Completing a clinical audit cycle in practice

auditAjay Dhunna outlines the necessary steps taken to complete a clinical audit in practice.

How do we improve in clinical practice? Going on course after course after course? Finding a suitable mentor? Shadowing more experience clinicians? All of these are great methods in theory. However, the only way to truly improve is by reflecting back on your own work. See what you can improve. Implement these changes and review the work again. This is called auditing.

Over the last couple of years, I have attended numerous courses. Not all of them have led to the protocols I use today. The only thing that has allowed me to achieve the results I do is by testing different methods. I then review the results and repeat this after changing something.

This change can be as simple as what instrument to use, time length of light curing, which matrix system to use. Auditing does not have to be as tedious as everyone thinks. In reality, a lot of us subconsciously audit our work using our clinical photographs to reflect on our work. That is, in essence, what ‘to audit’ is, a formalised method of reflection and improvement.

Audit cycle

To look at what auditing is, it is important to see what auditing is not. Auditing is not just a clinician doing research followed by collecting and analysing data. Auditing in the clinical environment involves a number of steps outlined in the audit cycle illustration.

This process is all in the view of improving patient care after identification of a problem. The use of clinical audit can also help improve efficiency, accuracy and long-term success. This is something we all want in this day and age.

I will talk through the different parts of the cycle, giving examples of a problem that I identified in practice.

Identification of a problem

This can be a problem regarding any aspect of practice for you or the other clinicians. The best audits are carried out on problems that can help the whole practice rather than a single clinician and can then therefore be extrapolated to help clinicians outside the practice, too.

The best way to identify a problem is by observing your diary and seeing if there are numerous emergency appointments of the same kind. Alternatively, you can identify a problem by doing a simple practice clinician survey; this may not work if you are in a one or two surgery clinic.

Example: the problem I identified involved a number of orthodontic emergencies occurring as the practice carries out quite a lot of fixed orthodontics. This resulted in a portion of the clinical time during the week being dedicated to dealing with this.

Defining standards

When discussing an audit, standards of the audit must be established. These involve:

  • Inclusion criteria
  • Exclusion criteria
  • Dates for data collection
  • Methodology for data collection.

The inclusion and exclusion criteria are set standards for which bits of data can be included in the audit in order to make the study valid and reliable without too many variables.

Once these are established, the data collection can begin. This first cycle can be classed as being a pilot cycle to obtain a baseline of what to compare future improvements to.

Data collection

For the initial collection of data, this is classed as a pilot cycle of which to use a baseline for future audits, improvements that are made and analysis. The data collection methods have been set in the previous section.

Collection can be carried out in a number of ways: survey, tick-box method, tally, simple observation – the list can go on. The main thing for data collection is to record the data accurately so it can be used in the future.

Example: the pilot cycle is the initial baseline investigation. This can actually be done retrospectively by looking back at the diary, which is what I did for the pilot cycle; looking back at the number of orthodontic emergencies and following my set inclusion and exclusion criteria to provide a valid set of data for the initial cycle.

This was recorded by deciding the amount of time spent on certain types of orthodontic emergencies to determine what the main cause of time spent on these is.

Data analysis

When analysing the data, the data must always be compared to the initial mission of the audit, so that its actual practicality is good. The data can be analysed just by creating connections between the problem identified and the data available. This should then be presented in a way that is easy to observe.

Part of the analysis of the data should also include changes to implement that will help aid the problem identified. This should be based on literature or measured protocols.

Example: when the audit was carried out, the results measured that there were five or so main areas as to reasons for orthodontic emergencies. The main cause of this was orthodontic debonding. Due to the sheer amount of orthodontics carried out in the practice, it was seen that in the two months retrospectively studied in September and October 2018, an average of 235 minutes of clinical time was being spent on orthodontic debonding.

After seeing that orthodontic debonding was a major use of clinical time, the protocol used to bond brackets was observed and this was seen to not follow the manufacturing guidance of the bond and the orthodontic bracket paste. These were the protocols that were changed for the bracket bonding process.

Implementing the changes

Once the changes were identified, following analysis of the results, these changes should be implemented within the same audit but using the same processes as the pilot cycle. These changes should then be left in place and monitored for a sufficient amount of time for these changes to have profound effect.

Example: the existing bonding protocol was observed and compared to the manufacturer’s guidance for the bonding protocol of these brackets. Any discrepancies were noted and then implemented as the changes required to be made.

To aid the adherence to the new protocol, the bonding protocol was printed out and placed with the orthodontic equipment so it was constantly referred to when bonding brackets.


Once the changes have been identified and implemented, a sufficient amount of time should be left before carrying out audit again. This time length will be dependent on what changes were made. Once the time length has lapsed and you are ready to audit again, the cycle must be started again. You must establish the problem again with inclusion and exclusion criteria and then more data collection with these changes.

Example: a period of four months was left to wait for these implemented changes to take effect. The next re-audit was established with inclusion and exclusion criteria that made sure the emergencies recorded were only from those brackets placed in the four-month period after the changes were implemented. The cycle was repeated and results analysed.

Following the adherence to the manufacturing guidance, an average of 115 minutes of clinical time was saved per month. This was time that was now able to be spent on other patients; booking them in for other treatments or taking on new orthodontic patients.

Best care

There you have it: this is the audit cycle. For me, this is the only way to formalise your improvement in clinical practice to ensure you give your patients the best care possible. I truly think that if you want to improve, then you need to research into different ways to do so.

Not only research, but you also need to test these changes based on the research. See if there is any improvement in whatever problem you have identified. This way, you really see that the changes you are making are actually working over a number of patients, not just on a couple of patients that you have noticed here and there.

This is the formalised audit cycle and process, but as mentioned, it does not always have to be so intricate. Identifying a problem from taking regular photographs is just as useful. Continuously reflecting over the photographs after you have implemented changes can help you see how you have improved.

I believe this is a route all dentists, not just young dentists, should go down in order to improve clinical.

This article first appeared in Dentistry magazine. You can read the latest issue here. 

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