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A clinical audit can be defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Clinical audits are central to effective clinical governance as a measure of clinical effectiveness. This chapter discusses the history of clinical audits, components of clinical audit, and the steps in performing an audit project.

This chapter focuses on the evolving and volatile UK National Health Service (NHS) regulatory and governance frameworks, and considers their impact upon healthcare organization and clinical practice. It reviews the inquiry culture that has influenced government policies on accountability and transparency in health care delivery, and critically assesses the central place accorded to clinical governance. The rise and function of audit and risk management, and the escalatory relationship between risk and regulation, are explored. The paradox that regulatory failures engender tighter controls which, in turn, generate further regulatory failures, is illustrated by reference to several case studies, including that of the death of ‘Baby Peter’, and its aftermath. The chapter concludes with a consideration of the limitations of regulatory control, highlighting the potential for constant review and reform to exacerbate gaps between policy and practice.

Any jurisdiction needs to assess whether its healthcare system is performing well. There are many dimensions of evaluation, but a basic set includes saving life, relief of suffering, and treating patients with dignity: these may be monitored by statistics of mortality, quality of life, and patient experience. Sets of indicators can give a system-wide overview, and aspects of individual services can be evaluated by clinical audit. Confidential enquiries are useful for rare, serious events. Investigation may need to be followed by action, but the decision to act is never simple. New health systems can be evaluated by the standard research designs, but qualitative investigation is important.

This chapter looks at the topic of health services quality from a commissioning and whole population perspective. Quality is noted to be a multidimensional concept and dimensions of quality are considered. The role of the commissioner in maintaining and improving quality of services is explored, and this is seen within a wider backdrop of a health system with commissioner and provider functions (if there are such distinctions in the system). Commissioners need to know whether they are securing quality care for their population for the money spent. They also need an understanding of how this dovetails with the provider perspective on this topic. Commissioners also need to be able to articulate what they wish to assess in practice under the guise of quality. Finally, at a system level there are also bearings on how to compile and interpret a picture of a population’s health if needed.