What is Clinical Audit as per NABH?
Clinical audit is a quality improvement tool that aims to improve patient care and outcomes through systematic review of care against explicit criteria and implementing change. As per NABH 6th Edition standards, clinical audit falls under the Continuous Quality Improvement (CQI) chapter.
NABH requires that clinical audit is not about finding faults — it is about finding ways to improve care and save lives. The process follows the PDCA cycle: Plan, Do, Check, Act.
NABH 6th Edition Requirements for Clinical Audit
- The organisation shall have a documented Clinical Audit policy
- Clinical audits shall be planned, conducted, and reported systematically
- Audits shall be based on evidence-based criteria, guidelines, and standards
- There shall be defined roles and responsibilities for auditors
- Data shall be accurate, reliable, complete, and confidential
- Results shall be analysed and action taken for improvement
- Effectiveness of action taken shall be monitored
Types of Clinical Audits
1. Medical Record Review Audit
Review of patient records against defined criteria. Checks documentation completeness, consent records, discharge summaries, and adherence to clinical protocols. This is the most commonly conducted audit type in NABH-accredited hospitals.
2. Process Audit
Evaluation of care processes and practices. Checks whether clinical procedures are being followed as per SOPs — hand hygiene compliance, medication administration, surgical site infection prevention, etc.
3. Outcome Audit
Evaluation of patient outcomes and results. Tracks indicators like hospital-acquired infection rates, fall rates, pressure ulcer incidence, unplanned readmission rates, and mortality rates against benchmarks.
4. System / Compliance Audit
Assessment of adherence to policies, guidelines, and standards. Checks whether the hospital's systems — infection control, medication management, patient identification — are functioning as designed.
Clinical Audit Process – PDCA Cycle
Plan
- Identify topic and purpose of audit
- Define objectives and scope
- Select criteria and standards
- Determine data sources
- Plan audit methodology
- Assign roles and responsibilities
- Plan for data analysis
- Obtain necessary approvals
Do
- Collect data as per plan
- Ensure accuracy and completeness
- Maintain confidentiality of patient data
- Document observations systematically
- Record any deviations from plan
Check
- Analyse data collected
- Compare with criteria and standards
- Identify gaps and root causes
- Prepare audit report
- Share findings with stakeholders
Act
- Develop and implement action plan
- Address root causes identified
- Monitor and evaluate improvement
- Update policies and procedures if needed
- Re-audit to assess effectiveness of actions
Documentation Requirements for Clinical Audit
| Document | Purpose |
|---|---|
| Clinical Audit Policy and Procedure | Defines scope, frequency, roles, and process |
| Audit Plan and Schedule | Annual calendar of planned audits |
| Audit Tools and Criteria | Standardized checklist for data collection |
| Data Collection Sheets | Raw data captured during audit |
| Audit Report | Findings, analysis, and recommendations |
| Action Plan and Implementation Record | Corrective actions with responsibility and timeline |
| Monitoring and Re-audit Records | Evidence that actions were effective |
Roles and Responsibilities
- Top Management: Provide resources, support, and review audit outcomes
- CQI Team: Facilitate audits and monitor implementation of improvements
- Auditors: Conduct audits objectively and professionally
- Department Heads: Support audit activities and implement changes
- Staff: Cooperate and participate in audit activities
Common Clinical Audit Topics in NABH Hospitals
- Hand Hygiene Compliance (5 Moments)
- Antibiotic Prescription Pattern
- Fall Incidence and Prevention
- Pressure Ulcer Prevention
- Discharge Summary Timeliness
- Patient Identification Compliance
- Informed Consent Documentation
- Medication Error Reporting
- Surgical Safety Checklist Compliance
- CLABSI and CAUTI rates
Key Principles of Clinical Audit
- Patient Safety First — audit exists to protect patients
- Evidence Based — criteria drawn from guidelines and standards
- Confidentiality Maintained — patient data protected throughout
- Non-punitive Approach — focus on systems, not blame
- Data Driven Decisions — actions based on evidence
- Continuous Improvement — re-audit to close the loop
- Quality Culture — audit as learning, not policing
Frequently Asked Questions
How many clinical audits are required per year for NABH?
NABH does not specify a fixed minimum number of audits. However, the expectation is that audits are planned and conducted systematically throughout the year. Most NABH-accredited hospitals conduct at least 4-6 clinical audits annually, with monthly or quarterly data collection for ongoing indicators.
Who can conduct clinical audits in a hospital?
Audits must be conducted by trained auditors with defined competency. Auditors should be objective and not audit their own department's work. The CQI team typically facilitates the process while clinical staff with relevant expertise conduct the actual audit.
What is the difference between internal audit and clinical audit?
Internal audit in NABH context typically refers to system and process audits against NABH standards — checking whether the hospital's quality systems are in place. Clinical audit specifically reviews patient care quality against clinical criteria and focuses on improving patient outcomes.
Does AccredReady support clinical audit tracking?
Yes. AccredReady includes 35 pre-built clinical audit tools mapped to NABH standards. You can conduct, record, and track clinical audits directly within the platform, with findings automatically feeding into your CAPA workflow.
Run Clinical Audits with AccredReady
AccredReady includes 35 clinical audit tools pre-mapped to NABH 6th Edition standards. Plan, conduct, document, and close audit findings — all in one place. Start free.
Start free trial →