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Audit Watch

Clinicians and Managers agree that audit is both important and necessary. Nevertheless, it has proved extremely difficult to gather useful audit data which can be used to improve service.

The ideal audit system is where the data collection takes place automatically when the service is provided; a simple example is billing in the private sector. Where automatic data collection is not possible a system should gather simple but relevant data at minimal expense.

Experience has shown that data collected by clinicians tends to be incomplete. Clinicians would argue that it is the managers who want the information and it is they who should collect it. If managers are to do this job, then the facts that are collected must be obvious and unequivocal so that they do not require clinical skills to gather or interpret.


One way to do this is to identify flags which indicate automatically that the standard of care for a particular patients appears to have fallen below standards set by the hospital. Some flags can be general to any patient admitted to hospital, while others can be more specific to specialties or even procedures.

Flags and quality

A patient who is treated in hospital without a flag episode could be used as a mark of good practice and the number of flag-free admissions used as a positive measure of quality in a hospital. Each time a flag is raised then an explanation for this should be found and action taken to prevent it happening again.

The flags presented in the figure relate to admissions for total hip replacement, although six could refer to any elective surgical admission. The key feature of each of the flags is that it is a piece of information which could be collected by a manager on a daily visit to each ward without needing any specialist expertise.

New Flags?

There must be other flags, both general and specific, which are clear, relevant to patient satisfaction and simple to collect. Bandolier would be delighted to receive and print suggestions.

Source: lecture notes on "Medicine for Managers - the Scale of the Demand for Total Joint Replacement" given by Mr Chris Bulstrode, Clinical Reader in Orthopaedic Surgery, John Radcliffe Hospital, Oxford.

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