Clinical Audit Tool


Clinical audit activities are designed to provide individual physicians or groups of physicians with data and feedback on their performance. Clinical audit activities measure current performance against established measures and provide feedback to facilitate the identification of areas where performance meets or exceeds expectations, and areas where improvement is either desirable or helpful to improve the outcomes for patients.

Clinical audit is a formative assessment strategy that is part of Section 3 of the MOC Program and is assigned 3 credits per hour.

The design and implementation of a clinical audit process can be based on the following steps.

Step 1: Define the focus of the clinical audit

The development of a clinical audit starts with identifying an area of professional practice and defining a question(s) that you will use the data and feedback to answer.

  1. The area of practice that I have selected to assess is:

  2. The question I would like the clinical audit to answer is:

Step 2: Select the measures, quality indicators or professional standards

In step 2 you will need to select the performance measures, quality indicators or standards of care you will use to compare your performance in practice against.

  1. List the performance measures, quality indicators or professional standards you will use to compare your performance against. Note: We recommend that you select a minimum of 3 validated measures or quality indicators.

    Measure 1

    Measure 2

    Measure 3

Step 3: Access and collect your performance data

Once you have identified the performance measures to compare your performance, the next step is to collect data from either patient charts or an electronic health record (if applicable).

Note: We recommend that you consider including a minimum of 10 patients, incidents, slides or x-rays. This minimum number will provide you, for the purposes of learning, a reasonable summary of your ‘usual’ practice.

Step 4: Summarize and compare your performance against the selected measures

After you have collected the data the next step is to summarize the data you collected and compare your performance with the performance measures or quality indicators you selected to answer the question you posed in Step 1.

Note: The approach to how to summarize the data will be dependent in part on the type of data you intend to obtain. Dichotomous measures (did/did not perform a task such as ordering a test or prescribing a specific treatment) focuses more on adherence. Continuous variables (such as the level of BP or asthma control) focus on the percent of patients who meet established targets.

Step 5: Obtain feedback

Now that you have accessed, summarized and compared your performance against the selected performance measures you must identify how you will obtain feedback on your performance from a colleague, peer or mentor.

Question: How will you obtain feedback in reviewing your data and helping you come to conclusions?

Step 6: Coming to conclusions

The data and feedback on your performance will allow you to come to some important conclusions on which aspects of your performance are meeting or exceeding standards, and which areas you have identified for further improvement. As you come to conclusions here are some important questions to consider:

Question: Is there an area of my practice that I would like to improve?

Question: What specific actions or learning options should I implement?

Question: What will be the key challenges or barriers in my workplace?

Step 7: Documenting the process and outcomes in your MAINPORT ePortfolio

Once you have completed each step above, there are two additional final actions to complete:

  1. From your MAINPORT ePortfolio, use the template in Section 3: Practice Assessment to document the clinical audit question, key findings, conclusions reached, and time spent.
  2. If you have identified an area for further learning and improvement, you are encouraged to develop and document the plan using the Goal Setting tool located in the “My CPD Planning” tab within your MAINPORT ePortfolio.

Note: The MAINPORT ePortfolio goal setting tool will provide you with an opportunity to describe the goal you intend to complete, how you intend to accomplish the goal and set a date for when you intend to accomplish this goal. MAINPORT ePortfolio has the capability to allow you to add learning activities against a specific goal and track your progress towards achievement over time.