Quality and Audit

Defining audit

Clinical audit is one of the driving forces of clinical governance. Audit methodology helps you evaluate your performance on any topic against a chosen standard. Its purpose is to help you continuously improve your own performance. You should look at it as an upward spiralling process. Choose a topic, set a standard for your own performance then assess your performance to see if you're meeting your minimum standard. If not, you'll need to make a few changes then re-audit to ensure the changes have had a positive impact. In a very basic sense, anything where you've thought 'this isn't really working - I'll try it another way' is an audit. You've made an observation of current practice (ie 'this isn't really working'), compared it to a standard (ie how you expect it to perform), then implemented change. The primary aim of audit is to improve the quality of care for patients.

The process

1. The first step in auditing is choosing your topic. Initially, it may be difficult to come up with ideas, but they will soon flood you. Be careful not to choose anything too ambitious with your first topic and stick to subjects you know. Ask the team for their ideas. Involving them early in the process gets them onboard with the audit and supportive of the concept of continual improvement. You, or any member of your team, can audit anything within your practice. Generally, audit topics fall into 3 categories: clinical (e.g. radiographs, clinical outcomes of endodontic treatment), administrative (e.g. record keeping) and business systems (effectiveness of advertising, customer satisfaction surveys). Easy topics to start with are waiting times or the quality of your radiographs.

2. Your next step is to set a standard. Ideally, your standard should come from external sources like the Faculty of General Dental Practitioners (FGDP) or any of the specialist societies. If no standard is available, set your own. Speak with colleagues or do a literature search on Medline or through the British Dental Association's Information Centre to get some ideas. Your standard may be something simple like '90% of patients wait no longer than 10 minutes'.

3. After you've set your standard, you need to collect data to determine your own level of performance. You'll need a well thought out data collection sheet, which you or another member of the team will use to write down what's happening. You may write in your data as it happens, like with appointment times, or you may collect data retrospectively from record cards. You will also need to give some thought to sample sizes. Don't go overboard collecting too much data. Typically, your sample size is likely to range from 20 to 200 cases, depending on what you're looking at.

4. The next step is to analyse your collected data and compare it to your standard. A spreadsheet might be the best way of doing this as it will accurately do the sums for you. Consider what mathematical analyses seem best - percentages, averages, minimums, maximums, comparisons between variables. For a waiting time audit, you may decide you want to know the percentage of patients waiting no more than 10 minutes. For a crown audit, you may want to assess crown type against fit or patient satisfaction.

5. If you've fallen short of your standard think about implementing changes to improve your performance. For waiting times this may mean reviewing the amount of time allocated to different types of patients. For crowns it may mean undertaking further learning, changing techniques or switching materials.

6. An audit isn't really complete until you've re-audited to see if your changes have had a positive impact. As soon as you've completed the first audit, put a reminder in your diary to re-audit to complete your journey up the audit spiral.