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Principles for Best Practice in Clinical Audit
  1. K M J Walshe
  1. University of Manchester, Manchester M13 9PL, UK; kieran.walshe{at}

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After over a decade of investment in clinical audit in the NHS, it might seem a little late for the National Institute for Clinical Excellence (NICE) to be publishing a book on how to do it. In the foreword by NICE there is a clue to the reason why. It says, rather charitably, that audit has a “mixed record”, and then goes on, less charitably, to list its flaws and shortcomings. A litany of problems is recited—including poor project design, inadequate data, bad project management, lack of commitment, poor change management, patchy follow up, and inadequate support. With such a track record, the continuing policy commitment to clinical audit looks like a triumph of hope over experience, or an admission that no realistic alternatives to persisting with clinical audit exist. The obvious question is why should this be so? Why has clinical audit often failed to deliver meaningful improvement, and what can be done about it?

The book does a good job of pulling together useful resources and information on clinical audit from all sorts of places, and it provides a great primer on clinical audit. It shows very clearly that good clinical audit is not rocket science; indeed, that perhaps it is too simple for some clever people’s liking. A series of chapters take the reader through the stages of the clinical audit cycle, from preparation to making and sustaining change. But three quarters of the book is dedicated to a series of appendices which provide a diversity of materials from a guide to online resources to a summary of the recommendations from the Bristol Inquiry. It is very extensively referenced and has lists of further reading. Overall, as a general resource, it should be useful to anyone working in clinical audit or clinical governance and to many clinical professionals.

However, the book does not really answer the obvious question posed earlier—why has clinical audit often failed to deliver meaningful improvement and what can be done about it? The book makes audit sound simple, which makes it all the harder to understand why it is so often ineffective. The truth is that we know how to do clinical audit well, and have known it for several years. Only in the early days of the 1990s was there much uncertainty about why clinical audit worked in some places or cases, but failed miserably in others. We know how to do it, and yet we still get it wrong. The continuing failure of clinical audit in many NHS organisations is not a failure of knowledge, which this book might help to address. It is primarily a failure of leadership and organisational culture, something which this book cannot really help to solve.

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