Logo of qualhcLink to Publisher's site
Qual Health Care. 2000 Mar; 9(1): 23–36.
PMCID: PMC1743496

Reviewing audit: barriers and facilitating factors for effective clinical audit


I K Crombie, professor and E M Alder, senior lecturer

H T O Davies, reader

A Millard, research fellow

Objective—To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process.

Design—A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of "audit", "audit of audits", and "evaluation of audits" and a handsearch of the indexes of relevant journals for key papers.

Results—Findings from 93 publications were reviewed. These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians, from medical consultants to professionals allied to medicine and from those involved in unidisciplinary and multidisciplinary ventures. Perceived benefits of audit included improved communication among colleagues and other professional groups, improved patient care, increased professional satisfaction, and better administration. Some disadvantages of audit were perceived as diminished clinical ownership, fear of litigation, hierarchical and territorial suspicions, and professional isolation. The main barriers to clinical audit can be classified under five main headings. These are lack of resources, lack of expertise or advice in project design and analysis, problems between groups and group members, lack of an overall plan for audit, and organisational impediments. Key facilitating factors to audit were also identified: they included modern medical records systems, effective training, dedicated staff, protected time, structured programmes, and a shared dialogue between purchasers and providers.

Conclusions—Clinical audit can be a valuable assistance to any programme which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at nurturing effective audits, valuable opportunities will be lost. Paying careful attention to the professional attitudes highlighted in this review may help audit to deliver on some of its promise.

(Quality in Health Care 2000;9:23–36)

Key Words: audit; attitudes; barriers; facilitating factors

Full Text

The Full Text of this article is available as a PDF (175K).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Hopkins A. Clinical audit: time for a reappraisal? J R Coll Physicians Lond. 1996 Sep-Oct;30(5):415–425. [PubMed]
  • Barton A, Thomson R, Bhopal R. Clinical audit: more research is required. J Epidemiol Community Health. 1995 Oct;49(5):445–447. [PMC free article] [PubMed]
  • Rawlins M. In pursuit of quality: the National Institute for Clinical Excellence. Lancet. 1999 Mar 27;353(9158):1079–1082. [PubMed]
  • Miles A, Bentley P, Polychronis A, Price N, Grey J. Clinical audit in the National Health Service: fact or fiction? J Eval Clin Pract. 1996 Feb;2(1):29–35. [PubMed]
  • Robinson MB. Evaluation of medical audit. J Epidemiol Community Health. 1994 Oct;48(5):435–440. [PMC free article] [PubMed]
  • Nolan M, Scott G. Audit: an exploration of some tensions and paradoxical expectations. J Adv Nurs. 1993 May;18(5):759–766. [PubMed]
  • Maynard A. Case for auditing audit. Health Serv J. 1991 Jul 18;101(5261):26–26. [PubMed]
  • Mooney G, Ryan M. Rethinking medical audit: the goal is efficiency. J Epidemiol Community Health. 1992 Jun;46(3):180–183. [PMC free article] [PubMed]
  • Shortell SM, Bennett CL, Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Q. 1998;76(4):593–510. [PMC free article] [PubMed]
  • Scally G, Donaldson LJ. The NHS's 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998 Jul 4;317(7150):61–65. [PMC free article] [PubMed]
  • Black N. The new NHS: commentaries on the white paper. Encouraging responsibility: different paths the accountability. Clinical governance: fine words or action? BMJ. 1998 Jan 24;316(7127):297–298. [PMC free article] [PubMed]
  • Smith LF, Harris D. Clinical governance--a new label for old ingredients: quality or quantity? Br J Gen Pract. 1999 May;49(442):339–340. [PMC free article] [PubMed]
  • Donaldson LJ, Gray JA. Clinical governance: a quality duty for health organisations. Qual Health Care. 1998 Dec;7 (Suppl):S37–S44. [PubMed]
  • Webb SJ, Dowell AC, Heywood P. Survey of general practice audit in Leeds. BMJ. 1991 Feb 16;302(6773):390–392. [PMC free article] [PubMed]
  • Johnson R. Where have all the pennies gone? The work of Manchester Medical Audit Advisory Group. BMJ. 1994 Jul 9;309(6947):98–102. [PMC free article] [PubMed]
  • Tabandeh H, Thompson GM. Auditing ophthalmology audits. Eye (Lond) 1995;9(Pt 6 SU):1–5. [PubMed]
  • Medical audit in general practice. I: Effects on doctors' clinical behaviour for common childhood conditions. North of England Study of Standards and Performance in General Practice. BMJ. 1992 Jun 6;304(6840):1480–1484. [PMC free article] [PubMed]
  • Toy PT. Effectiveness of transfusion audits and practice guidelines. Arch Pathol Lab Med. 1994 Apr;118(4):435–437. [PubMed]
  • Penney GC, Templeton A. Impact of a national audit project on gynaecologists in Scotland. Qual Health Care. 1995 Mar;4(1):37–39. [PMC free article] [PubMed]
  • McKenna HP. A multiprofessional approach to audit. Nurs Stand. 1995 Aug 9;9(46):32–35. [PubMed]
  • Smith HE, Russell GI, Frew AJ, Dawes PT. Medical audit: the differing perspectives of managers and clinicians. J R Coll Physicians Lond. 1992 Apr;26(2):177–180. [PubMed]
  • Lewis C, Combes D. Is general practice audit alive and well? The view from Portsmouth. Br J Gen Pract. 1996 Dec;46(413):735–736. [PMC free article] [PubMed]
  • Kinn SR, Smith PJ. Medical audit activity in primary and secondary care in the west of Scotland. Health Bull (Edinb) 1996 May;54(3):252–257. [PubMed]
  • Soundings. BMJ. 1992 Oct 17;305(6859):961–961. [PMC free article]
  • Sherwood T. Exitus auditus--no fun. Lancet. 1992 Jul 4;340(8810):37–38. [PubMed]
  • Black N, Thompson E. Obstacles to medical audit: British doctors speak. Soc Sci Med. 1993 Apr;36(7):849–856. [PubMed]
  • Firth-Cozens J, Storer D. Registrars' and senior registrars' perceptions of their audit activities. Qual Health Care. 1992 Sep;1(3):161–164. [PMC free article] [PubMed]
  • Gabbay J, McNicol MC, Spiby J, Davies SC, Layton AJ. What did audit achieve? Lessons from preliminary evaluation of a year's medical audit. BMJ. 1990 Sep 15;301(6751):526–529. [PMC free article] [PubMed]
  • Lough JR, McKay J, Murray TS. Audit and summative assessment: two years' pilot experience. Med Educ. 1995 Mar;29(2):101–103. [PubMed]
  • Gabbay J, Layton AJ. Evaluation of audit of medical inpatient records in a district general hospital. Qual Health Care. 1992 Mar;1(1):43–47. [PMC free article] [PubMed]
  • Lough JR, Mckay J, Murray TS. Audit: trainers' and trainees' attitudes and experiences. Med Educ. 1995 Jan;29(1):85–90. [PubMed]
  • Karran SJ, Ranaboldo CJ, Karran A. Review of the perceptions of general surgical staff within the Wessex region of the status of quality assurance and surgical audit. Ann R Coll Surg Engl. 1993 Jul;75(4 Suppl):104–107. [PubMed]
  • Robinson S. Audit in the therapy professions: some constraints on progress. Qual Health Care. 1996 Dec;5(4):206–214. [PMC free article] [PubMed]
  • Baker R, Robertson N, Farooqi A. Audit in general practice: factors influencing participation. BMJ. 1995 Jul 1;311(6996):31–34. [PMC free article] [PubMed]
  • Chambers R, Bowyer S, Campbell I. Audit activity and quality of completed audit projects in primary care in Staffordshire. Qual Health Care. 1995 Sep;4(3):178–183. [PMC free article] [PubMed]
  • Spencer JA. Audit and academic departments of general practice: a survey in the United Kingdom and Eire. Br J Gen Pract. 1992 Aug;42(361):333–335. [PMC free article] [PubMed]
  • Eccles MP, Deverill M, McColl E, Richardson H. A natural survey of audit activity across the primary-secondary care interface. Qual Health Care. 1996 Dec;5(4):193–200. [PMC free article] [PubMed]
  • Lord J, Littlejohns P. Clinical audit. Secret garden. Health Serv J. 1994 Aug 25;104(5417):18–21. [PubMed]
  • Berger A. Why doesn't audit work? BMJ. 1998 Mar 21;316(7135):875–876. [PMC free article] [PubMed]
  • Thomson R, Elcoat C, Pugh E. Clinical audit and the purchaser-provider interaction: different attitudes and expectations in the United Kingdom. Qual Health Care. 1996 Jun;5(2):97–103. [PMC free article] [PubMed]
  • Derry J, Lawrence M, Griew K, Anderson J, Humphreys J, Pandher KS. Auditing audits: the method of Oxfordshire Medical Audit Advisory Group. BMJ. 1991 Nov 16;303(6812):1247–1249. [PMC free article] [PubMed]
  • Crombie IK, Davies HT. Towards good audit. Br J Hosp Med. 48(3-4):182–185. [PubMed]
  • Parker J, Barnes S. Auditing audits. BMJ. 1992 Jan 25;304(6821):254–254. [PMC free article] [PubMed]
  • Walshe K. Opportunities for improving the practice of clinical audit. Qual Health Care. 1995 Dec;4(4):231–232. [PMC free article] [PubMed]
  • Hearnshaw HM, Baker RH, Robertson N. Multidisciplinary audit in primary healthcare teams: facilitation by audit support staff. Qual Health Care. 1994 Sep;3(3):164–168. [PMC free article] [PubMed]
  • Lervy B, Wareham K, Cheung WY. Practice characteristics associated with audit activity: a medical audit advisory group survey. Br J Gen Pract. 1994 Jul;44(384):311–314. [PMC free article] [PubMed]
  • Grol R, Wensing M. Implementation of quality assurance and medical audit: general practitioners' perceived obstacles and requirements. Br J Gen Pract. 1995 Oct;45(399):548–552. [PMC free article] [PubMed]
  • Reizenstein P. Quality and health care in Sweden. BMJ. 1991 Oct 12;303(6807):900–902. [PMC free article] [PubMed]
  • Collopy BT. Audit activities in Australia. BMJ. 1991 Dec 14;303(6816):1523–1525. [PMC free article] [PubMed]
  • Giraud A. Medical audit in France: historical perspective. BMJ. 1992 Feb 15;304(6824):426–428. [PMC free article] [PubMed]
  • Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998 Sep 16;280(11):1000–1005. [PubMed]
  • Douglas C. Clinical governance made simple . BMJ. 1998 Jul 25;317(7153):287–287. [PMC free article] [PubMed]
  • Goodman NW. Clinical governance. BMJ. 1998 Dec 19;317(7174):1725–1727. [PMC free article] [PubMed]

Articles from Quality in Health Care : QHC are provided here courtesy of BMJ Group


Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...


  • PubMed
    PubMed citations for these articles

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...