Procedure for undertaking a clinical audit at Kingston Hospital

  1. Choose audit topic from Trust's Clinical Audit Programme 2012/13 (a specific list has been created for junior doctors) and agree with your Specialty Audit Lead (see list).  If you choose a topic that is not on the Clinical Audit Programme please come to discuss this with your Clinical Audit Facilitator before proceeding further.  Obtain a presentation date from your Specialty Audit Lead.  Find the guideline/policy associated with your topic.
  2. If you have not carried out a clinical audit project before, please attend a classroom or online clinical audit training session (see details on Intranet: Departments: Audit and Effectiveness Centre: Services)
  3. ALL AUDITS MUST BE REGISTERED BEFORE THEY ARE STARTED. Register the audit with the Clinical Audit Centre, using the online Project Form (on the intranet go to Departments: Audit and Effectiveness Centre. Click the 'Register an Audit' tab at the top of the page, and follow the guidance.) Complete this and submit it. If you require assistance please contact the Audit Centre Help Desk X2582.
  4. You will receive acknowledgement from the Audit Centre within a week.  If you have requested help with your audit project, your Clinical Audit Facilitator (see list) will contact you to discuss this and let you know whether or not help is available. Available support includes full and partial project management, including notepulling, but the level of support given will depend on the priority of your audit topic.  You will be sent the Trust's audit project report and presentation templates to use to write up your audit.
  5. Carry out your audit project independently or with Clinical Audit Centre support.
  6. Present the audit findings to Specialty Audit meeting and agree action plan with colleagues.  Send your Clinical Audit Facilitator and Specialty Audit Lead a copy of your final report/presentation including the action plan.  Plan a re-audit date with your Specialty Audit Lead and Clinical Audit Facilitator.
  7. Implement the action plan and tell your Clinical Audit Facilitator when this has been fully implemented.