Clinical audit in radiology – An Indian perspective

While many of us have heard the term “audit,” not many really appreciate its true nature. An audit is basically a systematic review of radiological processes with an aim for quality improvement, thereby leading to better patient care. It is also intended to promote effective resource utilization and organization of clinical services and to enhance professional education.

A variety of audit projects can be undertaken to improve radiology services. These may range from the quality of clinical referral to technical aspects such as the quality of scan, amount and adequacy of contrast examinations, drug dosages in various interventional procedures, and radiation exposure to the patient during various computed tomography and fluoroscopic procedures, as also the quality and adequacy of reporting of various radiological tests when compared to well-defined standards in practice.

Worldwide, clinical audits are considered an integral part of radiology practice with international guidelines as to how to include these in a busy work environment. An “internal” audit is conducted within the institution and auditors may be from the same department or different departments, as long as they have extensive knowledge and experience of the attributes being audited. There is however a possibility that internal auditors may not be able to identify shortcomings in routine practices in their own environment. Hence, an “external” audit brings a more universal perspective, wherein the auditors from different institutes may be able to better evaluate variations in medical practices.

One needs to understand that although the “external” audit may bear a close resemblance to other assessment systems for accreditations and certifications, the focus and consequences are different. An audit is more like a peer-review activity, focusing on the comparison of clinical practices against well-defined standards and if these are not met, recommendations are made to address the reasons. Once these changes are incorporated, re-audit is done to ensure improvement thereby completing the audit cycle. On the other hand, regulatory inspections focus on the legal requirements for accreditations and can lead to enforcement actions such as certification/accreditation withdrawal. There is no such legal or inherent obligation to enforce recommendations made in a clinical audit. The two activities should thus supplement and not duplicate each other.

Clinical audit is a beneficial process for all stakeholders including patients and medical and supporting staff. Not only does it improve standards of practice but also it ensures better patient safety and experiences. For instance, the justification of imaging examinations can reduce unnecessary radiation exposures, improve patient wait times, and reduce the burden on radiographers as well as radiologists. Involvement in an audit process improves job satisfaction as there is a feeling of contribution to enhanced patient care. Being an educational activity, it gives an opportunity to learn research skills such as data collection, analysis, writing reports, and communication skills. The audit reports can also be presented at conferences and published in journals.

While these have measurable and immeasurable benefits, one does not see audits happening as a routine practice in Indian radiology setups. Among the many barriers, a big one is a lack of awareness of what a radiological audit truly is and how it should be conducted. As a general rule, work pressures are high with a lack of dedicated time or resources/funding for any research or audit activities. Even for the statutory regulatory audits, many things at many workplaces are spruced up in a short interval of time and even these are looked down upon as unnecessary or hassling. A clinical audit, bearing no legal requirement, is thus way down on the list of national and hospital priorities. Furthermore, there is an inherent fear that an audit is a way of “fault finding” and would thus be an embarrassment if lacunae are found. A radiology audit may not be confined to the department of radiology only and would often be a multidisciplinary effort. Something as simple as assessing the radiology request form can lead to finding inadequacies at many levels from different departments. However, one must remember that the focus in such an exercise is on the correct interpretation of images and answering specific clinical queries with a background knowledge of the patient, rather than just finding deficiencies in filling forms. A dysfunctional multi professional team is thus another hurdle to conducting audits.

Since there is a wide variability in terms of awareness, resources, and expertise among health institutions across the country, recommendations for conducting audits need to be tailored as per local requirements and availability of resources. An audit should not become another “burden” for the already overburdened doctors and staff. The very first step in ensuring this is creating awareness at every level about the aforementioned benefits of conducting audits and assuring a “no threatening” and “no-blame” culture. This should be promoted and integrated into radiology education right from the undergraduate and postgraduate level with adequate training of senior consultants so as to encourage team participation. The national professional societies, like the Indian Radiology and Imaging Association (IRIA) in India, need to be at the forefront of developing and ensuring such programs. Allocation of resources/funding is instrumental for the success of the audit system.

Auditing is a beneficial self-assessment and improvement process that needs to be ingrained into radiology practice. While the challenges in India are multifactorial and complex, the solutions can be simple. A little effort and a lot of patience are needed to overcome these barriers and inculcate auditing as a habit.