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July 2012, Volume 62, Issue 7


Clinical audit: Time to mandate

Qudsia Anjum  ( Family Medicine, International Medical Center, Satellite Clinic, Saudi Arabia. )

Audit has been used in different contexts in health care system to evaluate patient care from assessment through outcome. It should not be taken as an on-off exercise; rather it is a systematic continuous process of quality improvement.1 The advantages of undertaking audit are promotion of good practice, providing opportunities for training and education, better use of resources and increase in efficiency. Clinical audit tends to be used as an umbrella term for any audit conducted by health care professionals. The best and the only method to perform an audit is the clinical audit cycle, which is a stepwise pattern of comparing data with the standards, to improve practice by implementing change and monitoring. The standards are established criteria of practice taken into account for evaluating health care management. This could be done by integrating individual practice to the best available clinical evidence from systematic research, which is also termed as evidence based practice.2
Science and technology is rapidly updating making it difficult to keep pace with advancements in Medical Sciences. Clinical audit can be used as a tool to identify and rectify deficiencies in day to day practice. The Western world keeps audit as a valuable part of practice for all levels of care. Worth mentioning is National Health Service, UK, that has published guidelines for clinical audits. In addition, there are many published articles from the developed world related to using of audit cycle for improvement in practice. A systematic review on clinical auditing for surgical oncology revealed that quality information from audits could help improve quality management in surgical care.3 Another article showed that evidence based standard guidelines used through clinical audit made it possible to validate areas of improvement and verify standard achievements.4 A couple of other studies from rural settings have also proved to identify insufficiency in practice and marked improvement canĀ  e achieved by audits.5,6 Computer and information technology is becoming part of our clinical practice also, where clinical data nowadays is computerized. One University health center used electronic medical records for performing audit and reached a conclusion that audit does improve quality of care.7
The strong link between audit cycle and evidence based practice is understandable as both take into account standards for evaluating health care providers\\\' approach to patient care. Yet, little attention has been paid to this important aspect in our settings. This is evident from multiple studies done locally, where "audit" is mentioned in titles, but these were only descriptive studies, not pure audits. The studies did not focus on comparing standards and monitoring the change, which is an integral part of audit. These studies have been published in indexed and non indexed medical journals of Pakistan form different disciplines.8,12
It can be assumed that there might be a lack of knowledge and understanding of audit and audit cycle among Pakistani health professionals. This is strengthened by the findings of an international article that has highlighted lack of training, supervision and experience could be attributed to pitfalls in health care.13 It is known that clinical audit is not regarded as research, but it makes use of research methodology to assess practice. It can be stated that research needs to be audited to ensure performance of high quality work.
Therefore it is time to mandate audit as part of research methodology. It should be used to evaluate the structure, process and outcome of health care management improvement. Clinical audit should be made part of programmes for health care professionals and key stake holders at all levels of care. This will not only help improve the practice in line with evidence based medicine, but also will keep the medical community updated with standards and guidelines.


1. Clinical audits. Royal College of Physicians. (Online) 2011 (Cited 2011 December 11). Available from URL:
2. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn\\\'t. BMJ 1996; 312: 71-2.
3. van Leersum NJ, Kolfschoten NE, Klinkenbijl JH, Tollenaar RA, Wouters MW. [\\\'Clinical auditing\\\', a novel tool for quality assessment in surgical oncology]. Ned Tijdschr Geneeskd 2011; 155: A4136.
4. Mandato VD, Formisano D, Pirillo D, Ciarlini G, Cerami LB, Ventura A, et al. Province wide clinical governance network for clinical audit for quality improvement in endometrial cancer management. Int J Gynecol Cancer 2012; 22: 94-100.
5. Nyamtema AS, Jong AB, Urassa DP, Roosmalen J. Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania. BMC Pregnancy Childbirth 2011; 11: 94.
6. Cleary A, Walsh F, Connolly H, Hays V, Oluwole B, Macen E, Dowling M. Monitoring and documentation of side effects from depot antipsychotic medication: an interdisciplinary audit of practice in a regional mental health service. J Psychiatr Ment Health Nurs 2011; [Epub ahead of print].
7. Al-Shidhani TA, Bhargava K, Rizvi S. An audit of hypertension at university health center in Oman. Oman Med J 2011; 26: 248-52.
8. Memon FA, Khooharo Y, Ali S, Sajjad A. Clinical audit of stroke patients presenting at a teaching hospital. Pak J Med Sci 2009; 25: 968-71.
9. Shaheen F. Clinical Audit of Perinatal Mortality in a teaching hospital. Pak J Obstet Gynaecol 1997; 10: 27-30.
10. Siddiqi AM, Ali A, Masrur S, Monga MA, Tauqeer A, Rehman KU. Clinical Audit of Patients with CVA in Medical Unit-I, Jinnah Hospital, Lahore. Ann King Edward Med Uni 2001; 7: 79-82.
11. Ally SH, Ahmed A, Hanif R. An audit of serological tests carried out at clinical laboratory of Ayub Teaching Hospital, Abbottabad. J Ayub Med Coll Abottabad 2005; 17: 75-8.
12. Khawaja N, Zahid B, Tayyeb R. Clinical Audit of hysterectomies. Ann King Edward Med Uni 2005; 11: 219-21.
13. Gumber R, Khoosal D, Gajebasia N. Non-medical prescribing: audit, practice and views. J Psychiatr Med Health Nurs 2011. doi: 10.1111/j.1365-2850.2011.01779. (Epub ahead of print].

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: