Clinical audit in veterinary practice: theory v reality

Katie Waine and Marnie Brennan discuss some of the contentious issues relating to the application of clinical audit in veterinary practice and examine the benefits of using audit to improve patient care.


Clinical audit in the veterinary context
There are a number of issues facing the veterinary profession that makes the direct translation and interpretation of the clinical audit framework used by the medical field challenging.

Steps involved in a clinical audit
The clinical audit process can roughly be broken down into a five-step cycle (Fig 1). A topic should be chosen to audit and preparations made in relation to the logistics of how the audit will be carried out. Data are then collected and analysed, and a discussion held to decide if and how changes need to be made. Any changes are then implemented and a re-audit carried out to see what effect the changes might have had.
However, stages of the audit process as demonstrated by schematics of the audit cycle vary in the veterinary literature (Table 1) and this can lead to confusion and difficulties in determining how to carry out an audit. Some clinical audit cycles explicitly involve comparing clinical practice to pre-existing 'gold standards' (Dunn 2012), while others suggest that, due to the lack of pre-existing standards in the veterinary profession, the process should be about creating guidelines that can be used to audit against (Viner 2009).
Some cycles suggest that a clinical audit should be based on standards derived from evidence-based veterinary medicine, but not all of them recommend assessing against these standards (Table 1). There is a well-documented lack of evidence-based standards available that relate to first-opinion veterinary practice (Mair and White 2008, Mair 2009, Wylie 2015, which may explain some of the variation. The re-audit stage is also a crucial part of the process in which progress made after setting new goals and implementing changes can be assessed; however, this is advocated in very few audit cycles (Table 1).
It could be argued that the differences between audit schematics in the veterinary literature are due to the fact that they are explained as different types of audit; this will be discussed in detail later. However, there are some key aspects of the audit process that appear to be agreed on by the majority of veterinary authors. These are that an audit should: n Be a continuous cycle; n Use the best available evidence (where applicable); n Lead to improvements in patient care.
Greater benefits are gained if the process is performed as a cycle in which continuous monitoring, changes  and improvements are made (Mosedale 1998, Rayment 2002, Viner 2005, Mair 2009, HQIP 2010, Dunn 2012. Ultimately, this should lead to an upwards spiral of overall improvement in the quality of clinical care provided (Mair 2009, Viner 2009, HQIP 2010.

Defining what standard is used in the clinical audit cycle
The Oxford online dictionary definition of the term 'standard' (OUP 2015b) is: n A level of quality or attainment; for example, 'The practice provides a high standard of clinical care to its patients'. Or n A required or agreed level of quality or attainment; for example, 'The practice met the strict health and safety standards outlined in the document'.
When considering standards as a level of quality, it can be safely assumed that the vast majority of veterinary surgeons aim to offer high standards of care to their patients. In reality, standards of care provided by a practice may range from suboptimal to excellent; clinical audit can therefore be used to assess clinical standards and ultimately improve them.
Some authors define 'standard' along the lines of the second definition above; that is, a required level of quality. This particular use of the word relates to a more complicated concept than the first definition. The NHS often uses the NICE guidelines to audit against, and these guidelines act as standards in this context. The equivalent evidencebased guidelines do not tend to exist in veterinary medicine, and there are few results on studies collected from firstopinion practice that can act as standards, which makes this type of scenario difficult to execute. Some authors suggest setting your own standards to audit against (Rayment 2002, Burford andothers 2014); this may be appropriate in some instances, but the standards chosen may be somewhat arbitrary if little is known about the baseline level. Another way of identifying a standard for your practice is to run an initial round of audit (known as a service evaluation [NHS 2014]) and use this as your future standard to audit against (Burford and others 2014). The various possible ways of defining standards for use in clinical audit are discussed in Table 2, using an example clinical scenario.
There appears to be confusion in some publications about the difference between criteria and standards. Criteria identify what is being reviewed as part of the audit and should be describable and quantifiable (NICE 2015).
The NICE guidelines used as standards by the NHS in many cases are recommendations based on the best available evidence, such as systematic reviews and randomised controlled trials; they provide advice on how people with specific conditions should be cared for by healthcare providers (NICE 2015). Viner (2009) suggests that the veterinary audit process should involve the establishment of guidelines to audit against. The development of evidence-based veterinary clinical guidelines is a challenging and detailed process, and often involves the creation of the evidence initially, which may be difficult for busy vets in practice to achieve. There may, however, be situations where, at the practice level, staff wish to create localised guidance for certain procedures to ensure consistency of care. Localised guidance should be re-evaluated on a regular basis by consulting the literature for any new evidence that arises.

Reasons for undertaking a clinical audit
The divergence of presetting standards in comparison to creating your own, and other differentiations between the various published audit processes, may be a result of the different reasons that an audit is undertaken and the different types of audit that can be carried out.

Benefits
Previous articles have highlighted the benefits of carrying out an audit (Mosedale 1998, Rayment 2002, Mair and White 2008, Viner 2005, Dunn 2012), with many emphasising why an audit is useful in relation to clinical governance and how it meets requirements set out by the RCVS (RCVS 2014(RCVS , 2015. Undertaking an audit indicates continual monitoring and improvement of clinical standards in relation to the RCVS Practice Standards Scheme (RCVS 2014). However, clinical audit can bring benefits to veterinary surgeons and practices other than those cited in relation to clinical governance. It is likely that the numerous reasons for undertaking an audit may be the cause of why various definitions of the audit process exist in the veterinary literature and could lead to confusion as to how to best undertake an audit. From an evidence-based perspective, the primary goal is ultimately to improve decision-making at the level of the patient, and clinical audit sits within this framework, whatever aspect is focused on. Clinical audit can be incorporated into different aspects of veterinary

Patient care
Clinical audit is central to patient care (Mair and White 2005) and can be used to assess the quality of care being provided by a practice and as a tool to improve overall patient safety (Oxtoby 2014).

Professional development
Clinical audit allows you, as an individual, to monitor how well you perform as a clinician and improve your own processes and outcomes. The audit may highlight areas in which you need further training or continued professional development (CPD), as well as itself counting towards your CPD requirement (Moore and Klingborg 2003). It can also be used to highlight areas where good practice is being performed.

Practice interests
A clinical audit allows the practice to gather information on clinical activities. It may be used as a defence in litigation cases and as part of defensive medicine (Mosedale 1998, Dunn 2012. Clinical performance can be compared with other vets and practices through benchmarking, and the results of an audit can be used to demonstrate how efficient certain clinical services are (Mair and White 2008). Viner (2009) also suggests that clinical audit can increase the confidence of the public in the veterinary profession, as well as being used as a tool to increase the income of the practice.

Evidence-based veterinary medicine
Audit is an effective way of undertaking evidence-based medicine (Warman 2014) and can be used to demonstrate the benefits of certain procedures or treatments, as well as highlighting research gaps or areas requiring further research (Viner 2009). It allows clinical standards to be improved in an evidence-based way (Dunn 2012).

Differences between audit and research
There is often some confusion about what is audit and what is research. While some types of audit may seem similar to research, there are some clear differences.
Put simply, clinical research is concerned with finding the best way to do something, while clinical audit is about finding out if the best thing is being done (Smith 1992). Viner (2009) and Wylie (2015) clearly highlight the main differences between audit and research. This figure is a good place to start. However, a definite figure for parvovirus in dogs specifically was not easily found. In human medicine, 95 per cent of people need to be vaccinated against measles for herd immunity to be effective (Oxford Vaccine Group 2015), so potentially the figure used as the standard could be a lot higher. The percentage of the population needing to be vaccinated to give good herd immunity will depend on many factors. Any figures found in the evidence, however, can certainly be taken into consideration

Setting your own 'standard'
You can't find a solid evidencebased standard that relates to your circumstances so you create your own The practice team feels that 95 per cent of the dogs registered with the practice should be vaccinated as this represents the best clinical care for the patients There may be some situations where setting your own standard is appropriate. However, care should be taken with the level the standard is set at -setting a high ideal standard may lead to disappointment after the first round of audit -for example, if only 20 per cent of the practice's dog population is being vaccinated annually, 95 per cent may seem completely unattainable and discourage the practice from continuing with the audit

Running an initial round of audit to create your own 'standard'
You feel that the evidence base may not be appropriate to the circumstances of your practice and want to investigate your baseline of cases first before you decide on a suitable level of improvement You're aware that many of your clients often bring their dogs in late for their booster vaccinations, so you search the past 18 months of clinical records and discover that 40 per cent of the dogs registered with the practice have been vaccinated in that time Running an initial round of audit has given you a real figure on which to base your improvement. This will enable you to set a more realistic target in your next round of audit, which should help with staff motivation Fig 2: How clinical audit is beneficial to veterinary practice

Types of audit
Clinical audit has been described in a number of different ways by different authors, possibly due to the many different types of audit that can be undertaken (Table 3). Which one should be run in your practice depends on your previous experience of audits and the resources available to you.
What does this mean for me in my practice? Burford and others (2014) suggest that an audit should be used to ensure that 'what is being done should be done'. Choose the type of audit that will be most suited to your practice (Table 3) and spend some time planning how it will run. The publications discussed in this article provide good guidance on how to conduct an audit in practice. For a very effective introductory audit in practice, start by simply looking at what you do, using the audit cycle in Fig 1. Collect some data and hold a discussion; once you've identified any changes that need to be made, re-audit with your new targets and discuss the results again to see if you have made a difference.

Conclusion
Clinical audit can bring many different benefits to veterinary practice. However, there are disparities in the veterinary literature regarding how an audit is defined and the processes involved in carrying one out. The reasons for carrying out audit, whether for governance purposes or not, and the different types of audit that can be undertaken are likely to have an effect on how the literature on clinical audit is perceived. This can make understanding the clinical audit process challenging. However, despite the controversies, a clinical audit

Clinical Audit
can be a valuable tool. Ultimately, attempting any form of clinical audit can be rewarding at an individual or a practice level.
Further work is required to determine how clinical audits can best be run in a variety of practice environments.