Clinical audit template and guide

Use the RANZCP Clinical Audit template [PDF; 99KB] to develop your own clinical audit under the headings below.

As significant time is needed for an effective audit cycle, you can spread your activities over multiple CPD years.

1. Background and aim

Define the aim of your clinical audit based on what you hope to achieve, either as a desired outcome or as a question the audit seeks to answer. The aim of the audit should demonstrate that practice and service delivery improves as a direct outcome and that efficiency is enhanced.

2. Select an aspect of practice to audit

Choose an aspect of practice that is:

feasible – possible to implement the changes identified
relevant – to the quality of care provided
measurable – possible to measure against established standards
impactful – affects patient outcomes.

3. Standard (audit criteria)

Consider what standards exist for the measurement of the system, process or activity you have identified. You could use RANZCP clinical guidelines or another standard or guideline provided by a professional body.

Standards should be expressed as statements that outline the aspects of patient care and management you will measure current practice against. They should be specific, measurable, achievable, realistic and time bound (SMART).

4. Methodology

Decide the criteria for the study group. For example, patients who have been treated with a specific medication.

Decide whether you will audit a sample of cases or all available cases. It’s rarely practical to audit all patients, so it’s likely you will need to select a sample size.

It is essential to keep your audit achievable. RANZCP CCPD recommends approximately five (5) patient records/files are selected for an audit cycle for a psychiatrist undertaking an audit on their own. If multiple psychiatrists are participating, each could audit five cases and then compare results.

Decide how and when you will collect your data – this can be done retrospectively or prospectively. For example, if data is already recorded in patient notes, you could assess past episodes of patient care.

Data sources and ideas for audits may include:

patient notes
strength, weakness, opportunities and threats (SWOT) analysis
issues identified from patient feedback or complaints
issues identified in sentinel events
performance indicators/KPIs
recommendations from accreditation visits
team meeting feedback
focus groups
standards and performance indicators.

If you are collecting live data, set a time frame for your data collection, allowing enough time to collect useful information.

Use a data collection tool or template (for example, a spreadsheet), to ensure results are collected consistently.

5. Results

Compare data against an agreed standard (if available), or peers, to identify what is working well and what requires additional consideration or improvement.

Identify which standards are being met and which are not.
Consider the cause.
Highlight problems that need to be addressed.
Identify why and how practice can be improved to ensure the standard is met in the future.

6. Conclusion

Draw conclusions on whether standards have been met. If standards haven't been met, identify changes and why they are needed to improve compliance.

7. Recommendations and quality improvement plan

Implement the outcomes of the audit

Implementing the findings of the audit is very important and should reflect change to current processes and care. This may lead to quality improvement activities to address the issues identified.

Sustain the changes

Review the implemented changes at intervals to ensure quality improvement is sustained. Allow time to embed changes before re-auditing to test the effectiveness of the changes.