Clinical Audit vs Quality Improvement: Which NICE Guidance Should You Use?
This definitive resource provides NHS clinicians and governance teams with a practical framework for selecting appropriate NICE standards and methodologies for clinical audit and quality improvement projects. Understand the distinct roles of each approach and learn how to apply NICE guidance effectively across different training levels and clinical settings.
Defining Clinical Audit and Quality Improvement in the NHS Context
Clinical Audit: The Systematic Approach to Standards Compliance
Clinical audit is defined by NHS England as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria". This involves the established five-stage cycle:
- Stage 1: Preparing for audit and selecting criteria
- Stage 2: Measuring performance against criteria
- Stage 3: Implementing changes
- Stage 4: Sustaining improvement
- Stage 5: Re-audit to confirm improvement
The fundamental characteristic of clinical audit is that it measures current practice against pre-existing, evidence-based standards. The outcome is binary: you are either meeting the standard or you are not.
Quality Improvement: The Iterative Approach to Enhancing Care
Quality Improvement (QI) is defined as "a systematic, continuous approach that aims to improve patient care by testing and implementing changes on a small scale". QI uses methodologies like Plan-Do-Study-Act (PDSA) cycles and focuses on:
- Understanding systems and processes
- Measuring using statistical process control
- Testing changes rapidly
- Implementing successful changes more broadly
Unlike audit, QI doesn't necessarily start with a fixed standard. It seeks to make processes better, safer, or more efficient, often exceeding baseline standards.
| Feature | Clinical Audit | Quality Improvement |
|---|---|---|
| Primary Question | Are we meeting this standard? | How can we make this better? |
| Starting Point | Pre-existing standard | Identified problem or opportunity |
| Methodology | Five-stage audit cycle | PDSA cycles, Model for Improvement |
| Measurement | Snapshot compliance percentage | Run charts, statistical process control |
| NICE Guidance Fit | NICE Guidelines (NG), Quality Standards (QS) | Broader range including technology appraisals |
Matching NICE Guidance to Your Project Type
NICE Guidance Types and Their Applications
NICE Guidelines (NG) – The Gold Standard for Clinical Audit
NICE Guidelines provide "evidence-based recommendations on health and social care". They represent the ideal standard against which to audit practice. For example:
- NG28: Parkinson's disease in adults
- NG136: Antenatal care for uncomplicated pregnancies
- NG191: COVID-19 rapid guideline: managing suspected or confirmed pneumonia
These are particularly suitable for clinical audit as they provide specific, measurable recommendations.
Quality Standards (QS) – Ready-Made Audit Criteria
NICE Quality Standards are "concise sets of prioritised statements designed to drive measurable quality improvements". Each standard includes:
- Quality statement
- Rationale
- Quality measures (structure, process, outcome)
QS statements are essentially pre-packaged audit criteria. For example, QS204 on neonatal infection includes the statement: "Babies with suspected early-onset neonatal infection have blood cultures taken before starting antibiotics."
When to Use Local Policies vs NICE Guidance
CQC Alignment: Quality Statement – Safe and Effective Care
The CQC expects providers to "use evidence-based guidelines and standards" while also having effective local governance. Local policies should align with NICE guidance unless there are documented, justified reasons for variation.
Audit against NICE guidance when:
- You want to benchmark against national standards
- The guidance is recent and relevant to your practice
- There is no specific local policy, or the local policy references NICE
Audit against local policy when:
- The policy is more specific or restrictive than NICE guidance
- There are resource constraints that justify deviation from NICE
- The policy has been recently updated with local consensus
Decision Framework: Which Standard Should I Audit Against?
Clinical Audit Standard Selection Algorithm
Use this step-by-step approach to select the most appropriate standard for your clinical audit:
Step 1: Identify Your Clinical Area
Be specific about the patient group, condition, or process you want to audit.
Step 2: Check for Relevant NICE Guidelines (NG)
Search the NICE website using specific clinical terms. Prioritize guidelines published or updated within the last 3-5 years.
Step 3: Check for Quality Standards (QS)
If a QS exists for your topic, it often provides more audit-ready criteria than the full guideline.
Step 4: Review Local Policies
Check if your Trust has specific policies that either adopt or adapt NICE guidance.
Step 5: Determine the Gold Standard
Select the highest applicable standard: QS > NG > Local Policy (if NICE-aligned) > Local Policy (if NICE-deviant)
Template: Audit Standard Justification Proforma
Copy and paste this template when planning your audit:
AUDIT STANDARD JUSTIFICATION
Clinical Area: [e.g., Management of type 2 diabetes in primary care]
Selected Standard: [e.g., NICE Guideline NG28 - Type 2 diabetes in adults]
Rationale for Selection:
- Published [date], most recent evidence-based standard
- Relevant to [specific patient group/clinical setting]
- Addresses [specific aspect of care] identified as local priority
Local Policy Alignment:
- Trust diabetes policy last updated [date]
- Policy [fully aligns/partially aligns] with NG28
- Key differences: [list any significant variations]
Expected Impact:
- Measuring compliance with [specific recommendations]
- Potential to improve [specific outcomes]
- Aligns with CQC Quality Statement: [relevant statement]
Practical Project Examples by Training Level
Foundation Year 2 (F2) Audit Examples
Example 1: Venous Thromboembolism (VTE) Risk Assessment
NICE Guidance: NG89 - Venous thromboembolism in over 16s
Audit Criteria: Percentage of adult inpatients who have VTE risk assessment completed within 24 hours of admission
Methodology: Retrospective case note review of 30 consecutive admissions
CQC Alignment: Safe care and treatment
Example 2: Antibiotic Prescribing for Community-Acquired Pneumonia
NICE Guidance: NG138 - Pneumonia in adults
Audit Criteria: Compliance with recommended first-line antibiotics and duration of treatment
Methodology: Review of antibiotic charts and electronic prescribing records
GP Specialty Trainee (GPST) Examples
Example 1: CKD Monitoring in Patients with Diabetes
NICE Guidance: NG28 - Type 2 diabetes, plus NG203 - Chronic kidney disease
Audit Criteria: Percentage of diabetic patients with annual UACR measurement and appropriate ACE inhibitor prescribing
Methodology: Search of practice diabetes register and review of records
Example 2: QI Project: Improving Asthma Control
NICE Guidance Reference: NG80 - Asthma
QI Approach: PDSA cycles to increase asthma review completion rates
Methodology: Implement text message reminders, measure impact on attendance
Internal Medicine Training (IMT) Examples
Example 1: Heart Failure Management Post-Discharge
NICE Guidance: NG106 - Chronic heart failure in adults
Audit Criteria: Timeliness of echocardiogram, appropriate medication initiation, specialist follow-up
Methodology: Retrospective review of heart failure admissions over 3 months
Example 2: QI Project: Reducing Door-to-Needle Time in Stroke
NICE Guidance Reference: NG128 - Stroke and transient ischaemic attack
QI Approach: Process mapping and sequential PDSA cycles to streamline thrombolysis pathway
Methodology: Statistical process control charts to monitor improvement
Implementing Your Findings: From Data to Improvement
Clinical Audit: The Action Plan Template
AUDIT ACTION PLAN
Audit Title: [Insert title]
Date: [Insert date]
Lead Clinician: [Insert name]
Key Findings:
- Standard: [% compliance]
- Areas of good practice: [List]
- Areas for improvement: [List]
Action Plan:
1. [Specific action] - Responsible: [Name] - Deadline: [Date]
2. [Specific action] - Responsible: [Name] - Deadline: [Date]
3. [Specific action] - Responsible: [Name] - Deadline: [Date]
Re-audit Date: [Insert date - typically 6-12 months]
QI Project: PDSA Cycle Template
PDSA CYCLE RECORD
Cycle Number: [Insert]
Date: [Insert]
Plan:
- Objective: [What are you trying to accomplish?]
- Prediction: [What do you expect to happen?]
- Plan: [Who? What? When? Where?]
Do:
- Observations: [What actually happened?]
- Data collected: [Quantitative and qualitative]
Study:
- Comparison: [How did results compare to predictions?]
- Learning: [What did you learn?]
Act:
- Adapt: [What changes will you make for next cycle?]
- Adopt: [What will you implement permanently?]
- Abandon: [What will you stop doing?]
CQC Alignment: Learning, Improvement and Innovation
The CQC expects providers to "continuously improve the quality of care" by using audit and QI findings effectively. Documenting your action plans and sharing learning through governance structures demonstrates compliance with this fundamental standard.
Conclusion: Choosing the Right Approach
Selecting between clinical audit and quality improvement depends on your specific objectives:
- Choose clinical audit when you need to measure compliance against established standards, particularly when using NICE Guidelines or Quality Standards
- Choose quality improvement when you want to enhance processes beyond baseline standards or address complex system issues
- Consider hybrid approaches where audit identifies problems and QI methodologies address them
Regardless of your chosen methodology, ensure your project is appropriately scoped, uses relevant standards, and contributes to the broader quality improvement agenda within your organisation. Properly conducted audit and QI projects not only fulfill training requirements but genuinely enhance patient care and safety.
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