Key findings from the studies uncovered during the literature search
| Paper | Subjects/setting | Advantages identified or perceived | Disadvantages highlighted | Alleged or perceived barriers to effective audit | Perceived 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;311:31-4 | Interview and questionnaire survey of 147 general practices invited to take part in a single topic audit | Improves care; Relevant; Valuable; Essential | Interferes with important work; Irrelevant | Lack 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 audit | Worthwhile; Likely to produce change; A way of improving quality; A core activity | A waste of time; A fad; Irrelevant to quality | NA | NA |
| 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 hospitals | Good doctoring; Raises awareness and problems; Improves care; Improves clerical management | Suspicion 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 reports | Improvement in clinical care, practice management and preventive health | NA | NA | NA |
| Chambers R, Bowyer S, Campbell I. Audit activity and quality of completed audit projects in primary care in Staffordshire. Quality in Health Care 1995:4:178-83 | 189 General Practices-visit to study best audit project | Educational; Increased awareness; Improved communication; Increased teamwork | Modifications 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 trust | Worthwhile | Spending 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 time | Lack of dedicated time; Lack of training | Locally 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' remit | NA |
| 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 approach | Opportunity 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 region | Helps patient care; Educational | Negative 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 resources | Short 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 practice | Repetitive; 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 problems | Support 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' notes | Initial improvements in notekeeping | Disaffection; Boredom; Junior doctors felt audit being done to them | Lack of feedback to junior doctors; Lack of reinforcement from senior colleagues | Lack 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 practitioners | NA | NA | Lack of time; Colleagues' negative attitudes; Fear of assessment and criticism; Lack of knowledge and skills; Problem in practice management; No financial help | Regular 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 practices | Increased teamwork; Increased confidence in staff that standards were being met; Adoption of new skills in audit methods | NA | Illness of team members; Changes in practice membership | Team 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 group | Summarising casenotes; Openness among doctors about the work they do; Improved teamwork; Standard setting | NA | Contractual 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 region | Collection of clinical outcome information; Vital; Useful; Helpful | NA | Lack of time; Lack of support staff; Lack of secretarial support; Lack of commitment | NA |
| 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 policies | Medical 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 structure | Ring 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 Boards | General improvements; Useful tool for bidding for resources; Patient benefits | Irrelevant; Too many trivial audits | NA | Working 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 practices | NA | NA | NA | Modern 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 authority | NA | De-skilling of practice based audit; Time spent on collaboration | NA | Large practice; Multi-disciplinary groups; Audit co-ordinators |
| Lough JM, McKay J and Murray TS. Audit: trainers' and trainees' attitudes and experiences. Med Educ 1995;29:85-90 | 155 GP trainers and their trainees in West of Scotland | Useful way of assessing work; Improves patient care | May be used to assess doctors; Inappropriate use of time | Lack 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 changes | Protected 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 Scotland | Increased confidence in introducing change | Difficulties with audit process; Lack of cooperation from partners and trainers; Lack of time; Lack of feedback and encouragement from trainers | Support 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 CRAG | Self 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. | NA | Inter 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 exercises | Clerical 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 purchasers | Non-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 1994 | Change in practice; Reconsider aspects of practice. | NA | NA | Feedback; 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-ordinators | Positive impacts on the delivery of care, careers and morale of therapists | NA | Lack of resources; Lack of expertise or access to advice; Relations between groups; Organizational structures; Lack of an overall plan for audit | Time; 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. | NA | Changes 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 proficiency | Interference 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 evidence | Lack 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 audit | NA | Time spent on audit; Not auditing own work | Lack 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 programme | Educational; Baseline information; Improved patient care; Effect on practice | Time 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 providers | Reluctance 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 technologists | NA | NA | Education |
| 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 practice | Potent 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 freedom | The 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 GPs | NA | NA | Lack 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; Educational | Unnecessary 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 authority | Change in clinical practice e.g. changes in treatment, setting up of new clinic, policy changes | Time spent on inappropriate tasks; Cost | Pressure of clinical work; Lack of clerical support or audit administrators Lack of financial support from management to effect change; Lack of confidence in audit committees | Audit 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, 1995 | Document review and semistructured interviews with audit representative from 11 Royal Colleges in England | Mechanism for change; Quality accreditation; Change in attitude towards audit; Establishment of audit departments | Resistance to change; Doubt about its value; Threatening | Confusion 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 mechanisms | Dissemination 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 studies | Greater 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 investment | Reduced 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 involvement | Topics 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 activity | Organisational 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 guidelines | NA | Lack 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 ownership | Organisational 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 survey | NA | NA | Few 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 level | Development 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 England | Changes 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 prescribing | NA | Lack 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 plan | Co-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 |