Do Audits Work to Improve Hospital Care?

Researchers from the University Medical Centre Groningen and the Erasmus School of Health Policy & Management, The Netherlands, recently published findings on “Understanding how and why audits work in improving the quality of hospital care: A systematic realist review”.

Quality and safety issues are becoming increasingly important in hospital care as the focus shifts to clinical outcomes and patient satisfaction. Health authorities and hospitals use audits for quality improvement (QI) by evaluating care, improvement areas and changes. However, the problem remains that implementing the suggested improvements do not address the quality gap. It seems that this process is not straightforward at all.

Literature abounds about the workings of audits, but there is little to be found about in-depth theory on the casual mechanisms that determine the effectiveness of audits in a specific context. 

Audits on improving healthcare are divided into external audits (insights on hospital’s compliance with external criteria); internal (in preparation for an external audit); clinical (local initiative) or peer reviews. The aim of this research was to find the mechanisms and contextual factors that determine why audits may (not) lead to improved quality of hospital care.

After reviewing 85 papers, the researchers identified seven context-mechanism-outcome configurations that would explain how audits work. Audits that are externally initiated create awareness of quality improvement, but the impact does not last long. If a healthcare professional has a sense of urgency, they will actively engage with the audit. However, the healthcare worker will only make an effort if the audit is championed by others. Sustained change has a better change of taking place if the audits are initiated bottom-up.  Knowledge-sharing within externally mandated audits triggers participation by healthcare professionals. Audit data support healthcare workers to raise issues in their dialogues with people in leadership roles. Finally, audits legitimise feedback to colleagues, which encourages constructive cooperation.