Quality improvement is a continuous process that aims to maintain and improve standards of a service or product. In occupational health, as in other health services, quality improvement is central to the delivery of the highest standard of care and is also the lynchpin of clinical governance1.
Quality improvement in the clinical setting can only be achieved through setting standards, monitoring and auditing the standards in practice, implementing measures for improving performance and re-auditing.2 Clinical audit, which consists of observing practice, comparing the observed practice with the standards and implementing changes to effect improvement is central to ensuring sustained improvements in the quality of care delivered.
Standards are written statements of professionally agreed, evidence-based levels of performance and service delivery. Clinical decisions cannot be based on opinion alone and practice must be based on sound evidence. Standards must be acceptable, observable, achievable and measurable and should:
- Be clinically sound
- Take into account current research
- Take into account professional guidance and standards
- Be realistic in their expectations
- Be specific
- Be reviewed periodically in the light of new research or changing practices or procedures
- Meet legislative requirements
- Be written in a clear, understandable, unambiguous style
- Be auditable.4
Reviewing standards is a continual process. New developments in both clinical practice and in technology mean that clinical practice is always changing and evolving. For this reason OH advisers must keep abreast of these changes through research to ensure that the standards on which their practice is based reflect these changes. Standards may also have to be reviewed in the light of audit findings.
Nature and objectives of audit
An audit is a systematic and independent examination to determine whether quality activities and related results comply with planned arrangements and whether the arrangements are implemented effectively and are suitable to achieve objectives5. Audits involve:
- comparison of what is, against what should be
- making recommendations for remedial action
- gaining commitments for the recommendations.
The overall aim of clinical audit is to improve patient/client outcomes by improving the service delivered6.
Clinical audit is a cycle of activity involving a systematic review of practice, identification of problems, development of solutions, implementation of change and further review.7
Audit must be systematic, documented, periodic, and objective. It must also be a planned process, subject to formal review procedures, and formal recognition and status.8 An effective audit programme helps to provide the necessary assurance to clients, practitioners, and managers that an agreed quality of service is being provided within the resources available. Without some form of audit it is difficult to know whether the practitioner is practising effectively and safely and even more difficult to demonstrate to others.
In occupational health an audit can be used to:
- ensure that performance meets the criteria in the written standards
- ensure that the needs of the organisation are met
- increase client/organisation satisfaction
- highlight action required to improve performance and lead to sustained quality improvement.9
Audit can also be used as a marketing tool where occupational health is provided to external clients, giving an assurance that the provider is actively seeking to improve performance and will deliver a high standard of service.10 Audit can also provide evidence of the effectiveness of the OH service and can be used to help focus the service on areas which are beneficial to the business.4
To assist the auditing process OH can be divided into three distinct areas, structure, processes and outcomes.11
Structures can be audited against best practice elsewhere and their suitability in meeting the clients’ needs. Structures that can be audited include:
- Staffing levels
Processes include all the functions that OH practitioners carry out. Auditing processes provides a direct measure of the care being delivered. Processes to be audited will depend on the type of occupational health service being delivered. Examples of processes that may be audited are:
- Health surveillance
- Management referrals
- Sickness absence management
- Case conferences
- Immunisation clinics
- Record keeping
- Health promotion
- Pre-employment and other health screening.
Outcomes are the results of what is actually done. Outcomes are much more difficult to audit than processes. Measuring outcomes involves analysing the results in terms of the success of OH activities and deciding whether health and safety is improved by OH interventions and actions. Outcomes that may be audited will include:
- Sickness absence trends
- Epidemiological trends, eg ill-health retirement
- Meeting service level agreements
- Personnel seen within agreed timescales
- Evaluating health promotion initiatives.
Clinical audit is not a one-off exercise. To ensure that audit meets the aim of reviewing and improving the quality of care it needs to be a well planned ongoing process. In principle, there is no end point in quality improvement – the concept is that there will always be room for improvement.12 For this reason clinical audit should be seen as an integral part of the occupational health delivery and be built into business plans and development programmes.
Normally audits are a planned activity, carried out at regular intervals as part of an ongoing audit programme. In many occupational health practices the number of structures, processes and outcomes to be audited may be substantial and will require prioritisation. It may, as research by RM Agius points out, be necessary to concentrate on auditing areas and processes that have a critical bearing on occupational healthcare.13 Audits may also be conducted outside the planned audit programme where there are indications that the agreed standards of care are not being met. This is often described as dip sampling.
Resources and re-assurance
Ensuring that the necessary support and resources are available is critical to the success of the audit programme. One of the most frequently cited barriers to successful clinical audit in the NHS is the failure of NHS organisations to provide sufficient protected time and support to carry out the audit. Indeed, the time taken to conduct audits can be considerable and will include devising the audit programme, carrying out the audit, writing the audit report, implementing measures to improve practice and re-auditing to ensure that the required standard of practice is met. Staff time, is, according to Agius, the biggest resource required to carry out audit and implement the changes required to effect improvements in care.
As well as ensuring that the necessary time and other resources are available, occupational health staff should also ensure that management clearly demonstrates ownership of the audit and subsequent action plan to ensure that the aims of the audit in improving client care is successful4. Most organisations will have structures in place already to audit all aspects of the organisation’s activities. Furthermore, the importance of audit in ensuring quality and effectiveness will be well understood so gaining support and resources for conducting clinical audit should not be difficult.
It is important to ensure that the aims of the audit programme are clearly communicated to all staff in the occupational health department. Staff may be suspicious of the reasons for conducting clinical audit. In research, Palmer found that there is often a real fear that participation in clinical audit will lead to punishment for poor performance.2 An audit is a fact-finding exercise, not a fault-finding exercise. The purpose of audit is to uncover any gaps which indicate that standards set are not being met. Audit can be a very important educational tool as well as a means of improving the quality of care.15
Clinical audit must always be conducted within an ethical framework. At a practical level, this means ensuring client confidentiality at all times.16 OH professionals must be aware of the ethical implications of audit and their responsibilities under the Data Protection Act (1998)17 when collecting data for audit and presenting results. If information is obtained from OH records the client must consent to it being used or the information should be made anonymous before it is used in the audit report.
Collecting information and audit report
Relevant information about the practitioner’s practice to inform the audit process can be collected by asking appropriate questions, verifying what is actually happening and observing practice. Checklists are a valuable tool in audit as they allow for the systematic and methodical collection of information4 against the standard.
The information collected during the audit is used to compile an audit report which should:
- Identify strengths and areas of best practice as well as any weaknesses4
- Identify areas of non-compliance where the practice observed does not meet the requirements of the standard
- Recommend action for improvement
- Prioritise actions
- Compare with previous results
- Compare the results with the desired standards
- Review and agree gaps or deficiencies
- Agree corrective action.
Non-compliances may be rectified in any of the following ways:
- Reviewing the standard
- Preparing guidance notes or other instructions.
Corrective action must be given a reasonable time scale for completion and communicated to the appropriate personnel. A review should be carried out to ensure that the agreed corrective action has been completed. A follow-up audit may be required in some cases to ensure that the action taken has been effective. All staff in the OH department should be involved in planning any changes identified as a result of the audit.
Ensuring that a high quality of care is delivered to clients should be central to the work of all occupational health practitioners. Setting standards, regularly auditing practice against the standards and implementing measures to improve practice is the only practical way of doing this. Clinical audit provides a way in which the quality of care can be reviewed objectively within an approach which is developmental and supportive18 and properly carried out will add value to the occupational health delivery.
- Palmer, C (2002) Clinical governance: breathing new life into clinical audit: Advances in psychiatric treatment, 8: 470-476.
- Scally, G and Donaldson, J (1998) Clinical Governance and the Drive for Quality, Improvement in the new NHS, The British Medical Journal, 317: 61-65
- McDonald, EB Audit and Quality in Occupational Health, Occupational Medicine, 42: 7-11.
- The Royal College Of Nursing (1999) Occupational Health Audit, A practical guide for occupational health nurses. London: The RCN.
- BS (1994) International Quality, the Right Direction, London: BSI
- Copeland, G (2005) A Practical Handbook for Clinical Audit. Clinical Governance Support Team NHS
- Reilly, J (2001) Clinical governance in the real world, Nursing Times, 97: 50: 36-37.
- Starey, N (2001)What is Clinical Governance?, London: Hayward Medical Communications.
- Agius, RM (1995-2001) Audit in Occupational Health: 2, The Application of Audit to Occupational Health and Medicine.
- Maynard, Linda (2002) Quality and Audit in Occupational Health Nursing, 2nd ed. Ed Oakley, K. London Whurr Publishers.
- Dunabedian, A (1996) Evaluation of the quality of medical care. Milbank Memorial Fund Quarterly. 44:166-206.
- The Faculty of Occupational Medicine (1995) Quality and Audit in Occupational Medicine, London.
- Agius, RM (1995-2001) Quality and Audit in Occupational Health, the Intranet,
- National Institute for Clinical Excellence (2002) Principles for Best Practice in Clinical Audit. Oxon: Radcliffe Medical Press Ltd.
- Agius, RM (1995-2001) Audit in Occupational Health: 6 Auditing Occupational Health Consultation
- The Gloucester Health Community (2007) Clinical Audit, Research and the Use of Patient Data.
- The Data Protection Act 1998. HMSO.
- Jones, T and Cawthorn, S (2007) What is Clinical Audit? What is Series: Hayward Group