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Why clinical audit doesn't work

BMJ 1998; 316 doi: (Published 20 June 1998) Cite this as: BMJ 1998;316:1905

Clinical audit in nursing homes has proved ineffective

  1. Graham C Sutton, Senior clinical lecturer,
  2. Jayne Collingwood, Nurse audit project coordinator,
  3. Keith Pattison, Project manager,
  4. Mike Walker, Nursing home adviser
  1. Nuffield Institute for Health, Leeds LS2 9PL
  2. Wakefield and Pontefract Community Health NHS Trust, Castleford Health Centre, Castleford WF10 5LT
  3. Wakefield WF2 7EB
  4. Wakefield Health Authority, Wakefield WF1 1LT
  5. Medical Sickness Society, Exeter EX2 5SP
  6. Cassel Hospital, Richmond, Surrey TW10 7JF
  7. County Durham Health Authority, Durham DH1 5XZ

    Education and debate p 1893

    EDITOR—We share Berger's frustration with clinical audit in its current form.1 Between 1995 and 1997 we tried to introduce clinical audit into nursing homes in Wakefield. There are 24 registered homes with nearly 1000 beds equivalent to an entire hospital and their quality of care has obvious and lasting relevance to the quality of life for residents.

    The project coordinator (JC) introduced the concept of clinical audit to local homes, provided training, and helped each home conduct an audit of its own choosing. One home refused to participate. The other 23 were receptive, but in five no progress was made because of staff changes. Eleven topics were audited by 15 homes; the other three conducted pseudo-audits that were actually management activities, such as stock control.

    The 11 topics were: reporting of accidents; procedures of staff changeover; continence care, activities and stimulation of residents (3 homes); individual keyworker system, where each resident has a named worker on their case; compliance with safety standards in the workplace; quality of laundry; planning of food and menus (2 homes); ordering and planning of drug treatments; moving and handling; and quality of written care plans (2 homes). A year after they began, most of these audits remained incomplete, and only three are likely to have brought about improvements that are perceptible to residents. These are small benefits for the effort and resources invested, and we are pessimistic about auditing topics that may be on the health authority's agenda but that homes are reluctant to address.

    We are aware of 16 audit exercises in UK nursing homes (3 from peer reviewed sources). These suggest that clinical audit may have more success if it is combined with both external leverage (such as the cycle of registration and inspection) and an internal …

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