An Introduction to Clinical Audit for Radiographers

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Course: International Covid-19 support for Radiographers and Radiological Technologists
Book: An Introduction to Clinical Audit for Radiographers
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Date: Monday, 15 August 2022, 12:29 PM

1. Why audit is essential in the pandemic

During the pandemic, radiology services around the world have needed to adapt rapidly to provide suspected and proven Covid-19 patients with the imaging support that they require, while at the same time maintaining a safe service to other patients requiring access to imaging. During this period of rapid change and disruption, keeping imaging staff and their patients safe is of paramount important.

Safety is a powerful driver of improvement in any healthcare setting, particular as any change carries additional risk. This pandemic has forced change on us very quickly, and while audit may be the last thing on our minds, it is nevertheless more important than ever. Audit is an essential mechanism for imaging departments to work collectively to ensure safety continues to be at the heart of what they do, alongside identifying best practice in the 'new normal' during and after the Covid-19 pandemic. The role of radiography leaders in audit and governance is clear:

“Underpinning a culture of safety are good leadership at all levels, strong governance within the service and a culture of openness and transparency”1

This resource will review the different types of audit and their relevance to a mobile chest radiography service. It will explore the fundamental components of the audit process from initial question design, to identifying criteria and standards, and then to review and dissemination. It will provide examples of audit questions, criteria, and standards that may be relevant to a chest radiography imaging service.


2. What is audit?

Audit is a well-established method of systematically measuring and analysing workplace processes that are already in place, with an aim to identify and implement improvements. Known as clinical audit in healthcare settings, this vital process can be explained as follows:

Clinical audit is a way to find out if healthcare is being provided in line with standards [and allows] care providers and patients to know where their service is doing well and where there could be improvements. The aim is to allow quality improvement to take place where it is most helpful and will improve outcomes for patients." 2

Audit assesses routine activity and ensures that patients are receiving an effective service or treatment and that a high quality of care is consistently delivered. By working through a process of setting standards, observing practice, evaluating results, communication of results and when necessary implementing changes3 it provides a systematic process that allows us:

"to assess if we are doing what we should be doing in terms of the care we deliver to our patients"4

3. How does audit differ from research?

Clinical audit, research, and service evaluation are processes that occasionally overlap as they may utilise similar data collection tools and processes. However there are fundamental differences: Service evaluation aims to benchmark routine practice; clinical audit identifies if evidence-based practice is being followed; and research focusses upon the creation of new knowledge, often via a change to current practice. While definitions may differ between countries, a useful guide outlining the key differences is presented by the UK Health Research Authority 5

However, all clinical audits must be agreed locally (managerial approval) and should follow institutional processes for clinical audit which will provide guidance on local approval and reporting requirements. Most hospitals will have a Clinical Audit or Clinical Governance department which can provide helpful advice and support.

4. Who should do audit?

Many Trusts will have a department dedicated to Clinical Audit, with experts contributing to strategic audit planning, project design, project management, data collection, data analysis and report production. In addition, many Diagnostic Imaging departments will have a named radiography clinical governance lead or clinical quality coordinator 3. For some types of audit (e.g. financial audits) it may be appropriate for an independent auditor to take the lead, as there is a low risk of bias. However the majority of audits should be delivered by practitioners working closest to the audit area, as they are best-placed to identify areas for improvement. Although there is a potential risk of bias, there is conversely a much better chance of the audit recommendations being implemented and patient care being improved. Medical consultants are required to undertake and lead on clinical audit, however in most countries radiographers are also required by their registering body (e.g. Health and Care Professions Council) to be engaged in auditing their practice6 . However clinical audits should where possible involve a wider group, including commissioners, managers, practitioners and service users. For most audits of processes, a multi-disciplinary team approach is essential.

Covid-19 Example:

Issue: Given the transmission risks to patients and staff, you want to assess whether the chest radiographs requested during the Covid-19 pandemic are making a difference to patient management

Audit team: While a radiographer could lead this process audit, it would need to be undertaken in conjunction with radiologists and referring clinicians. This could be a prospective audit (simple checklist to be completed by clinicians when receiving the radiograph / report) or a retrospective audit (of case notes and radiological reports).

5. Types of audit

There are several different types of audit, with variations around the scope, timeline and methodology:

1. Scope: National clinical audits are large multi-centre studies which are often responding to current country-wide concerns in healthcare. They audit against published national or international standards of care or in some cases gather evidence to set national standards. One recent example is the Care Quality Commission review of radiology reporting in NHS organisations within England7 . In contrast, local clinical audit often involves a single centre, and may be uni-professional or span a whole patient pathway. While local studies will always audit against national standards where they are available, often an audit standard needs to be developed by local stakeholders.

2. Timeline: Retrospective audits involve auditing existing information sources such as patient records and reports stored on radiology information systems, and while they are less intrusive on staff and patients they are often compromised by incomplete data. Prospective audits may be more intrusive over a longer period of time but are likely to yield more accurate data sets. This may require a data collection template to be produced; subsequently, these may be adopted as a useful clinical tool. Some templates are already available such as the Society of Radiographers Chest x-ray (CXR) report template for ICU settings 8
Prospective audits should be designed so that they do not impinge on normal radiography clinical activity and this is of great importance when dealing with high workloads and/or significant change, as recognised within the current Covid-19 pandemic.


3. Methodology: Compliance Audits (ensuring compliance with a set standard taken from professional guidelines or national / local policies)3 are often used within radiography settings to review radiation doses, image quality or appropriate justification of procedures. Process Audits (assessing the efficiency or effectiveness of a process such as a patient pathway) 3, may be used to review timelines such as referral to imaging examination, or examination to radiological report. Either of these methods can be used within a wider Improvement audit, used mainly 'where an issue has already been identified and a systematic approach is required to implement change'3. The final audit methodology is a Documentation audit where a document (such as an imaging protocol) is reviewed to ensure content is current and relevant to current practice.

6. The audit cycle

Each hospital Clinical Audit team will have a preferred audit process to follow, and they may have helpful audit plan templates to use in both the planning and data collection phases. Audit processes are often explained as being cyclical in nature, as shown in the diagram below9. Once an audit question has been identified, appropriate standards need to be set and a method designed for gathering appropriate data to measure current practice. This data then needs to be analysed and measured against the standard, with appropriate recommendations for change made (if required). The audit process normally leads to a re-audit to assess the impact of the changes made, or continuing compliance to the standard.


The audit cycle
The audit cycle 9

7. Designing an Audit question

An audit question will often emerge from review of the literature, practitioner concerns raised or review of preliminary data highlighting a potential issue. It needs to be written in the form of a 'criteria statement' that clearly describes the quality issue and, more importantly, is measurable.


Covid-19 Example:

Issue: You want to be sure that radiographers and patients are not put at risk undertaking unnecessary chest radiographs during the Covid-19 pandemic.

Criterion: ALL chest x-ray referrals should contain sufficient clinical information to be justified by the radiographer

8. Defining an Audit Standard

The standard describes the level of care to be achieved for any particular criterion. In some cases, there should be an ideal standard which we aim for at all times. For example, a radiographer should always aim for an imaging exposure to be 'correct first time'; our ideal standard would be 100% (all exposures should be diagnostically acceptable). However we know that an ideal standard may only be deliverable under ideal conditions with minimal constraints. We might therefore set an optimum standard which is agreed by the team to be achievable under normal working conditions (for example, 90%). In some cases it is essential to also have a minimum standard which might help to distinguish between acceptable and unacceptable practice which requires urgent attention.

The indicators are measurable variables (percentages, numbers, averages) that should be identified during the planning stage; if it is a re-audit, then the same indicators should be used 3. A successful audit also needs careful consideration about sample sizes and confidence levels, which determine how many pieces of data you need to collect and over what timeframe. The Clinical Audit department will advise on this; normally larger sample sizes give you greater confidence that the results of your audit are valid and have not occurred by chance, however, smaller audits may also provide radiographers with very useful information that can assist them to recommend improvements.


Covid-19 Example:

Issue: You want to be sure that chest radiographs have the maximum potential to influence patient management during the Covid-19 pandemic. This might include ensuring that there is a written report by an imaging expert, and that this is received in a timely manner.

Criterion: ALL chest x-rays should receive a definitive report by a radiologist or reporting radiographer within [1 hour] of upload to PACS.

Standards: 100% chest radiographs have a definitive report (Ideal standard). 80% receive the report within 1 hour (optimum standard), 100% receive the report within 4 hours (minimum standard). Not achieving the latter target may require further review of available resources.

9. Where do you find the standards?

Where possible, refer to evidence based guidelines and professional body guidance to see if standards exist in your audit area. Remember that these standards may be available wider than your own professional area, for example in guidance documents for radiographers, radiologists, respiratory and intensive care physicians, and the wider multi-disciplinary community. A useful hierarchy of resources is found here http://www.clinicalauditsupport.com/clinical-audit-resources.html and is summarised below 10:

1. International - worldwide best practice e.g. World Health Organisation; ISRRT guidance11

2. National - distils evidence into national standards e.g. National Institute of Clinical Excellence (England) https://www.nice.org.uk/guidance https://www.nice.org.uk/standards-and-indicators 12 Professional body guidance 13 https://www.rcr.ac.uk/clinical-radiology/publications-and-standards

3. Local - regional or local hospital guidelines and radiology department protocols or procedures

4. Literature - outlines current thinking where best practice has not yet been agreed

5. Consensus - where there is no agreement on best practice, experts can come together to develop new (often local) guidance

Covid-19 Example:

While most Covid-19 radiology professional documents focus on the role of CT, some give guidance that may be useful to the delivery of chest radiography services.

The following are excerpts related to justification for chest x-rays during the Covid-19 pandemic:

  1. There is no indication for daily chest radiographs for ICU patients who are stable on ventilators (no improvement in outcome, increased risk to staff and use of limited PPE). This is relevant to chest x-ray justification and monitoring previous requests. [Radiology Fleischner consensus statement 14]
  2. Chest radiographs are not valuable in asymptomatic population / for screening / early Covid-19 symptoms - CT would be more sensitive. However it will show signs for moderate to severe symptoms." This is relevant to chest x-ray justification [Radiology Fleischner consensus statement 14]
  3. Departments should work with local clinicians to ensure relevant clinical information on all imaging requests. The following information should be documented in the imaging request:
    • Suspicion of COVID-19
    • Infection risk - impacts on how, where and when patients are imaged
    • Raised WCC / lymphopaenia - usually present in COVID-19
    • CRP - unusual to be COVID-19 +ve if CRP is normal
    • Relevant respiratory history
    • Smoking history
    [British Society of Thoracic Imaging, 15]

10. Audit timelines and feedback loops

When undertaking a more complex process audit, several indicators may be required. A review of a patient pathway may require a range of data to be collected 'in situ' and analysed rapidly to facilitate an on-going feedback loop. Trends over time are also important, and some aspects, such as radiation doses, may need to be reviewed retrospectively 16. This more detailed analysis may provide longer term recommendations for the management of patients.


Covid-19 Example:

Issue: A radiology manager wishes to measure the effectiveness of the chest imaging service during the pandemic, so that he/she may learn lessons for any future outbreaks.

In situ feedback loops - Several criteria and indicators may be assessed either continuously or at certain points in time (e.g. weekly) during the pandemic. Concurrent 'in situ' data collection may include imaging activity data, staff availability, referral to test times, test to report times, reject rates, compliance with justification, safety etc. Information is captured and analysed immediately to enable rapid resource management and process issues to be addressed.

Longer term outputs - Some aspects are better suited to retrospective audit after the pandemic, or perhaps after a first wave has concluded. Data collection may be via case note review or activity and reporting database review. Examples include the impact of chest radiographs on patient management; accuracy of chest radiographs compared to CT; staff dose monitoring review. These may give longer term recommendations for the management of patients in future epidemics, such as the need for, or timing of, chest x-rays.

11. Audit report and dissemination

Sharing the results of an audit with relevant stakeholders (radiography staff, radiologists, managers and referring clinicians) is vital to either provide reassurance that best practice is being adhered to, or to highlight areas for improvement. Sharing these results is likely to provide more support and 'buy in' for any implemented changes.

A standard audit report would normally include aims, methodology, results, analysis and conclusion along with recommendations for any changes in practice, policy or protocol 3. This report should follow the institution's own audit template if one exists, and should have the audit methodology accurately recorded so that it can be repeated at a later date if required.

Often the most effective dissemination is by presenting the audit via a Power Point presentation or similar, supported by visual displays and charts. This can help to promote group discussion regarding the significance of the audit and any changes in practice required. Some audits would be valuable if shared with a wider community, and while conferences are not feasible at this time, they could be shared online with professional networks and professional interest groups.

12. Examples of audits relevant to a mobile chest radiography service

The following tables present potential audits that could be undertaken to review a mobile chest radiography service during or after the Covid-19 pandemic. The audits are divided into four 'service requirement' sections:

Section A - Imaging Activity Audits

Section B - Imaging Operational Performance

Section C - Technical Aspects

Section D - Accuracy and Effectiveness

Each section suggests several different areas for audit, and gives guidance on potential audit criteria, example audit statements, purpose, indicator/standard, audit type and evidence.


12.1. Imaging Activity Audits

Service Requirement Section A - Imaging Activity Audits
Criteria A1 A2 A3 A4
CXR referrals per day/week
CXR referrals from each location CXRs referrals per patient and timeline (suspected or proven Covid-19) No. patients having both CXR and CT chest (suspected or proven Covid-19)
Example audit statement CXR demand should remain within work capacity 
CXR demand in each setting should remain within work capacity 
CXR demand should follow guidance and may be predicted. Stable Patients do not require daily chest x-rays. 
CXR and CT demand should follow guidance
Purpose Resource management: review workload trends
Resource management: deploy staff and equipment Resource management: review compliance with imaging referral guidance
Resource management: review compliance with imaging referral guidance
Indicator / Standard Number and percentage above baseline (dept mean)  Number and percentage CXRs undertaken in x-ray dept; wards; A&E; ICU Record imaging requests in light of Covid-19 status + no. days post admission or first onset symptoms Resource management: review compliance with imaging referral guidance
Audit type Monitoring / on-going Monitoring / on-going Monitoring and compliance Compliance
Evidence / Previous audits / literature Comparison to local activity and work force capacity figures Comparison to local activity and workforce capacity figures Local guidelines / international decision tools e.g. https://www.bsti.org.uk/media/resources/files/BSTI_COVID-19_Radiology_Guidance_version_2_16.03.20.pdf As A3



12.2. Imaging Operational Performance

Service Requirement Section B - Imaging Operational Performance
Criteria B1 B2 B3
Time of referral to CXR completion (suspected or proven Covid-19)
Time from CXR completion to definitive report (suspected or proven Covid-19) Time for CT imaging to occur if CXR report urgently recommended CT (suspected or proven Covid-19)
Example audit statement All CXRs completed within [1 hour]* of referral (*insert local standard) All CXRs reported within [30 mins]* of completion (hot reporting)   (*insert local standard) All patients offered CT within [4 hours]* of CXR recommendation  (* insert local standard)
Purpose Capacity indicator - radiographers and equipment. May apply prioritisation criteria for concurrent referrals Capacity indicator - radiologists and reporting radiographers Capacity indicator - CT availability
Indicator / Standard 100% compliance (ideal standard); 100% compliance within [4 hours]* (minimum standard) (* insert local standard) 100% compliance (ideal standard); 100% compliance within [4 hours]* (minimum standard) (* insert local standard).
80%* compliance   (* insert local standard)
Audit type Compliance / process
Compliance / process Process
Evidence / Previous audits / literature Mobile radiography KPIs (Wong et al, 2013) https://www.ncbi.nlm.nih.gov/pubmed/23986937
 Patient pathway documentation. https://www.health.org.uk/sites/default/files/ImprovingPatientFlowAcrossPathwaysAndOrganisations.pdf 
 https://www.cqc.org.uk/sites/default/files/20180718-radiology-reporting-review-report-final-for-web.pdf
 All medical exposures to have a clinical evaluation (report) recorded: IRMER 2017 http://www. legislation.gov.uk/uksi/2017/1322/contents/made
 Euratom: https://eur-lex. europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2014:013:0001:0073:EN:PDF
https://www.health.org.uk/sites/default/files/ImprovingPatientFlowAcrossPathwaysAndOrganisations.pdf  




12.3. Technical Aspects

Service Requirement Section C - Technical Aspects
Criteria C1 C2 C3 C4 C5
No. CXR referrals with appropriate clinical information No. CXRs diagnostically acceptable 'right first time' Monitor and act upon any safety concerns raised Monitor and act upon staff dose monitoring indicators Patient doses
Example audit statement All CXRs have sufficient clinical information for justification by the radiographer All CXRs should be diagnostically acceptable No safety concerns should be raised by radiographers undertaking CXRs Staff doses should be <10% of median dose values (* insert local standard) Patient doses should be recorded (e.g. DAP) and remain within acceptable local DRLs and DAP and EI ranges
Purpose Safety: Appropriateness of clinical information to enable justification, and appropriate use of limited PPE. CXRs NOT required for screening or for mild symptoms. Safety and efficiency: the number of CXRs repeated and the reason (reject analysis) should be monitored Safety - e.g. PPE availability; radiation protection issues, lack of available assistance to safely undertake CXR; staff Covid infection Safety: compliance with good practice; rotation of imaging staff into high risk areas; consider ICU staff monitoring and rotation Safety: compliance with good practice in view of some patients receiving multiple imaging examinations: As Low as Reasonably Practicable (ALARP)
Indicator / Standard 100% compliance. Review referrals against justification criteria - all Covid-19 positive patients should be classed as moderate to severe symptoms. 100% Compliance (ideal) Local optimum standard set 100% compliance 100% compliance Review locally - there are no dose limits set.
Audit type Compliance / on-going Compliance / improvement Compliance Monitoring / Compliance (N.B. will be retrospective) Monitoring
Evidence / Previous audits / literature No imaging for screening or mild Covid-19 symptoms: https://pubs.rsna.org/doi/10.1148/radiol.2020201365
 Covid-19 referral criteria available at: https://www.bsti.org.uk/media/resources/files/BSTI_COVID-19_Radiology_Guidance_version_2_16.03.20.pdf
Review against any national Diagnostic Reference Levels and local reject analysis rates. Review CXRs against 10 point plan (Image review and reporting):  https://www.elearning.isrrt.org/mod/book/view.php?id=255
Refer to WHO and subsequent national guidance on PPE: https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf
ISRRT PPE document: https://www.isrrt.org/full-guideline-protective-measures
Refer to local staff dose records and consult with Radiation Protection Advisor if concerns are raised. 
Moloney F et al . Radiation exposure in ICU patients https://www.ncbi.nlm.nih.gov/pubmed/27158429
Patient doses in critical care (McAvoy et al 2019): https://search.informit.com.au/documentSummary;dn=623334492317151;res=IELHEA

Did all exposures have a recorded clinical evaluation (report)? Regulation 12(9) of IR(ME)R, Ionising Radiation (Medical Exposure) Regulations 2017. These regulations implement some provisions of the European Council Directive 2013/59/Euratom. Ref:
The Ionising Radiation (Medical Exposure) Regulations 2017 No.1322 (2017). (Queen’s Printer of Acts of Parliament) Available at: http://www. legislation.gov.uk/uksi/2017/1322/contents/made [accessed 27.06.2019]
European Commission (2013), Council Directive 2013/59/EURATOM. Official Journal of the European Union (2013) Available at: https://eur-lex. europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2014:013:0001:0073:EN:PDF [accessed 27.06.2019].




12.4. Accuracy and Effectiveness

Service Requirement Section D - Accuracy and Effectiveness
Criteria D1 D2 D3 D4
Did the CXR report answer the clinical question? Accuracy of CXR compared to CT or Covid-19 test result CXRs should have a positive impact on patient management (affect decision making) Accuracy of radiographer preliminary clinical evaluation
Example audit statement All CXRs will receive a recorded clinical report, and did this answer the question posed or refer for further imaging? The number of negative CXRs should be low in moderate/severe cases confirmed by CT All CXRs should have a positive impact on patient management Radiographer PCE / triage should reflect the definitive report
Purpose To ensure the CXR is able to influence patient management Review accuracy of CXR to consider where and when it is best utilised Ensure appropriate use of resources, reduce unwarranted exposures Review effectiveness of triage or immediate review for referring clinician; to highlight training needs
Indicator / Standard 100% (minimum standard) 80%* CXRs have positive findings (*local agreed figures) 100% CXRs should change management (ideal standard), 80% change management (optimal standard) 80%* PCE findings should concur with definitive report (*locally agreed standards depending on level of training)
Audit type Compliance Accuracy Effectiveness Accuracy / Effectiveness
Evidence / Previous audits / literature Need for all exposures to have a report: https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr181_standards_for_interpretation_reporting.pdf
No imaging for screening or mild Covid-19 symptoms: https://pubs.rsna.org/doi/10.1148/radiol.2020201365 
Prospective: In situ referrer template completion; Retrospective: case note and radiology report review Prospective: radiographer PCE checklist with limited choice to facilitate completion and comparison