ETHIOPIAN

POLICE FORCE G
Terms of Reference (TOR) for the HOSPITAL
Clinical Audit Team & Clinical QUALITY
Audit Protocol OFFICE
April .2025
 I. Terms of Reference (TOR) for the Clinical
Audit Team
II. Clinical Audit Protocol

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 1. Terms of Reference (TOR) for the Clinical
Audit Team

The Clinical Audit Team plays a crucial role in assessing and improving the quality of clinical care
in healthcare settings.

The team's main responsibility is to ensure that clinical practices are aligned with established
standards, guidelines, and best practices, ultimately improving patient outcomes, safety, and the
efficiency of care.

1. Background

Clinical audit is a process of evaluating clinical performance and identifying areas for improvement.
This process involves systematically reviewing care provided to patients, comparing it with
established clinical standards, and implementing necessary changes to ensure that care is evidence-
based and effective.

2. Objectives of the Clinical Audit Team

The primary objectives of the Clinical Audit Team are to:

 Ensure quality improvement in clinical practice.

 Assess adherence to clinical guidelines, protocols, and best practices.
 Identify areas for improvement in patient care and safety.
 Monitor clinical performance and outcomes.
 Promote evidence-based decision-making within clinical practices.
 Facilitate the implementation of corrective actions where deficiencies are identified.

3. Responsibilities of the Clinical Audit Team

a. Audit Planning

 Develop an annual audit plan based on priorities, patient safety concerns, and clinical needs.
 Define the scope, objectives, and criteria for each audit.
 Select appropriate clinical areas, departments, or specific processes for audit.
 Establish measurable standards or benchmarks for auditing.

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b. Data Collection

 Collect and analyse relevant data for clinical audits, including patient records, clinical
processes, and outcome measures.
 Ensure the use of reliable, valid, and ethical methods of data collection.
 Coordinate with clinical departments to gather necessary information.

c. Conducting Audits

 Review clinical practices, procedures, and outcomes in relation to established standards.

 Conduct regular or ad-hoc audits (e.g., clinical record audits, infection control audits,
medication management audits).
 Identify non-compliance or discrepancies between actual practices and established clinical
guidelines.

d. Analysis and Reporting

 Analyse the audit results to identify areas of excellence and areas needing improvement.
 Prepare detailed audit reports outlining findings, conclusions, and recommendations for
clinical improvements.
 Present audit results to relevant clinical and administrative staff, including department heads
and senior management.

e. Action Plans and Recommendations

 Develop action plans in collaboration with clinical staff to address areas of improvement
identified in the audit.
 Recommend changes in clinical processes, policies, or practices based on audit findings.
 Support the implementation of corrective measures and improvements.

f. Follow-Up and Re-Audit

 Monitor the implementation of action plans and corrective measures.

 Conduct follow-up audits to ensure improvements are sustained and verify that corrective
actions have been effectively implemented.
 Track the progress of recommendations over time and report on the outcomes of re-audits.

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g. Staff Education and Training

 Support the development of educational programs based on audit findings, ensuring that
clinical staff are updated on best practices and quality standards.
 Promote continuous professional development through feedback from audits and audits-based
learning.

4. Structure and Composition of the Clinical Audit Team

The Clinical Audit Team should consist of individuals with varied skills and knowledge to ensure a
thorough and effective audit process. The team may include the following members:

a. Team Leader (Chair)

 Responsibilities: Oversee the audit process, provide strategic direction, and ensure audit
activities are aligned with the organization’s quality improvement goals.
 Qualifications: Senior clinical leadership position (e.g., Chief Medical Officer, Director of
Quality).

b. Clinical Representatives

 Responsibilities: Provide clinical insights and perspectives on specific audit areas.

 Qualifications: Experienced clinicians (e.g., physicians, nurses, allied health professionals)
representing various departments.

c. Audit Manager/Coordinator

 Responsibilities: Manage audit processes, organize data collection, and prepare reports.
 Qualifications: Experience in clinical auditing, data analysis, and project management.

d. Data Analyst

 Responsibilities: Analyse audit data, identify trends, and generate actionable insights.
 Qualifications: Expertise in statistical analysis and interpreting clinical data.

e. Infection Control or Specialist Advisors

 Responsibilities: Provide expert advice on clinical standards related to infection control or

other specialty areas.
 Qualifications: Certification and expertise in infection control or other relevant specialties.

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f. Administrative Support

 Responsibilities: Provide logistical support for scheduling, documentation, and

communication of audit-related activities.

5. Authority and Reporting Structure

 The Clinical Audit Team has the authority to access clinical records, data, and other
necessary information to conduct audits.
 The team reports to the Quality Improvement Committee, Clinical Governance
Committee, or Medical Board, depending on the organization's structure.
 Audit findings and recommendations are formally presented to the relevant department heads,
senior management, and key stakeholders.

6. Scope of Work

The Clinical Audit Team is responsible for auditing a wide range of clinical areas, including but not
limited to:

 Patient care quality: Adherence to clinical guidelines, protocols, and patient safety practices.
 Clinical outcomes: Monitoring and evaluating patient outcomes related to clinical
interventions.
 Compliance with regulatory standards: Ensuring compliance with national and
international healthcare standards and regulations.
 Risk management: Identifying potential clinical risks and implementing measures to
mitigate them.
 Medication management: Auditing medication prescribing, administration, and
documentation practices.
 Infection control: Evaluating infection prevention and control practices.
 Clinical documentation: Reviewing the quality and accuracy of clinical records and notes.

7. Meetings and Frequency

a. Regular Meetings

 The Clinical Audit Team should meet regularly (monthly) to discuss audit activities, progress,
and emerging issues.
 Meetings should be used for:
o Planning upcoming audits.

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 o Reviewing audit findings.
o Discussing action plans and strategies for improvements.

b. Ad-Hoc Meetings

 The team may convene for special meetings if urgent audits or issues arise that require
immediate attention.

8. Evaluation and Continuous Improvement

The effectiveness of the Clinical Audit Team should be evaluated on an ongoing basis through:

 Reviewing the impact of audits on clinical outcomes and quality improvement.

 Gathering feedback from clinical staff about the audit process and action plans.
 Continuously improving the audit process based on lessons learned and evolving standards
of care.

9. Confidentiality and Ethical Considerations

 The Clinical Audit Team is responsible for ensuring that all audit activities are conducted in
accordance with ethical guidelines.
 Patient confidentiality and privacy must be maintained at all times, and any personal data
must be handled securely in compliance with relevant data protection laws (e.g., HIPAA,
GDPR).
 Audit results should be reported in aggregate form to ensure confidentiality and avoid
individual patient identification.

10. Review of the TOR

This Terms of Reference (TOR) document should be reviewed regularly (at least annually) and
updated as necessary to reflect changes in clinical practices, audit objectives, or healthcare
regulations.

Conclusion
The Clinical Audit Team plays a critical role in improving the quality of patient care through
systematic reviews of clinical practices, identification of areas for improvement, and implementation
of corrective actions. By adhering to the responsibilities, structure, and objectives outlined in the
TOR, the team can help ensure high standards of clinical care, patient safety, and continuous
improvement within the healthcare organization.

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 2. Clinical Audit Protocol
A Clinical Audit Protocol is a structured guideline designed to assess and improve the quality of
clinical care. It ensures that healthcare services meet defined standards, identify areas for
improvement, and enhance patient outcomes through continuous evaluation and feedback. Below is
an example of a Clinical Audit Protocol:

Clinical Audit Protocol

1. Purpose

 To evaluate and improve the quality of clinical care provided to patients.

 To ensure adherence to clinical guidelines, protocols, and best practices.
 To promote patient safety, improve clinical outcomes, and reduce variations in practice.

2. Scope of the Audit

The clinical audit will cover:

 Clinical care practices: Assessment, diagnosis, treatment, and discharge processes.

 Compliance: Adherence to established clinical guidelines, protocols, and standards.
 Patient outcomes: Monitoring the effectiveness of care and interventions.

3. Objectives

 To assess clinical practice and identify areas where improvements can be made.
 To ensure that patient care is aligned with evidence-based guidelines and institutional
standards.
 To monitor and evaluate patient outcomes, such as recovery times, complication rates, and
satisfaction.
 To recommend and implement corrective actions and re-audit practices as necessary.

4. Audit Cycle

The clinical audit cycle typically includes the following steps:

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a. Planning

 Define the audit topic: Determine the focus of the audit (e.g., infection control, pain
management, medication administration).
 Set objectives: Specify the purpose of the audit and what is expected (e.g., improving
medication safety).
 Identify standards and guidelines: Reference clinical guidelines, protocols, or best practice
standards that will be used for comparison.

b. Data Collection

 Select a sample: Identify the patient sample size and the data to be collected (e.g., patient
records, clinical procedures).
 Collect data: Review clinical records, interview healthcare providers, or observe clinical
practice. Use audit tools (checklists, data forms).
 Ensure consistency: Train auditors to follow the same methodology and use the same
criteria.

c. Data Analysis

 Compare against standards: Analyze the collected data against the established clinical
guidelines and standards.
 Identify gaps: Evaluate the areas where clinical practice deviates from the expected standards
or where there are performance variations.
 Measure outcomes: Analyze patient outcomes related to the audit topic (e.g., infection rates,
complication rates).

d. Reporting

 Summarize findings: Write a report detailing the audit process, findings, and key areas for
improvement.
 Present findings: Share the audit results with healthcare teams, management, and relevant
stakeholders.
 Recommendations: Provide recommendations for corrective actions or practice changes to
address identified gaps.

e. Implementation of Changes

 Action Plan: Develop a plan for implementing changes based on audit findings.

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  Staff engagement: Educate and involve healthcare staff in implementing recommended
changes.
 Monitor progress: Ensure that corrective actions are being implemented and that
improvements are sustained.

f. Re-Audit

 Follow-up audit: Conduct a re-audit to evaluate the effectiveness of the changes made and
ensure compliance with the standards.
 Continuous improvement: Use the audit results to support ongoing quality improvement
efforts.

h. Time frame

 Conducted every 3 months. The audit cover 19 patient chart for each department according to
case selection.

5. Audit Tools and Methods

 Checklists: Used to assess adherence to clinical standards and procedures.

 Surveys/Interviews: Gather feedback from healthcare staff and patients.
 Patient Records Review: Analyse clinical documentation for compliance and quality of care.
 Observational Studies: Observe clinical practices and procedures in real-time.
 Statistical Analysis: Use data analysis tools to evaluate outcomes and identify trends.

6. Team Composition

The clinical audit team will consist of:

 Audit Lead: Senior healthcare professional (e.g., Clinical Director, Head of Department).
 Clinical Auditors: Healthcare providers with expertise in the audit area (e.g., nurses,
doctors).
 Data Analysts: Individuals skilled in data collection, analysis, and interpretation.
 Quality Improvement Manager: Coordinates and tracks improvements following audit
recommendations.

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7. Confidentiality and Ethics

 Patient data and clinical information will be handled with the utmost confidentiality and in
compliance with data protection laws (e.g., HIPAA, GDPR).
 The audit team will ensure that there is no breach of patient or staff privacy during data
collection and reporting.

8. Reporting and Feedback

 Audit Report: The audit lead will prepare a formal report that includes objectives, methods,
findings, and recommendations.
 Stakeholder Engagement: Audit findings will be shared with senior management,
department heads, and relevant clinical staff.
 Feedback to Participants: Provide feedback to healthcare staff regarding audit results and
recommended changes to improve care quality.

9. Review and Revision

 The audit protocol will be reviewed annually or as needed to ensure it aligns with updated
clinical guidelines and quality improvement goals.
 Adjustments to the protocol will be made based on the evolving needs of the healthcare
facility or practice area.

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