Journal of Evaluation in Clinical Practice, zyxwvut 2, zyxwvutsr 1, 37-64 The Total Health Care Audit System: a systematic methodology for clinical practice evaluation and development in NHS provider organiza t i on s Andrew Miles BSc(Hons) MSc MPhll PhD,' Paul Bentiey MB ChB PhD FRCP FRCPath,2 Nicholas Price BA ( H ~ n s ) , ~ Andreas Polychronis MB BCh: Joseph Grey BSc (Hons) MB BCh PhD MRCP' and Jonathan Asbrldge DipN RGN' 'Deputy Director, Centre for the Advancement of Clinical Practice, European Institute of Health and Medical Sciences, University of Surrey, UK, and Visiting Professor, University of Westminster, UK 'Consultant Haematologist/Former Medical Director, Llandough Hospital and Community NHS Trust, Cardiff, UK %linical Audit Coordinator, National Hospital for Neurology and Neurosurgery, Queens Square, London, UK 4House Physician, Department of Medicine, Llandough Hospital, Cardiff, UK 'Senior Registrar in General Medicine, University of Wales College of Medicine, University Hospital of Wales, Cardiff, UK 'Nursing Director, John Radcliffe Hospital, Oxford, UK Correspondence Professor Andrew Miles Deputy Director Centre for the Advancement of Clinical European Institute of Health and Medical University of Surrey Guildford GU2 5XH UK Practice Sciences Keywords: audit, change implementation, clinical guidelines, evidence-based medicine, methodology, organization Accepted for publication: 20 December 1995 Abstract Writing in zyxwvuts Medical Education in 1982, Fowkes (1982) noted the lack of general agreement within the medical profession on methods of audit, a deficiency previously articulated by Shaw (1980) and later emphasized by McIntyre (1985). More recently, a study by Black & Thompson (1993) of consultant and junior medical staff in four London district general hospitals revealed that 'many doctors did not understand how to undertake audit', and major research by both Hopkins (1993, 1994) and Buttery et zyx al. (1994) described a multiplicity of methodological deficiencies in the general approaches to audit adopted by clinicians since the promulgation of the White Paper definition in 1989. Soundness of methodological approach is fundamental to securing the success of clinical audit within Provider orga- nizations and is thus central to the generation of measurable improvements in the quality of clinical care being delivered to patients. It is therefore dis- turbing that methodological deficiencies may still be observed in general approaches to audit (Buttery et al. 1994), with no author yet recommending a formal system for critical inquiry into clinical practice. It was the recognition of the unsatisfactory nature of this situation which led us to develop a system aimed at assessing, in a critical fashion, the quality of the totality of care dispensed within NHS provider organizations. The system is presented here for the first time. Introduction Critical inquiry into clinical practice The quality of clinical care can be markedly enhanced by critical inquiry into clinical practice. Progress in this context can be assured through more rational use of existing techniques and the accelerated develop- ment of new ones. Increases in the quality of clinical practice are also associated with a multidisciplinary approach to practice development and with the replacement, where appropriate (Miles et al. 1995; Polychronis et al. 1996a,b), of clinical opinion with definitive research evidence (Miles 1995a<; Miles & Bentley 1996; Miles & Lugon 1996; Miles et af. 1996a, b). Sound methodologies are fundamental to the translation of such rhetoric into reality (Miles et al. 1996c-e). zyxwv 0 1995 Blackwell Science 37