General Medical Council guidance on clinical audit

Good medical practice (3rd ed, 2001, paragraph 12): Maintaining your performance

12. You must work with colleagues to monitor and maintain the quality of the care you provide and maintain a high awareness of patient safety. In particular, you must:

  • take part in regular and systematic medical and clinical audit, recording data honestly. Where necessary you must respond to the results of audit to improve your practice, for example by undertaking further training;
  • respond constructively to the outcome of reviews, assessments or appraisals of your performance;
  • take part in confidential enquiries and adverse event recognition and reporting to help reduce risk to patients;

Confidentiality: Protecting and Providing Information (April 2004, paragraphs 13-15): Disclosing information for clinical audit

13. Clinical audit is essential to the provision of good care. All doctors in clinical practice have a duty to participate in clinical audit1. Where an audit is to be undertaken by the team which provided care, or those working to support them, such as clinical audit staff, you may disclose identifiable information, provided you are satisfied that patients:

  • have been informed that their data may be disclosed for clinical audit, and their right to object to the disclosure; and
  • have not objected.

14. If a patient does object you should explain why information is needed and how this may benefit their care. If it is not possible to provide safe care without disclosing information for audit, you should explain this to the patient and the options open to them.

15. Where clinical audit is to be undertaken by another organisation, information should be anonymised wherever that is practicable. In any case where it is not practicable to anonymise data, or anonymised data will not fulfil the requirements of the audit, express consent must be obtained before identifiable data is disclosed.

Glossary

Anonymised data

Data from which the patient cannot be identified by the recipient of the information. The name, address, and full post code must be removed together with any other information which, in conjunction with other data held by or disclosed to the recipient, could identify the patient. Unique numbers may be included only if recipients of the data do not have access to the ‘key’ to trace the identity of the patient.

Clinical Audit

Evaluation of clinical performance against standards or through comparative analysis, to inform the management of services. Studies that aim to derive, scientifically confirm and publish generalisable knowledge constitute research and are not encompassed within the definition of clinical audit in this document.