Audit measures existing practice against an evidence-based standard, research generates new knowledge where the evidence does not yet exist, and quality improvement changes a process and measures whether the change worked. According to the Healthcare Quality Improvement Partnership, clinical audit is itself a quality improvement cycle, which is why the three overlap. Comparing them is a named Stage 1 capability in the Royal College of Anaesthetists 2021 curriculum, so the interview can ask it directly.

Key takeaways

  • HQIP defines clinical audit as a quality improvement cycle that measures the effectiveness of healthcare against agreed and proven standards and takes action to bring practice in line with them
  • HQIP's simple rule for research is that it generates new knowledge where there is no or limited research evidence and has the potential to be generalisable or transferable
  • Service review sits between the two, covering service development and service evaluation, and it must comply with clinical audit governance rather than research governance
  • Unlike research, clinical audit does not need approval from a research ethics committee, according to HQIP quoting the National Research Ethics Service
  • The Royal College of Anaesthetists 2021 curriculum sets a Stage 1 key capability to compare audit, research and quality improvement
  • The same curriculum expects involvement in quality improvement activities within the anaesthetic department as a minimum, assessed with the Anaesthesia Quality Improvement Project Assessment Tool

What is clinical audit?

Clinical audit is measurement of practice against a standard that already exists, followed by action and re-measurement. The Healthcare Quality Improvement Partnership defines it as a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with those standards.

HQIP puts the same idea more plainly: clinical audit is a way to find out if care is being provided in line with standards, and it lets providers and patients know where a service is doing well and where it could improve.

Its simple rule in the national guide is shorter still. Clinical audit measures existing practice against evidence-based clinical standards, and all clinical audit must comply with clinical audit governance requirements.

What is research, and how is it different?

Research creates the standard that audit measures against. HQIP's simple rule is that research generates new knowledge where there is no or limited research evidence available and which has the potential to be generalisable or transferable.

HQIP states the practical distinction as a difference of purpose: clinical audit tells us whether we are doing what we should be doing and how well; research tells us what we should be doing.

The governance follows the purpose. All research must comply with research governance requirements, and HQIP notes that, unlike research, clinical audit does not need approval from a research ethics committee.

What is quality improvement, and where does it sit?

Quality improvement is the wider activity of changing a process and measuring the effect, and audit is one of its methods. HQIP's own definition of clinical audit calls it a quality improvement cycle, so the two are not rivals.

The Royal College of Anaesthetists treats quality improvement as a body of method in its own right. Stage 1 key capabilities include describing quality improvement theories and methodologies, contrasting quantitative and qualitative analysis, and committing to the principles of continuous quality improvement.

In practice the distinction that matters in an anaesthetics interview is what you did with the data. If you compared practice to a published standard, that is audit. If you introduced a change and measured whether it worked, that is quality improvement.

Where does service evaluation fit?

Service evaluation asks how well an existing service works, without a standard to measure against and without generating generalisable knowledge. HQIP's guide groups service development and service evaluation together as service review.

  • Service or practice development introduces a change for which evidence already exists from research or from other settings that have introduced and evaluated it
  • Service or practice evaluation evaluates the effectiveness or efficiency of an existing or new evidence-based service, to inform local decision-making
  • New developments should always be evaluated, according to the same guide
  • Service review activities sit under clinical audit governance rather than research governance

However, HQIP is candid that categorisation is not always clean. Its guide says no toolkit can be fully reliable and advises seeking help from the relevant department for projects in a grey area.

What are the stages of the audit cycle?

The audit cycle is choose a standard, measure practice against it, act on the gap, then re-measure. HQIP describes it as a cycle in which any clinician or team can see where practice can be improved against given benchmarks, take action, then re-measure and make further improvements.

The word that earns marks is re-measure. An audit that stops at the first measurement has produced a snapshot, and HQIP's definition requires the action that brings practice into line with the standard.

HQIP also says that from the start you should involve anyone who might be affected by the result, including everyone who might be asked to change their practice, and that the project should be supported by people with the authority to see changes put into practice.

Does your project need ethics approval?

A clinical audit does not need research ethics committee approval. HQIP states that the National Research Ethics Service makes a clear distinction between clinical audit and research, and that unlike research, clinical audit does not need that approval.

That said, not needing a committee is not the same as having no obligations. HQIP's guide devotes a section to the ethical principles applicable to clinical audit and service review, and says all clinical audit must comply with clinical audit governance requirements.

For an anaesthetics interview the safe formulation is that the category decides the governance route, and that if you are unsure whether a project is research you check before you collect data, not after.

Why does the CT1 anaesthetics interview ask this?

Because comparing the three is written into the curriculum you are applying to. The Royal College of Anaesthetists 2021 curriculum sets a Stage 1 key capability, under Safety and Quality Improvement, to compare audit, research and quality improvement.

The same Stage 1 domain expects involvement in quality improvement activities within the anaesthetic department as a minimum requirement, and names the Anaesthesia Quality Improvement Project Assessment Tool as the supervised learning event for relevant projects.

ANRO adds the recruitment side. Its Commitment to Specialty descriptor treats the absence of quality improvement as a negative indicator, so audit and quality improvement feed two scored domains rather than one.

What does a worked spoken answer sound like?

A worked audit, research and quality improvement answer defines the three in three sentences and then spends the rest of the time on your own project. Here is one you could say aloud.

'Audit measures what we do against a standard that already exists, research generates new knowledge where that standard does not yet exist, and quality improvement changes a process and measures whether the change worked. The Healthcare Quality Improvement Partnership actually defines clinical audit as a quality improvement cycle, so audit is one method within quality improvement.'

'My own project was a quality improvement project on preoperative fasting. Our standard was the departmental guidance, and our first measurement showed a median clear fluid fast far longer than the guidance intended, mostly because patients were told nothing by mouth from midnight.'

'We changed the admission letter and the ward whiteboard, involved the surgical and nursing teams before we started, and re-measured after eight weeks. The median fell and we presented it at the departmental governance meeting.'

'What I learned was that the measurement was the easy part. The change only held because the ward sister was involved from the beginning, which is what the guidance means when it says to involve everyone who will be asked to change their practice.'

Which mistakes do candidates make on audit, research and QI?

The mistakes on audit, research and quality improvement are mostly about claiming the wrong category or the wrong credit.

  • Calling a single data collection an audit. Without a standard and a re-measurement it is a snapshot
  • Calling a questionnaire research. Patient satisfaction surveys are not audits either, because there is no standard being measured against
  • Saying audit needs ethics approval. HQIP says it does not, while research does
  • Describing audit and quality improvement as opposites, when HQIP defines audit as a quality improvement cycle
  • Taking credit for a project you registered and someone else finished
  • Leading with the topic rather than the change. The mark is for what happened to practice

How this comes up at the CT1 anaesthetics interview

Audit, research and quality improvement come up in the General Interview station, which is 15 minutes across communication, commitment to specialty and teamwork, scored by two assessors out of 50. The question is usually a request for your project, followed by a definition question.

  • Commitment to specialty: quality improvement is named in ANRO's descriptor, so a completed project is direct evidence
  • Teamwork: who you involved and how you handled the people being asked to change is a teamwork example as well
  • Communication: three clean definitions in three sentences is the clearest demonstration of concise answering you will get to give

anaestheticinterview's 340 questions cover the general interview station as well as the clinical one, with AI-marked spoken practice, which is where you find out that your definition of quality improvement takes forty seconds and should take ten.