Personal Development

What is clinical audit?

A clinical audit is a systematic process used to assess and improve the quality of care provided to patients (NHS England, 2025). It involves measuring current practice against established standards such as clinical guidelines, local policies, or evidence-based best practices to determine whether care is being delivered effectively and safely (Limb et al, 2017; Gush, 2024). The process follows a continuous cycle: identifying an area for improvement, setting clear standards for measurement, collecting and analysing data, comparing findings to those standards, making necessary changes, and re-auditing to measure progress (Health Quality Improvement Partnership (HQIP), 2020a).

In essence, clinical audit is about checking that what should be done is being done correctly, and that patients are receiving safe, effective, and high-quality care (Hughes, 2012; Limb et al, 2017). Within the NHS, numerous national audit programmes support benchmarking and shared learning across healthcare organisations (Gush, 2024; HQIP, 2025). However, at a local level, you may identify aspects of care within your own clinical area that appear below the expected standard or inconsistent with clinical guidelines. These areas can provide valuable opportunities for conducting a local audit to evaluate current practice and drive improvements in patient care.

Why is it important?

Monitoring the quality and safety of care and addressing any shortfalls is a core responsibility of all healthcare organisations (Blagburn, 2022; Care Quality Commission, 2024). Lord Darzi’s (2024) independent investigation of the NHS in England highlighted performance and outcome variations including lack of adherence to clinical guidelines across many areas of the NHS, which may lead to avoidable harm that could be identified through robust clinical auditing. Effective audits enable services to use data to standardise care, track improvements, and enhance overall quality and efficiency (HQIP, 2020a).

Clinical audit therefore plays a vital role in promoting safe, evidence-based practice and is an essential tool for continuous improvement in nursing practice (Hughes, 2012; HQIP, 2020a; Nursing and Midwifery Council, 2024). It empowers healthcare professionals to take ownership of care quality, ensuring that interventions are effective and aligned with best evidence (Hughes, 2012; Nursing and Midwifery Council, 2024). Audit can be used to identify gaps in practice such as inconsistent documentation, delayed interventions, or deviations from protocols, and targeted changes can be made to enhance patient outcomes (HQIP, 2020a; Nursing and Midwifery Council, 2024).

Beyond improving safety and efficiency, clinical audits also foster a culture of accountability and reflective practice, encouraging healthcare professionals to question existing methods and strive for excellence (Hughes, 2012; Nursing and Midwifery Council, 2024). Ultimately, clinical audit helps bridge the gap between theory and practice, turning evidence into everyday action that benefits both patients and the healthcare team (HQIP, 2020a; Gush, 2024). In healthcare, a significant amount of positive change and improvement results from clinical audits, largely because they are carried out more frequently than formal research studies (Blagburn, 2022). As a result, having the knowledge and skills to design and conduct an effective clinical audit is an important competency for healthcare professionals (Blagburn, 2022).

There are various approaches to implementing quality improvement and collecting supporting data within healthcare (Hughes, 2012). It is important for healthcare professionals to understand the differences between these methods of data generation and to be aware of the clinical governance requirements associated with each approach (Hughes, 2012). Table 1 highlights some of the main differences between research, clinical audit and service evaluation.
 

Table 1. Understanding the difference between research, audit and service evaluations (Adapted from Health Research Authority, 2017)
 

Aspect	Service evaluation	Clinical audit	Research
Purpose	To assess how well a service or care delivery is working in its current form	To measure current practice against agreed standards and identify areas for improvement	To generate new, generalisable knowledge or test a hypothesis or understand cause and effect
Main question	What is happening in this service?	Are we doing what we should be doing, according to standards?	What is the best thing to do for this population? May compare interventions or seek to understand people’s perceptions and behaviours
Change intent	May identify areas for improvement but does not necessarily involve change	Aims to improve practice and patient outcomes through measurable change	Aims to establish new practices or interventions that could change future care
Standards used	No pre-defined standards – looks at current practice or outcomes	Based on explicit standards or guidelines	No pre-defined standards – uses a research question or hypothesis
Methods	Data collection to describe or monitor service delivery	Data collection to compare current practice with standards followed by re-audit	Experimental or observational design using rigorous scientific methodology
Ethical approval	Not usually required (if no change to patient care)	Not usually required (as care is not altered) but depends on the subject of the audit	Required from a Research Ethics Committee before starting
Outcome	Provides information for service planning or management decisions	Lead to specific quality improvement and reassessment of care	Provides new evidence that can inform future guidelines, standards or treatments
Example in urology or continence	Reviewing waiting times for continence clinic referrals	Auditing compliance with aseptic technique during catheter insertion	Testing a new catheter coating to reduce infection rates

How do I choose between quality improvement and audit?

Audit and quality improvement projects share a common goal – to evaluate and enhance the quality of healthcare delivery (Limb et al, 2017). The main distinction lies in their approach and scope (Brain et al, 2012; Limb et al, 2017). Clinical audits typically assess performance against clearly defined standards or guidelines, are often conducted over a longer period, and are more clinically focused (Limb et al, 2017). In contrast, quality improvement projects can address wider issues and use more flexible, rapid methods, such as plan–do–study–act (PDSA) cycles which can be carried out over a shorter time span, to test and refine small changes in practice (Limb et al, 2017).

When deciding which approach to use, healthcare professionals should consider the purpose of the project. If the aim is to check whether current practice meets an existing standard, an audit is appropriate (Health Research Authority, 2017). However, if the goal is to test new ideas or introduce small, continuous improvements in day-to-day care, a quality improvement project is usually the better choice (Health Research Authority, 2017). Both approaches support a culture of reflection and improvement within clinical practice, particularly in areas such as urology and continence care.
 

Steps involved in clinical audit

Before starting any audit or quality improvement project, it is essential to obtain management support and involve the organisation’s research and development or clinical audit department (Brain et al, 2012; Limb et al, 2017; HQIP, 2020a). Your organisation may well have an audit submission form for you to complete and submit to the audit department. This ensures that the project aligns with organisational priorities and governance requirements. This is especially important if there are any ethical considerations such as an observational audit of an invasive procedure such as catheterisation. These departments can also provide valuable practical support throughout the audit process (Hughes, 2012; Limb et al, 2017).

Early engagement with senior staff and key stakeholders, particularly those who may be affected by the audit, helps promote cooperation, streamline the process, and increase the likelihood of successful implementation (Limb et al, 2017; HQIP, 2020a).  

Stages in the audit cycle (adapted from HQIP, 2020a):

 

1. Preparation and planning

Select an audit topic that is both relevant to your clinical area and aligned with organisational priorities (Hughes, 2012; HQIP, 2020a) (Table 2). Clearly define your aims and objectives using the SMARTER framework – specific, measurable, achievable, relevant, time-based, evaluated, and resourced (Blagburn, 2022). Identify the performance standards and outcomes to be measured; these are often expressed as percentage targets. For example, clinical guidelines in your organisation or nationally may state that every patient with an indwelling catheter must have the reason for insertion documented. Your audit could therefore measure the percentage of patient records where this has been recorded, with a target of 90% compliance considered acceptable. Finally, determine the resources required to carry out the audit and define clear inclusion criteria, such as all adult patients on the ward with an indwelling catheter.

Table 2. Some considerations when planning your audit project (adapted from Brain et al, 2012; Hughes, 2012; HQIP, 2020a).
 

Set objectives	Why is there a need for the audit and what will it set out to achieve
Consider your population – decide how many and who will be included in the audit, e.g. all adult patients on ward xx who had a catheter inserted during the first week of October	You may not be able to audit every patient with the specific condition or procedure (which would be the ideal). In this situation, selecting a sample population may make audit more manageable, but the sample used must be representative of the population as a whole
Ethical consideration and data protection	Does not usually need ethical consideration but has to fit within organisational protocols. Data should be collected and stored in line with organisational data protection policies
What should we look for to tell us we are providing quality care	Look for evidence-based standards or local policy to measure current practice against, e.g. to prevent infection following catheter insertion standards set out in the National Institute for Health and Care Excellence (2014) guidelines
How often should each part of the standard be followed to meet the expected quality?	Target % to be achieved within the audit. Hughes (2012) indicates that targets should aim to achieve 100% compliance
Exceptions to the standard	Are there any instances when deviation from the standard would be acceptable? This would have to be clearly identified within the audit
Define how and what data will be collected and how it will be safety stored in line with data protection	Clearly define instructions on standards to be measured and how data will be collected, stored and where it will be obtained from (e.g. patient catheter bundle documentation)

2. Measuring performance

Your data collection tool should be directly aligned with the evidence-based clinical standard or guideline you are auditing against (Blagburn, 2022). Before developing your own, it is worth checking whether a validated tool already exists within your specialty or topic area, as using an established tool can strengthen the reliability of your results. If you are developing your own data collection tool you may want to test it on a small sample to ensure it collects the right data accurately. If several people are involved in conducting the audit you will also need to develop a data collection protocol for everyone to follow to ensure data are captured in a consistent way (Brain et al, 2012; Hughes, 2012; HQIP, 2020a). You may need to tidy up or clean your data as you go, checking for any errors, or incomplete data (Hughes, 2012). This will improve your data collection.
To ensure that the data you collect are high quality and fit for purpose, they should meet the following criteria:
 

• Accurate: Information should be entered precisely to reflect the actual care that was delivered.
• Accessible: Data should be easy to locate and retrieve when required.
• Complete: All relevant details must be included, with no missing information.
• Relevant: Only collect data that directly relate to the audit objectives—avoid gathering unnecessary information.
• Reliable: Data should be consistent, even when collected by different individuals; clear guidance and definitions help maintain consistency.
• Timely: Data collection should align with the period of care being reviewed and occur within an agreed timeframe to support timely decision making about patient safety and service quality.
• Valid: The data must accurately represent what they are intended to measure.

(Adapted from Hughes, 2012; HQIP, 2020a)

Analyse data

When analysing data in a clinical audit, it is important to ensure that the process is systematic, accurate, and aligned with the audit objectives (HQIP, 2020a; Blagburn, 2022). If possible, try and resolve any missing or data errors by going back to the original source (Hughes, 2012).

Begin the analysis by comparing your collected data against the agreed clinical standards or benchmarks to determine the level of compliance (HQIP, 2020a). Use simple descriptive statistics, such as percentages or frequencies, to summarise your findings clearly (HQIP, 2018). Look for patterns, trends, or areas of variation that highlight where practice meets or falls short of expectations (HQIP, 2020a). Ensure data are interpreted in the context of your specific setting, considering factors such as patient complexity or resource limitations (HQIP, 2018, 2020b).

How to potentially avoid inaccurate data (Adapted from Brain et al, 2012; Hughes, 2012)
 

Ensure data collectors have adequate training and instructions before starting the audit Make the data collection tool simple and not too time-consuming to complete Carry out a pilot of data collection and revise the data collection tool if required Monitor and clean data as it comes in and check for any errors or incomplete data Give feedback to auditors if problems arises or consistent

 
Once the data have been analysed, the next step is to present and share the findings in a clear, meaningful way that encourages action (HQIP, 2018, 2020a). Summarise key results using visual tools such as charts, graphs, or dashboards to make trends and comparisons easy to understand (HQIP, 2018, 2020b). Highlight both areas of good practice and aspects requiring improvement, linking these to the original audit standards (HQIP, 2020a, 2020b). Sharing results with the multidisciplinary team, senior management, and relevant stakeholders ensures transparency and supports collective learning (HQIP, 2020b). Presenting findings through meetings, reports, or posters can help engage staff and foster ownership of any required changes (HQIP, 2020b). If possible, ascertain the reason for non-compliance with the audit standard – this could be done using techniques such as root cause analyses or process mapping (HQIP, 2020b).

It is important to write your audit findings up as a report. Following a template can be helpful, such as Documenting local clinical audit- a guide to reporting and recording (HQIP, 2020b), or your organisation may have its own template that it would prefer that you used.

 

3. Implementing change

Finally agree on an action plan and establish a timeframe for re-audit to assess whether the improvements have been achieved and sustained (HQIP, 2020a, 202b). The action plan will be developed to address shortfalls in practice and non-compliance with audit standards identified (Blagburn, 2022). For example, in your audit of patients with indwelling catheters you may find that only 60% of patients had a tube fixation device. To improve compliance with the standard you may put posters up in clinical areas alongside an education programme to highlight the importance of catheter fixation devices. 

4. Sustaining improvement

The audit cycle is only complete when there is clear evidence that compliance with the standard has been achieved and that measurable improvement has occurred following the intervention (HQIP, 2020b). A re-audit should then be conducted using the same methodology, allowing direct comparison with the original results to confirm whether the desired changes have been successfully implemented and sustained (HQIP, 2020b).
 

Conclusions

Clinical audit helps healthcare professionals make sure patients receive the best possible care. It involves looking at what we do in practice, comparing it to agreed standards or guidelines, and identifying where we can improve. By making small, evidence-based changes and checking progress over time, audits help keep care safe, consistent, and high quality. Taking part in clinical audits is a great way for staff to learn, share good practice, and make a real difference to patient outcomes.
 

References

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Brain J, Schofield J, Gerrish K et al (2012) A Guide for Clinical Audit, Research and Service Review. https://www.hqip.org.uk/wp-content/uploads/2018/02/hqip-guide-for-clinical-audit-research-and-service-review.pdf (accessed 11 November 2025)

Care Quality Commission (2024) The fundamental standards. Available from https://www.cqc.org.uk/about-us/fundamental-standards (accessed 3 November 2025)

Darzi A (2024) Independent Investigation of the National Health Service in England. Available from https://assets.publishing.service.gov.uk/media/66f42ae630536cb92748271f/Lord-Darzi-Independent-Investigation-of-the-National-Health-Service-in-England-Updated-25-September.pdf (accessed 3 November 2025)

Gush C (2024) Blog: Insights from Lord Darzi’s independent investigation of the English NHS. Available from https://www.hqip.org.uk/blog-darzi-response-sept2024/ (accessed 3 November 2025)

Health Quality Improvement Partnership (2018) An introduction to analysing quality improvement and assurance data. Available from https://www.hqip.org.uk/wp-content/uploads/2018/10/final-an-introduction-to-data-analysis-october-2018.pdf (accessed 3 November 2025)

Health Quality Improvement Partnership (2020a) Best practice in clinical audit. Available from https://www.hqip.org.uk/wp-content/uploads/2020/05/FINAL-Best-Practice-in-Clinical-Audit-2020.pdf (accessed 3 November 2025)

Health Quality Improvement Partnership (2020b) Documenting local clinical audit – a guide to reporting and recording. https://www.hqip.org.uk/resource/documenting-local-clinical-audit-a-guide-to-reporting-and-recording/ (accessed 3 November 2025)

Health Quality Improvement Partnership (2025) Clinical audit and patient outcomes review. Available from https://www.hqip.org.uk/services/clinical-audit/ (accessed 3 November 2025)

Health Research Authority (2017) Defining research. Available from https://www.hra-decisiontools.org.uk/research/docs/DefiningResearchTable_Oct2017-1.pdf (accessed 3 November 2025)

Hughes M (2012) Clinical Audit: A manual for Lay Members of the clinical audit team. Available from https://www.hqip.org.uk/wp-content/uploads/2018/02/developing-clinical-audit-patient-panels.pdf (accessed 3 November 2025)

Limb C, Fowler A, Gundogan B, Koshy K, Agha R (2017) How to conduct a clinical audit and quality improvement project. Int J Surg Oncol (N Y). 2(6):e24. doi: 10.1097/IJ9.0000000000000024
National Institute for Health and Care Excellence (2014) Long-term use of urinary catheters. In: Prevention and control of healthcare-associated infections in primary and community care. https://www.nice.org.uk/guidance/cg139/ifp/chapter/long-term-use-of-urinary-cath (accessed 3 November 2025)

NHS England (2025) Clinical audit. Available at https://www.england.nhs.uk/clinaudit/ (accessed 3 November 2025)

Nursing and Midwifery Council (2024) Standards of proficiency for registered nurses. Available from https://www.nmc.org.uk/globalassets/sitedocuments/standards/2024/standards-of-proficiency-for-nurses.pdf (accessed 3 November 2025)