify who should send them. Your standard statement may therefore read
as follows:
For 90% of cases a letter will be sent to the GP by the case consultant within one

week following the first assessment appointment.
You could then conduct another clinical audit to see whether the standards you have set are
being met.
REVIEWING STANDARDS SET
You may find that certain standards you had set were too high, too low or poorly worded.
Discussions with colleagues should be used to modify these standards appropriately.
27
Step-by-step guide
SS
SS
S
TT
TT
T
AA
AA
A
GEGE
GEGE
GE
10 – R 10 – R
10 – R 10 – R
10 – R
EE
EE
E


-
AA

AA
A
UDITUDIT
UDITUDIT
UDIT
The final stage in the clinical audit cycle involves deciding when and how to re-audit the topic.
THE IMPORTANCE OF RE-AUDITING
It is important to go around the clinical audit cycle for a second time in order to discover whether:
• agreed actions have occurred
• changes have achieved the desired improvements – i.e. closer to set target and, therefore,
improvements in service delivery
• standards continue to be met (where no changes were made).
HOW TO RE-AUDIT
Re-auditing involves repeating each stage of the clinical audit cycle. However, certain stages will
not require any further work, for example another literature search may be unnecessary if a
thorough one was conducted for the first clinical audit and the re-audit is performed shortly
afterwards. The clinical audit cycle may need to be repeated several times before you are confident
that improvements have been made to the quality of the service, and that these improvements
are being maintained.
You may decide that it would be more appropriate to conduct more specialised clinical audits
as a result of the first clinical audit project, rather than attempting to re-audit the whole topic
area at one time. The way in which you decide to approach the re-audit will depend on the
findings of your first clinical audit, as shown in Figure 2.5.
FF
FF
F
IGIG
IGIG
IG

.
2.5 2.5
2.5 2.5
2.5
RR
RR
R
ee
ee
e
-auditing-auditing
-auditing-auditing
-auditing
All standards wereAll standards were
All standards wereAll standards were
All standards were
metmet
metmet
met
Some standards wereSome standards were
Some standards wereSome standards were
Some standards were
not metnot met
not metnot met
not met
All/most standardsAll/most standards
All/most standardsAll/most standards
All/most standards
were not metwere not met

were not metwere not met
were not met
Conclusions could notConclusions could not
Conclusions could notConclusions could not
Conclusions could not
be reached – standardsbe reached – standards
be reached – standardsbe reached – standards
be reached – standards
unclearunclear
unclearunclear
unclear
RR
RR
R
epeat clinical audit process at aepeat clinical audit process at a
epeat clinical audit process at aepeat clinical audit process at a
epeat clinical audit process at a
later date to ensure this islater date to ensure this is
later date to ensure this islater date to ensure this is
later date to ensure this is
maintainedmaintained
maintainedmaintained
maintained
After action has been implemented,After action has been implemented,
After action has been implemented,After action has been implemented,
After action has been implemented,
repeat data collection only for thoserepeat data collection only for those
repeat data collection only for thoserepeat data collection only for those
repeat data collection only for those
standards not met (in the short term)standards not met (in the short term)

standards not met (in the short term)standards not met (in the short term)
standards not met (in the short term)
After action has been implemented,After action has been implemented,
After action has been implemented,After action has been implemented,
After action has been implemented,
repeat entire clinical audit processrepeat entire clinical audit process
repeat entire clinical audit processrepeat entire clinical audit process
repeat entire clinical audit process
RR
RR
R
eview and modify standards –eview and modify standards –
eview and modify standards –eview and modify standards –
eview and modify standards –
repeat entire clinical auditrepeat entire clinical audit
repeat entire clinical auditrepeat entire clinical audit
repeat entire clinical audit
NONO
NONO
NO
➤
NONO
NONO
NO
➤
NONO
NONO
NO
➤
YESYES

YESYES
YES
➤
YESYES
YESYES
YES
➤
YESYES
YESYES
YES
➤
YESYES
YESYES
YES
➤
28
fs
EE
EE
E
XAMPLEXAMPLE
XAMPLEXAMPLE
XAMPLE
: C: C
: C: C
: C
LINICALLINICAL
LINICALLINICAL
LINICAL

AA
AA
A
UDITUDIT
UDITUDIT
UDIT



ONON
ONON
ON



PREPPREP
PREPPREP
PREP
ARINGARING
ARINGARING
ARING



FF
FF
F
AMILIESAMILIES

AMILIESAMILIES
AMILIES



FORFOR
FORFOR
FOR



ASSESSMENTASSESSMENT
ASSESSMENTASSESSMENT
ASSESSMENT
Implementing change – possible suggestions
The clinical audit project may highlight that the following areas need to be addressed.The clinical audit project may highlight that the following areas need to be addressed.
The clinical audit project may highlight that the following areas need to be addressed.The clinical audit project may highlight that the following areas need to be addressed.
The clinical audit project may highlight that the following areas need to be addressed.
(a)(a)
(a)(a)
(a)
The content of the information leaflet needs modifyingThe content of the information leaflet needs modifying
The content of the information leaflet needs modifyingThe content of the information leaflet needs modifying
The content of the information leaflet needs modifying


.
(b)(b)
(b)(b)
(b)

TT
TT
T
he information leaflet needs to be written in a variety of different languages.he information leaflet needs to be written in a variety of different languages.
he information leaflet needs to be written in a variety of different languages.he information leaflet needs to be written in a variety of different languages.
he information leaflet needs to be written in a variety of different languages.
(c)(c)
(c)(c)
(c)
Contacting parents who work proves to be difficult and clinicians find themselves spending a lotContacting parents who work proves to be difficult and clinicians find themselves spending a lot
Contacting parents who work proves to be difficult and clinicians find themselves spending a lotContacting parents who work proves to be difficult and clinicians find themselves spending a lot
Contacting parents who work proves to be difficult and clinicians find themselves spending a lot
of time trying to speak to parents prior to the assessment appointment. One solution could be to send aof time trying to speak to parents prior to the assessment appointment. One solution could be to send a
of time trying to speak to parents prior to the assessment appointment. One solution could be to send aof time trying to speak to parents prior to the assessment appointment. One solution could be to send a
of time trying to speak to parents prior to the assessment appointment. One solution could be to send a
letter with the information leaflet giving a date and time when parents/carers can ring the clinician toletter with the information leaflet giving a date and time when parents/carers can ring the clinician to
letter with the information leaflet giving a date and time when parents/carers can ring the clinician toletter with the information leaflet giving a date and time when parents/carers can ring the clinician to
letter with the information leaflet giving a date and time when parents/carers can ring the clinician to
discuss the forthcoming appointment, if they wish.discuss the forthcoming appointment, if they wish.
discuss the forthcoming appointment, if they wish.discuss the forthcoming appointment, if they wish.
discuss the forthcoming appointment, if they wish.
Action plan for (a) may be as follows.Action plan for (a) may be as follows.
Action plan for (a) may be as follows.Action plan for (a) may be as follows.
Action plan for (a) may be as follows.
(a)(a)
(a)(a)
(a)
15 minutes of next team meeting will be spent discussing how the content of the information leaflet15 minutes of next team meeting will be spent discussing how the content of the information leaflet
15 minutes of next team meeting will be spent discussing how the content of the information leaflet15 minutes of next team meeting will be spent discussing how the content of the information leaflet
15 minutes of next team meeting will be spent discussing how the content of the information leaflet

could be improved, using feedback from parents/carers.could be improved, using feedback from parents/carers.
could be improved, using feedback from parents/carers.could be improved, using feedback from parents/carers.
could be improved, using feedback from parents/carers.
(b)(b)
(b)(b)
(b)
Clinician X will takClinician X will tak
Clinician X will takClinician X will tak
Clinician X will tak
e suggestions away and make suggestions away and mak
e suggestions away and make suggestions away and mak
e suggestions away and mak
e draft changes to the leaflet, which will be circulated toe draft changes to the leaflet, which will be circulated to
e draft changes to the leaflet, which will be circulated toe draft changes to the leaflet, which will be circulated to
e draft changes to the leaflet, which will be circulated to
all team members prior to the next team meetingall team members prior to the next team meeting
all team members prior to the next team meetingall team members prior to the next team meeting
all team members prior to the next team meeting


.
(c)(c)
(c)(c)
(c)
At the next team meeting (one week later), the draft changes will be discussed, modified and agreed.At the next team meeting (one week later), the draft changes will be discussed, modified and agreed.
At the next team meeting (one week later), the draft changes will be discussed, modified and agreed.At the next team meeting (one week later), the draft changes will be discussed, modified and agreed.
At the next team meeting (one week later), the draft changes will be discussed, modified and agreed.
(d)(d)
(d)(d)
(d)

The modified leaflet will be given to team administrator who will organise for it to be printed.The modified leaflet will be given to team administrator who will organise for it to be printed.
The modified leaflet will be given to team administrator who will organise for it to be printed.The modified leaflet will be given to team administrator who will organise for it to be printed.
The modified leaflet will be given to team administrator who will organise for it to be printed.
(e)(e)
(e)(e)
(e)
The leaflets will be sent out to all families coming for first assessment appointment starting theThe leaflets will be sent out to all families coming for first assessment appointment starting the
The leaflets will be sent out to all families coming for first assessment appointment starting theThe leaflets will be sent out to all families coming for first assessment appointment starting the
The leaflets will be sent out to all families coming for first assessment appointment starting the
following month.following month.
following month.following month.
following month.
(f)(f)
(f)(f)
(f)
The clinical audit lead, Clinician YThe clinical audit lead, Clinician Y
The clinical audit lead, Clinician YThe clinical audit lead, Clinician Y
The clinical audit lead, Clinician Y
, will monitor that the above is taking place according to time scale, will monitor that the above is taking place according to time scale
, will monitor that the above is taking place according to time scale, will monitor that the above is taking place according to time scale
, will monitor that the above is taking place according to time scale
outlined.outlined.
outlined.outlined.
outlined.
Re-audit
Four months after the introduction of the new information leaflet, parental satisfaction with the leaflet will beFour months after the introduction of the new information leaflet, parental satisfaction with the leaflet will be
Four months after the introduction of the new information leaflet, parental satisfaction with the leaflet will beFour months after the introduction of the new information leaflet, parental satisfaction with the leaflet will be
Four months after the introduction of the new information leaflet, parental satisfaction with the leaflet will be
rere
rere

re
-audited audited.
-audited audited.
-audited.