Key findings from the studies uncovered during the literature search

PaperSubjects/settingAdvantages identified or perceivedDisadvantages highlightedAlleged or perceived barriers to effective auditPerceived or reported factors facilitating effective audit
The literature cited under each of these headings is not exhaustive, but instead studies have been chosen to illustrate key points. *The CASPE publications can be purchased from CASPE Research, 22 Palace Court, Bayswater, London W2 4HU.
Baker R, Robertson N, Farooqi A. Audit in general practice: factors influencing participation. BMJ 1995;311:31-4Interview and questionnaire survey of 147 general practices invited to take part in a single topic auditImproves care; Relevant; Valuable; EssentialInterferes with important work; IrrelevantLack of time and knowledge; Boring topic; Already audited topic; Lack of resources; Lack of staff; Topic not a priority; Problems among team; Changes in partnership; Ill health of partner; Previously undertaken an audit which implemented change.Large practice; Partner who was college member; Discussion with colleagues; Positive attitude to audit; Age of partners; Advisory group; Training; Financial help; Administrative support.
Barton A, Spencer J. Differences in attitudes towards audit among specialities in the Northern Region. Medical Audit News 1994;4:78-9.Questionnaire survey of 148 senior undergraduate clinical tutors in one university about their attitude to auditWorthwhile; Likely to produce change; A way of improving quality; A core activityA waste of time; A fad; Irrelevant to qualityNANA
Black N, Thompson E. Obstacles to medical audit: British doctors speak. Soc Sci Med 1993;36:849-56.Interiews with 28 consultants and 34 junior doctors in 4 district general hospitalsGood doctoring; Raises awareness and problems; Improves care; Improves clerical managementSuspicion about government's motives; A means of disciplining doctors; Junior bashing; Thwarts individual patient care; Fear of conflict/ridicule; Inhibits criticism; Helps consultants to get papers Clinical aspects of care too difficult to audit; Lack of peer support/conducive social environment; Lack of time; Lack of resources e.g. secretaries; Extra work for junior staff; Lack of knowledge and training in audit methods; Short contracts; Lack of organisation.Introduction of audit officers and assistants.
Cooper A, French D. Illustrative examples of successful audit in General Practice. Audit Trends 1993;1:166-9.A review of Maags newlsetters and annual reportsImprovement in clinical care, practice management and preventive healthNANANA
Chambers R, Bowyer S, Campbell I. Audit activity and quality of completed audit projects in primary care in Staffordshire. Quality in Health Care 1995:4:178-83189 General Practices-visit to study best audit projectEducational; Increased awareness; Improved communication; Increased teamworkModifications made to tasks, people and technology.Lack of resources to make changes; Uncertainty over how to proceed with changes.Audit enthusiast in team; Practice manager; Greater use of computer; Organised notes; Being a training practice; Being a partnership
Davies C, Fletcher J, Wilmot J, et al. Co-ordinated audit in Warwickshire 1991-1993. Audit Trends 1995;3:121-6. 53 general practices (200 GPs) in one region Improved clinical care; Information for decision making; Financial efficiency Managerial tool Problems with standard setting External reviewer; Experienced practice in audit; Good information systems; Good practice team work; Interested people; Staff time; Data ownership; Product champion; Linked to main business
Davison K, Smith L. Time spent by doctors on medical audit. Psychiatric Bulletin 1993;17:418-19.Postal survey of 54 doctors working in psychiatric units managed by one trustWorthwhileSpending own time on audit related activities; Attendance at audit meetings at expense of other activities; Not worthwhile; Having to catch up with clinical work in own timeLack of dedicated time; Lack of trainingLocally agreed job plans with dedicated time for audit; Training days; Enthusiasm
Eccles MP, Hunt J, Newton J. A case study of an interface audit group. Audit Trends 1995;3:127-31. Case study of one interface audit group using interviews with 12 members Satisfaction at being part of an audit group; Learning experience to work with other disciplines NA Group too big; Fluctuating membership; Lack of clearly defined group task; Medical hierarchy impeded members who perceived themselves as junior; Different professional backgrounds; Language barriers; Different boundaries; Lack of knowledge of others' remitNA
Eccles MP, Deverill M, McColl E, Richardson H. A national survey of audit activity across the primary-secondary care interface. Quality in Health Care 1996;5:193-200. A three phase national postal survey using a cascade sampling approachOpportunity for discussion; Meeting colleagues from other disciplines; Meetings stimulated learning Difficult to establish common goals; Decisions took longer; Group disagreements Incompatible computer systems; Physical distance between group members Commitment; Enthusiasm; Time; Clear purpose; Money; Previous knowledge of a group member; Common objectives; Primary-secondary communication; Adequate resources and manpower
Firth-Cozens J, Storer D. Registrars' and senior registrars' perceptions of their audit activities. Quality in Health Care 1992;1:161-4. Postal questionnaire of 610 registrars and senior registrars in one regionHelps patient care; EducationalNegative feedback to juniors; Witch-hunting; Feeling threatened and blamed; Consultants not the subjects of audit; Reluctance to discuss for fear of being criticised; Having to do audit in own time; Using own resourcesShort term contracts; Lack of training in audit methods; Bickering between consultants; Lack of time; Lack of resources; Lack of recognition from management Better feedback; More training; Greater participation; Dedicated staff; Expert help; Better methods; Training; Computers; Funding; Action on results; Dedicated time; Self selection of topic
Gabbay J, McNicol MC, Spiby J, Davies SC, Layton AJ. What did audit achieve? Lessons from preliminary evaluation of a year's medical audit. BMJ 1990;301:526-9. Monthly casenote review. Forty doctors in one district general hospital dealing with 140 sets of notes Provided forum for discussion; Improved general communication about clinical matters between doctors; Improved casenotes; Changes to clinical policy; Development of minimum standards; Observation improved practiceRepetitive; Juniors felt unfairly criticised; Doubts about usefulness; Flagging morale of auditors and audited; Time and work spent on audit Administrative delays in changing practice; Differences of opinion about clinical management; Thwarted development of guidelines; Emphasis on standard of notes; Detracted from issues of clinical care; Logistical problemsSupport for audit
Gabbay J, Layton AJ. Evaluation of audit of medical inpatient records in a district general hospital. Quality in Health Care 1992;1:43-47.Retrospective comparison of the quality of recording in inpatients' notesInitial improvements in notekeepingDisaffection; Boredom; Junior doctors felt audit being done to themLack of feedback to junior doctors; Lack of reinforcement from senior colleaguesLack of audit tools
Grol R, Wensing M. Implementation of quality assurance and medical audit: general practitioners' perceived obstacles and requirements. Br J Gen Pract 1995;45:548-52.Interviews with 120 Dutch general practitionersNANALack of time; Colleagues' negative attitudes; Fear of assessment and criticism; Lack of knowledge and skills; Problem in practice management; No financial helpRegular meetings; Information; Data from other colleagues with which to compare performance; Support in data collection
Hearnshaw HM, Baker RH, Robertson N. Multi-disciplinary audit in primary health care teams: facilitation by audit support staff. Quality in Health Care 1994;3:164-8.Case control study of an audit facilitator intervention in 8 general practicesIncreased teamwork; Increased confidence in staff that standards were being met; Adoption of new skills in audit methodsNAIllness of team members; Changes in practice membershipTeam members should understand and be part of the process of managing audit; Stability of group membership; Willingness of all members to participate; External facilitator
Johnson R. Where have all the pennies gone? The work of Manchester medical audit advisory group. BMJ 1994;309:98-102.Review of the work of one medical audit advisory groupSummarising casenotes; Openness among doctors about the work they do; Improved teamwork; Standard settingNAContractual and organisational changes to GPs; Increase in amount of paperwork GPs have to do Help in carrying out audit ; GPs teaching other GPs; Staff training; Funding
Karran SJ, Ranaboldo CJ, Karran A. Review of the perceptions of general surgical staff within the Wessex region of the status of quality assurance and surgical audit. Ann R Coll Surg Engl 1993;75(Suppl): 104-7.Postal survey of 57 consultant surgeons and 48 registrars in one regionCollection of clinical outcome information; Vital; Useful; Helpful NALack of time; Lack of support staff; Lack of secretarial support; Lack of commitmentNA
Kerrison S, Packwood T, Buxton M. Medical audit. Taking stock. London: King's Fund Centre, 1993: Case study of audit activity in four sites Improves quality of care; Encourages efficiency of resources; Alterations to medical practice; Construction of local standards; Educational; Stimulates debate; Important mechanism for medical socialisation. Leads to recommendations and clarification of policiesMedical preserve; Provides an additional element in medical management; Makes little contribution to wider management; Dominated by enthusiasts; Rapidly implemented; Limited in scope Professional isolation; Logistical problems in organising groups and meetings; Lack of confidence in/access to audit support staff; Difficulty in determining action from results; Lack of knowledge; Work pressures; Poor information sources; Lack of structureRing fenced monies; Audit committees; Simple design and analysis; Formal training; Meeting with management; Choosing common problem as topic; Multi-disciplinary groups; Committed individuals; IT support
Kinn SR, Smith PJ. Medical audit activity in primary and secondary care in the West of Scotland. Health Bull 1996;54:252-7.An anonymised postal survey of 150 GPs and 150 hospital based clinicians in six Health BoardsGeneral improvements; Useful tool for bidding for resources; Patient benefitsIrrelevant; Too many trivial auditsNAWorking in a teaching hospital; Working in a large general practice; Being enthusiastic and motivated
Lervy B, Wareham K, Cheung WY. Practice characteristics associated with audit activity: a medical audit advisory group survey. Br J Gen Pract 1994;44:311-4.57 general practicesNANANAModern records systems; Three or more partners; Clinical summaries; Training practice
Lewis C, Combes D. Is general practice audit alive and well? The view from Portsmouth. Br J Gen Pract 1996;46:735-6.82 general practices in one health authorityNADe-skilling of practice based audit; Time spent on collaborationNALarge practice; Multi-disciplinary groups; Audit co-ordinators
Lough JM, McKay J and Murray TS. Audit: trainers' and trainees' attitudes and experiences. Med Educ 1995;29:85-90155 GP trainers and their trainees in West of ScotlandUseful way of assessing work; Improves patient careMay be used to assess doctors; Inappropriate use of timeLack of time and resources; Lack of motivation; Lack of co-operation from partners; Lack of knowledge/training; Agreeing and setting standards; Data collection; Lack of funding; Difficulty making changesProtected time; Small group skills; Training; Database of current practice; Routine collection of pre-agreed data; Agreed protocols; Support and guidance
Lough JM, McKay J, Murray TS. Audit and summative assessment: two years pilot experience. Med Educ 1995;29:101-103.117 GP trainees in West of ScotlandIncreased confidence in introducing changeDifficulties with audit process; Lack of cooperation from partners and trainers; Lack of time; Lack of feedback and encouragement from trainersSupport Protected time; Feedback; Encouragement; Practical help
Millard A. Perceptions of clinical audit: a preliminary evaluation. J Clin Effectiveness 1996;1:96-9. Semi-structured interviews in four Scottish Health Board areas with 5 audit facilitators, three clinicians, one CAMO, one director of quality, three national project coordinators and three members of CRAGSelf critical route to improving patient care. Unsystematic; Threatening. Lack of awareness of educational need to do audit among clinicians; Short term contracts; Competitive market where jobs are at stake; Lack of a shared understanding of audit; Lack of methodological rigour; Gap between theory and practice Collaborative environment; Clarity of question and project plan; Systematic approach; Multi-purpose; Intention to change practice; Clinician owned and driven audit with feedback; Resource centre; Expert advice; Central control and disbursement of audit funds; Action-based directives; Requirements for information set locally; A national framework for specialty groups; Overall plan; Clarity and openness; Accountability and evaluation; Promotion of clinical guidelines; Better outcomes; Using patients' views. Sharing good methods; Pulling specialties; Growing projects from national to local.
Millard A. Health professionals' needs: audit reports. Audit Trends 1996;4:129-132. 34 health professionals including nurses and PAMS in two Scottish Health Boards Local information; Learning from others; Ideas from others on topic selection and development; Information on better ways of delivering care; Information on audit methods used by others; Comparison and checking of practice; Collaboration; Change; Improved public relations.NAInter professional group barriers; Suspicion about the use of audit results; Lack of time; Lack of understanding of audit by managers; Too much information; Poor audit methods Audit facilitators as filters of information; Audit group meetings; Education and training; Reducing the element of threat
Normand C, Ditch J, Dockrell J, et al. Clinical audit in professions allied to medicine and related therapy professions. Report to the Department of Health on a Pilot Study. Belfast: Health and Healthcare Research Unit, Queen's University Belfast, 1991 250 health professionals from Clinical Psychology, Occupational Therapy, Physiotherapy and Speech and Language Therapy Improved standards; Better record keeping; Worthwhile; Recognition of the need for effective tools Administrative burden; Time directed from clinical work Inappropriateness and poor quality of routinely available information; Time involved in collecting and processing information; Lack of good tools to measure outcomes and quality; Scarcity of resources; Regrading exercisesClerical support; Recognition of time needed for audit; A common framework; Review of routine information collected on the activity of each profession; Dedicated time; Projects set up to test and validate existing tools; National framework
National Audit Office. Auditing clinical care in Scotland. London: HMSO, 1994 Five health boards and a selection of Trusts, provider units, general practices and specialty audit groups therein and 12 Royal Colleges interviews and reports Changes in clinical practice, organisation and management; Improved quality of care; Increased professional satisfaction; Improved cost effectiveness and efficiency; Provides indication of quality of care being bought by purchasersNon-clinicians setting priorities and making decisions about funding; Misinterpretation of results; Used inappropriately to influence purchasing decisions Shortage of time; Problems in the financial management of funds nationally; Lack of good quality clinical information systems; Lack of computing skills; Uncertainty over local funding arrangements Disseminate audit methodologies to National health Service; Reassess health professionals' concerns; Guidance for purchasers and providers on the rights and responsibilities of the health board; Consider ways to make clinical information more available; Purchasers should discuss audit strategy with providers before financial year; Distinguish how they intend to use results; Ensure audit strategy includes reference to arrangements for support; Trusts should provide purchasers with detailed costed programmes of audit; Ensure adequate support staff
Penney GC, Templeton A. Impact of a national audit project on gynaecologists in Scotland. Quality in Health Care 1995;4:37-9.Postal survey of all 128 consultant gynaecologists in Scotland in practice in 1994Change in practice; Reconsider aspects of practice.NANAFeedback; Sense of ownership; Co-operation
Pringle M, Bradley C, Carmichael C, Wallis H, Moore A. A survey of attitudes to and experience of medical audit in General Practice: Implications for MAAGS. Audit Trends 1994;2:9-13. Postal questionnaire to 323 GPs in Stockport and Derbyshire Improvements in patient care; Improvements in patient satisfaction; Better patient feedback; Increased knowledge among doctors; Increased awareness; Increased satisfaction; Improved performance; Communication and teamwork; Better record keeping; Improved practice administration; Uptake of services; Personnel deployment; Reveals interesting things about practice; A good use of time.Unnecessary; Waste of time; Boring; Bureaucratic ploy to limit clinical freedom NA Previous experience of audit and completing the audit cycle
Robinson S. Audit in the therapy professions: some constraints on progress. Quality in Health Care 1996;5:206-14. 62 Therapists and 60 stakeholders including nurses and doctors, managers, purchasers and quality co-ordinatorsPositive impacts on the delivery of care, careers and morale of therapistsNALack of resources; Lack of expertise or access to advice; Relations between groups; Organizational structures; Lack of an overall plan for auditTime; Support Staff; Training
Robinson S. Evaluating the progress of clinical audit. Int J Theory, Research and Practice 1996;2:373-92. 62 Therapists and 60 stakeholders including nurses and doctors, managers, purchasers and quality co-ordinators Professional confidence; Understanding of each other's role; Good for C.V.; Improved patient care; Enhanced accountability; Greater ability to complement each other's roles; Decreased professional marginalisation; Raised morale Intimidation of junior staff; Fear of losing job; Loss of autonomy; Highlighted limitations; Unfair; Disheartening; Time spent on paperwork Poor project planning; Lack of training; Poor relationships with management NA
Russell IT, et al. Medical audit in general practice. I: Effects on doctors' clinical behaviour for common childhood conditions. BMJ 1992;304:1480-4.Study of the impact of 4 different types of medical audit on the behaviour of 92 general practitioner trainers for five conditions. Before and after comparison.Change and improvements in prescribing practice; Improved follow up.NAChanges in partnership.Setting own standards; Medical records enhancement forms
Smith HE, Russell GI, Frew AJ, et al. Medical audit: the differing perspectives of managers and clinicians. J R Coll Physicians Lond 1992;26:177-80. A questionnaire survey of 144 clinicians and 70 managers in one health district about their perceptions of audit before its introduction Would improve the quality of patient care; Would be an important component of continuing medical education; Worthwhile; A means of maintaining professional freedom by demonstrating proficiencyInterference with routine clinical workload; Waste of effort; Will utilise resources more important for patient care; Would allow mangers to manipulate clinical practice; Restrict clinical activity; Lack of objective evidenceLack of time NA
Spencer JA. Audit and academic departments of general practice: a survey in the United Kingdom and Eire. Br J Gen Pract 1992;42:333-5.A questionnaire and telephone survey of 31 academic departments of General Practice in Britain and Eire about problems in teaching medical auditNATime spent on audit; Not auditing own workLack of time; Difficulty making topic interesting and relevant; Negative attitudes from colleagues NA
Tabendeh H, Thompson GM. Auditing ophthalmology audits. Eye 1995;9(Suppl):1-5.Evaluation of one departmental audit programmeEducational; Baseline information; Improved patient care; Effect on practiceTime consuming; Boring.Data collection; Poor planning. Education and training; Careful choice of topic; Link between routine data systems and audit; Prospective data collection; Development of databases; College guidance; Clear plan; Re-evaluation.
Thomson R, Elcoat C, Pugh E. Clinical audit and the purchaser-provider interaction: different attitudes and expectations in the United Kingdom. Quality in Health Care 1996;5:97-103. Interviews with chief executives, contracts managers, quality audit leaders, directors of public health, consultants, GPs, audit support staff and practice managers Measures and improves the quality of care; Evaluates practice; Produces outcomes; Educational; Results in change; Provides purchasers with provider performance data; Questions practice Causes resentment among providers; Diminishes clinical ownership; Lack of confidentiality; Little outcome on local purchasing decisions; Punitive to providersReluctance to share information; Lack of knowledge of purchasers re clinical practice may lead to inappropriate comparisons Mutual dialogue between purchasers and providers; Common understanding; Dedicated staff; Information technology; Money; Protected time; Realistic expectations
Toy PTCY. Effectiveness of transfusion audits and practice guidelines. Arch Path Lab Med 1994; 118:435-437 Literature review of published data which attested to the effectiveness of transfusion audits.Improvements in practice; Guidelines; Education of technologistsNANAEducation
Watkins CJ, King J. Understanding the barriers to medical audit: insights from the experience of one practice. Audit Trends 1996;4:47-52.Participant observational study in one 7 partner group practicePotent tool for understanding decision making in the consulting room; Facilitates communication and understanding between partners in practice; Changes in practice prescribing policy.Impedes individualised care; External threat; Reluctance to criticise colleagues; Threat to freedomThe presence of an enthusiast prohibited the development of colleagues' skills and excluded them from the audit activity Preserving confidentiality; Anonymising data; Objective outside sources of information
Webb SJ, Dowell AC, Heywood P. Survey of general practice audit in Leeds. BMJ 1991;302:390-2. Postal survey of 386 GPsNANALack of time; Size of task; Lack of knowledge of and training in audit methods; Lack of cooperation from other colleagues; Resources Modern records systems; Training; Time; Support; Strategy for General Practice; Co-operation from FHAs, MAAGS and government
Webb MD, Harvey IM. Taking stock of medical audit: a questionnaire survey. Medical Audit News 1992;2:18. Postal survey of 140 consultants in one health authority Improves performance; EducationalUnnecessary because medical practice is self-auditing Fear of litigation; Lack of clerical support; Lack of time; Lack of computers; Lack of finance; Lack of clinician involvement; Lack of education and training in audit methods.NA
Webb MD, Harvey IM. Auditing the Introduction of Audit. Medical Audit News 1994;4:19-20.Postal questionnaire to 147 consultants in one health authorityChange in clinical practice e.g. changes in treatment, setting up of new clinic, policy changesTime spent on inappropriate tasks; CostPressure of clinical work; Lack of clerical support or audit administrators Lack of financial support from management to effect change; Lack of confidence in audit committeesAudit administrators; Time; Clerical support
CASPE Evaluations*
Amess M, Walshe K, Shaw C and Coles J. The audit activities of the medical Royal Colleges and their Faculties in England, 1995Document review and semistructured interviews with audit representative from 11 Royal Colleges in EnglandMechanism for change; Quality accreditation; Change in attitude towards audit; Establishment of audit departmentsResistance to change; Doubt about its value; ThreateningConfusion about role of colleges in audit; Lack of direction; Fragmented approach; Isolation from practice; Short term funding; Medical dominance; Lack of evaluation of audit; programmes; Lack of training; Lack of reporting mechanismsDissemination of information; Long term funding; Clarification of role; Enhanced educational role; Collaboration with non-medical personnel
Bennett J and Coles J Brighton Health Care NHS Trust's clinical audit programme. 1996; Rumsey M Buttery Y Bennett J and Cole J North Staffordshire's joint clinical audit programme 1996; Buttery, Y, Rumsey M, Bennett J and Coles J Dorset Healthcare NHS Trusts Clinical Audit Programme 1995; Rumsey M, Buttery Y, Bennett J and Coles J Wythenshawe Hospital's clinical audit programme A case study 1996; Buttery Y, Walshe K, Rumsey M, Bennett J and Coles J. A review of 29 programmes 1995 A review of 29 audit programmes including 4 case studiesGreater interprofessional communication; Better understanding of each others' roles; More patient-centred approach; More effective audit; Improved quality of healthcare; Changes in clinical practice; Changes in service delivery; Changes in organisational structure; Quality management systems; Worthwhile; Good investmentReduced confidentiality of process; Harder to speak frankly and openly; Concerns of other professionals uninteresting; Different approaches and methods; Meetings too large and unmanageable; Medical staff expect to lead process; Differences in status and power; Suspicion about managerial involvementTopics individually determined; Not part of core business; Professional distance; Inegalitarian funding; Confusion; Overlap and duplication of effort; Territorial tension; Bad organisation; No audit strategy; Poor links between audit and education; Variations in leadership and size of audit committees; Confusion over role of audit support staff; Lack of organisation and skill mix among support staff; Lack of basic IT systems or purchase of complex systems; Lack of training in audit methods; Incomplete or unfocused data collection; Lack of effective monitoring strategies; Different attitudes; Differential benefits; Lack of selection and prioritisation of audit topics; Late involvement of managers and lack of ownership of audit activityOrganisational environment; Leadership and direction of audit programmes; Strategy and planning in audit programmes; Resources and support for audit programmes; Monitoring and reporting of audit activity; Commitment and participation; Nature of audit activity; Wide impact of audit
Foster J, Willmot M and Coles J. Nursing and therapy audit. An evaluation of twenty-four projects and initiatives Site visits to a sample of provider units hosting audit activity identified by a previous survey (Willmot et al, 1995)Improved professional communication; Changes to patient care; Raised awareness of audit subject; Cost effective; Raised profile of audit; Development of guidelinesNALack of skill in audit methods; Ambiguity about the difference between audit and research; Lack of direction or clarity to project; Difficulties in arranging multi-disciplinary meetings over large geographical area; Lack of dedicated time; Professional discontinuity; Isolation of groups; Lack of involvement of those being audited; Lack of ownershipOrganisational environment; Consistent and clear leadership; Education and expertise; Clear aims and objectives; Involvement of clinicians; Clear impact
Walshe K and Coles J.
Evaluating audit a review of initiatives Study of 20 initiatives to evaluate audit using a literature review and surveyNANAFew tools for evaluation exist; Little evaluation takes place; Predominance of provider-clinician perspective in evaluation; Little evaluation above provider unit takes place; Little knowledge of audit activity across NHS exists; Little knowledge of the costs and benefits; Limited involvement in evaluation at regional levelDevelopment of tools; More evaluations of clinical audit and from the perspectives of purchasers, providers and patients; Evaluations of audit programmes; Evaluation of audit across NHS; Evaluation of cost effectiveness
Willmot M, Foster J, Walshe K and Coles J. A review of audit activity in the nursing and therapy professions A national postal survey of recipients of nursing and therapy audit funding in the 14 regional health authorities in EnglandChanges in knowledge and awareness; Changes in communication with clinicians or patients; Changes in clinical management; Changes in record keeping/documentation; Development and implementation of guidelines and standards; Changes in culture and attitudes; New services; Changes in availability of training and education; Change in access to/cost of healthcare; Changes in prescribingNALack of resources; Lack of acceptance and commitment by staff poor project planning; Lack of experience in audit; Changes in structure or management; Small projects; Lack of strategy or business planCo-operation and commitment from staff; Good organisation and teamwork; An efficient audit department and facilitator; Appropriate information technology; Training in audit techniques; Raised awareness of audit activity e.g. posters, newsletters; Information