Annex A > Chapter 18 - Medical and Clinical Audit > Audit: the national perspective > The development of definitions
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The development of definitions
10 Whilst an early definition of audit is set out above at para 5 above, the understanding of the term, and the meaning ascribed to it, varied and was developed across the period with which the Inquiry was concerned.
11 Initial uncertainties about the meaning and scope of audit were captured in the first paragraph of the `First Report of the Royal College of Anaesthetists'Audit Committee', [8] November 1989:
`Audit is derived from the Latin and means "hearing". In financial terms it derives from the practice of a landowner calling his steward to give an account of the use of the landlord's property. (Look at the parable of the talents, Matthew, 25, 14-30). "The Economist's Pocket Accountant" shows that the aim of a financial auditor is to present a true and fair view of the financial state of an organisation. Essentially the accounts should show how the organisation has used its resources in the preceding defined period.
`There seems to be no generally accepted definition as to what medical audit is. But the idea behind most schemes is that the participants can demonstrate to themselves and their colleagues (not only in medicine) the quality and quantity of the work that they are doing. This entails an account of the use of the resources and the outcome of the clinical practice, to demonstrate the limitations of the clinical service and the needs for improvements.' [9]
12 Dr Jane Ashwell, who was, at the relevant time, a Senior Medical Officer at the DoH, referred to the Inquiry's Issues List in her statement [10] and said:
`I think the way the word audit is being used in issue M [the Issues List] is actually rather different from the Audit I am talking about and which the DH [Department of Health] was introducing in the early 1990s. There were no systems - it was new and developing. Much of the research information on which to base audit was not available and much of my work was aimed at helping doctors to establish research such that robust guidelines could be produced to do audit against. You can't look at practice unless you establish a standard to compare it with. Audit was not a means of measuring outcomes but a way of comparing what doctors did as against what the research evidence indicated they should do. Some professional bodies did collect anonymised outcome data as did NCEPOD [National Confidential Enquiry into Perioperative Deaths] but it was not robust research that could link the outcome with causes nor was it, strictly speaking, audit.'
13 For clinicians, therefore, audit could form an aspect of research and scientific development. It was also a form of continuing professional education, in that it involved scrutiny of aspects of clinical practice and care.
14 The Standing Medical Advisory Committee wrote:
`Since the technical competence to assess quality of medical care belongs to doctors, medical audit must be conducted by the medical profession as its success depends so much on medical knowledge. Medical audit needs to involve all doctors who should take corporate responsibility for it.
`Medical audit should lead to a better standard of patient care by better informed doctors. It must be an educational process, and this form of audit should not be used for disciplinary purposes.' [11]
15 Mr James Wisheart, consultant cardiac surgeon, saw audit as having:
`... a place in terms of education and peer review...to be an activity conducted by doctors in the interests of their education ...' [12]
`The initial view of audit was that it was an activity which was to be led professionally and undertaken professionally as a peer review, educational exercise.' [13]
Dr Trevor Thomas, consultant anaesthetist, and chairman of the United Bristol Hospitals NHS Trust (UBHT) Medical Audit Committee said that medical audit, was:
`... a system which was being used as an educational system ...' [14]
Mr Janardan Dhasmana, consultant cardiac surgeon, stated:
`The audit of one's own data was always considered essential in maintenance of professional standard and in improving performance.' [15]
16 Counsel to the Inquiry asked Dr Sally Masey, consultant anaesthetist at the BRI since 1984, what she thought the purpose of audit was. She replied:
`The purpose of audit in the broadest sense is to have a mechanism to look at our practice in order to improve the quality of care in the broadest sense.' [16]
17 Mrs Margaret Maisey, employed at the UBHT from 1986 to 1997 as a General Manager (South and later Central Unit), Director of Operations and Director of Nursing, stated that:
`The term [audit] has had a rather equivocal meaning during my recent employment within the NHS. To some it has meant an educational process, a structure for reviewing the process of health care, rather than the outcomes of that care. To yet others, it merely borrowed the word from accountancy to refer to the stocktaking process when applied to various aspects of the health care system.' [17]
18 Mrs Maisey demonstrated the use of `audit' to describe aspects of managerial activity, by giving the example of a `lifting equipment audit' that was instituted in 1992 by Janet Maher, then General Manager UBHT, and was an information-gathering exercise about the facilities for lifting, moving and handling patients. The results of this `audit', according to Mrs Maisey, were very helpful and a minimal lifting policy was introduced, but:
`There is no way in which such management activity can be called "clinical audit" as I understand the term to be used when applied to clinical situations today.' [18]
`I recall that the various advices and circulars from the centre, the College and others, over a number of years defined audit differently at different times. The view of what it might be, how it might be implemented and applied to one's own area of responsibility, changed with time.' [19]
19 Dr Ian Baker, Consultant in Public Health Medicine with the Bristol and District Health Authority (B&DHA), said:
`... I think health authorities were interested in audit in so far as it was a way of considering the heading "Quality" in contracting terms, and I think those of us in public health medicine had a professional interest in this tool, providing information on quality.' [20]
20 When Dr Baker was asked what obstacles stood in the way of the development of audit, he said:
`I think the main one was the feeling that audit was going to become some form of inspectorial management tool of professional practice. I think, in general, the medical profession, and possibly others, closed ranks to some extent to take ownership of this process to try and accept it as something which was educational and related to training and practice in that way, rather than a more general approach to quality assessment.' [21]
21 The 1992 UBHT Medical Audit Committee (MAC) report stated:
`... medical audit ... must continue to be seen to be a confidential and independent educational process - not merely the inquisitional arm of purchasers under the auspices of the Regional Health Authority.' [22]
22 Equally, audit was seen as a potential tool to persuade managers that further resources were needed. For example, the Audit Committee of the Royal College of Anaethetists (RCA) listed amongst the `good reasons' why audit should be performed:
`... the need for information to identify strengths and weaknesses of the various services, to ensure effective training of junior staff and finally to ensure that the capital and recurrent expenditure associated with anaesthesia is used effectively, and increasingly, economically. Audit should be usable in demonstrating to colleagues and managers that resources are used well and that claims for additional moneys are well supported.' [23]
23 In May 1991, the RCA advised its members:
`Representatives of the employing authority have a legitimate interest in those aspects of audit which include resource management, staffing levels, list cancellations or overruns and the use of ITU and recovery facilities.' [24]
24 There was potential confusion as to the difference between expressions or activities such as `quality assurance'and `audit'. Sir Barry Jackson gave evidence that:
'"Quality assurance" is a jargon phrase, which is widely in evidence at the moment. [25] I think it just refers to the broad field of quality in its entirety. Audit, I think, will be one aspect of a method of trying to ensure satisfactory quality, but there would be others such as the CME [Continuing Medical Education] and CPD [Continuing Professional Development], for example, ... examinations and other aspects of ensuring quality.' [26]
25 Dr Kieran Morgan, Director of Public Health Avon Health Authority (Avon HA), took the view that there were standards or benchmarks in relation to structures and processes even though there were none in relation to outcomes of care. He stated:
`Much of the monitoring we were trying to introduce was about following the introduction and development of structures and processes and, of course, this is something that the UBHT felt was not a concern of the Health Authority and wholly the responsibility of the Trust (see the note of the clinical audit review meeting of the UBHT in November 1992).' [27]
26 In a paper commissioned by the Inquiry entitled `Medical and Clinical Audit in the NHS', audit is explained as follows:
`To health professionals, audit offers a systematic framework for investigating and assessing their work and for introducing and monitoring improvements. The process of carrying out an audit involves a characteristic sequence of events which includes:
- `defining standards, criteria, targets or protocols for good practice against which performance can be compared;
- `gathering systematic and objective evidence about performance;
- `comparing results against standards and/or among peers;
- `identifying deficiencies and taking action to remedy them; and
- `monitoring the effects of this action ie. "closing the audit loop".
`Audit is regarded as a cyclical activity, on the assumption that reviews of this sort should be carried out continuously.' [28]
27 Dr Kieran Walshe, Senior Research Fellow in the Health Services Management Centre at the University of Birmingham, recognised there were various interpretations of the term `audit':
`I think the definition offered in the Inquiry's paper is a helpful one ... I think the definition you have offered in this paper is in some ways more helpful [than the Department of Health's 1989 definition referred to in para 5] because it makes it clear the process involves both gathering information about the quality of practice and performance, identifying problems and opportunities for improvement and then taking action to remedy those problems or difficulties, to bring about change. There are ways in which you can make differentiations - and the paper referred to distinguishes between medical audit, clinical audit and organisational audit and quality assurance and TQM [Total Quality Management] and CQI [Continuous Quality Improvement]. There are lots of definitional discussions you can have. What brings all those definitions all together is that they are all about systematically attempting to identify problems with the quality of care, and then taking action to understand their causes and bring about changes that make improvement in the quality of care take place.' [29]
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Footnotes
[8] The Committee was subsequently renamed the Quality of Practice Committee: see report of May 1991, WIT 0065 0595 Professor Strunin
[9] WIT 0065 0589 Professor Strunin. In the next report, May 1991, the definition in `Working for Patients: Medical Audit', Working Paper No 6, was set out. See WIT 0065 0595
[10] WIT 0338 0003 Dr Ashwell
[11] `The Quality of Care', report of the Standing Medical Advisory Committee, DoH, 1990, p. 16
[13] WIT 0120 0384 Mr Wisheart
[15] WIT 0084 0026 Mr Dhasmana
[17] WIT 0103 0072 Mrs Maisey
[18] WIT 0103 0072 Mrs Maisey
[19] WIT 0103 0072 - 0073 Mrs Maisey
[22] UBHT 0032 0080; MAC report 1992
[23] WIT 0065 0589; `First Report of the Audit Committee', November 1989
[24] WIT 0065 0598; `Report of the Quality of Practice Committee', May 1991
[25] WIT 0307 0018; Dr Kieran Morgan, Director of Public Health, Avon Health Authority commented on Mr Jackson's evidence that the phrase `quality assurance' was jargon. He said: `The term "quality assurance" is not a jargon phrase. It very clearly refers to the obligation of providers of services to demonstrate to those who receive the service that that service is of high quality'
[26] T28 p.89 Sir Barry Jackson
[27] WIT 0307 0015 Dr Morgan
[28] INQ 0011 0009; `Medical and Clinical Audit in the NHS'