Why doesn’t audit work?

When representatives from 10 British hospital trusts met last September to tackle the issue of why clinical audit has failed to bring about change, the NHS white paper and the term “clinical governance” had not been born. It is now clear, however, that the Action on Clinical Audit project, which brought these trusts together, was conceived in the same camp—and with the same aim, to improve clinical services.

Action on Clinical Audit is a two year project, funded by the NHS Executive, that is devised to unravel the complex relationships that seem to render audit unworkable.* On paper, clinical audit takes the form of a neat cycle of events, leading to harmonious improvement in the activity under scrutiny.¹ In the gritty world of doctors, patients, and managers, the cycle can all too easily lose its shape, stop short, or simply vanish. The promised improvement never materialises.

The founders of Action on Clinical Audit began with the premise that we hold unreasonable expectations of audit, and that discrepancies exist between theory and reality. The project’s aim is not to perform audit as an end in itself, but by encouraging each of the trusts to conduct an “action inquiry”—a systematic analysis of the stages of the audit process—to examine the processes which underpin audit. The action inquiry approach involves asking at every step why things are being done, rather than just doing them as normal without particularly questioning them. By asking questions, the participants themselves identify the barriers that are defeating their end product.²

Over the two years teams from 22 trusts will work together on the barriers that they identify and other topics related to clinical audit, learning from each other’s experiences. For example, some teams have identified that a significant obstacle to achieving change in their own trusts is the lack of priority given to audit by the trust board. Indeed one team has stated that audit is not achieving change in clinical practice in their trust—despite the huge regard paid to academic achievement—because the chief executive simply does not see audit as important: audit is something that clinicians should be doing, but he does not see its relevance to the trust as a whole. Some of the teams are therefore exploring ways of raising the profile of audit and getting it on to the boardroom agenda. To this end the NHS white paper has given them a leg up and boosted their credence with their chief executives. Clinical governance is no longer an added luxury: trust strategies must now be clinically driven and not simply financially accountable. Audit, the systematic examination and improvement of clinical activity, is an important component of clinical governance.

Another common theme identified by several trusts is that audit tends to be managerially commissioned in response to political pressure to “do something.” The values of the clinicians and the issues they are interested in studying, however, may well differ from those of managers. Clinicians, for example, may want to audit their management of patients with acute myocardial infarction, while managers are interested in the bed occupancy of the coronary care unit. For these trusts the tensions thrown up by such ideological mismatch have made it virtually impossible to achieve any real change with audit.

While Action on Clinical Audit is claiming no predetermined outcomes, there is clearly at least one pay off for the trusts taking part. When clinicians and managers are asked why something is being done they often come up with different answers. Patients should certainly benefit if the clinicians, managers, and audit staff learn to appreciate different vantage points and motivations and to understand each other’s language.¹ The BMJ will be following the project and reporting on the progress of individual trusts.

Action on Clinical Audit was born of a desire to turn audit into a more useful process than it often is now. For its participants it has already crushed two assumptions: firstly, that good audit always leads to a better quality of patient care, and, secondly, that clinicians and managers work well together. It remains to be seen if the action inquiry approach that has produced the insights so far can revitalise the whole activity of audit—not only for its participants but in the wider NHS.