Home Page MRCOG page How to pass the MRCOG 1st. time

List of contents.

  1. introduction
  2. definition
  3. the audit cycle
  4. College and NICE guidelines
  5. other sources of information
  6. how do you do an audit?
  7. other things that might be included in an exam question

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The NHS Clinical Governance Support Team has produced a handbook.






















This topic almost always appears in the exam.

It is an important part of Clinical Governance.

There are a number of important basics to remember.

The good undergraduate will be able to rattle off the essentials of the audit cycle.

But would not usually add the other stuff necessary for the MRCOG:

        the topic must be be important enough to merit audit,

        audit is normally done as part of the department's audit programme:

                this ensures it has authority: the department is in agreement with it being done and adopting its findings,

                it also makes available the resources and expertise of the audit department:

                        advice on how big the audit should be, what to do about missing data, appropriate methods of statistical analysis etc.,

                        practical help with getting out notes, designing and printing proformas etc.

The department's audit programme will include:

    topics that come round time and again, such as induction of labour, VTE prophylaxis, standard of note-keeping etc.,

    topics that someone thinks are worth looking at, e.g. as a result of:

            a serious adverse incident or "near miss",

            a series of less serious adverse incident reports,

            a complaint or complaints,

            a medico-legal case.

    topics derived from RCOG GreenTop guidleines, which come with auditable standards,

    topics that the CNST says you must audit.

In the case of an audit on screening for domestic violence in antenatal care you would mention:

    that the topic is important:

        the Maternal Mortality Report, 2003 - 2005, "Saving Mothers' Lives" stated:

                that enquiries about domestic violence should be made at booking,

                or at another opportune point during the antenatal period,       

                14% of maternal deaths are in women in known abusive relationships,

        NICE in its CG62 Antenatal Care document states that:

                 "Healthcare professionals need to be alert to the symptoms or signs of domestic violence ...

                  women should be given the opportunity to disclose domestic violence in an environment in which they feel secure".


Audit is one of the "buzz words" you must have in mind when writing an essay or doing an OSCE viva.

There are often extra marks for including "buzz words".

So, develop a litany of them that you can chant and recall in a flash.

Others are:

        clinical governance,


        multi-disciplinary working,

        resource management: people as well as buildings, equipment and so on,

        training: induction programmes, continuing professional education,

        fire drills,

        documented CTG and resuscitation training,

        risk management,

        adverse clinical incident reporting,

        near-miss clinical incident reporting.

Write a model essay on the subject that you can reproduce in the exam in 15 - 20 minutes.

Remember that you will have to shape it on the day to fit the template given with the question.

Practise explaining audit to:

    a colleague who knows the subject,

    a friend or relative who knows nothing about it.

Remember that you have 15 minutes in a viva with a stone-faced examiner who gives no prompts.

So you need a well-rehearsed plan.


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You need to be able to produce a definition.

For this, you need to understand the subject!

In essence, you select an aspect of patient care.

You decide what your ideal practice would be.

It is difficult to achieve our ideal practice 100% of the time.

Audit is the process of comparing what you are actually doing with this ideal.

Human beings and their systems never attain perfection.

So the audit will always throw up something.

        there were delays in doing some aspect of the protocol.

        a key element was omitted in X% of cases.

        and so on.

You try to identify why these imperfections occurred.

Then you make recommendations for improvement.

Once the improvements are in place, you check to ensure they have been effective.

These are the essentials that your definition must encompass.


When you first start to look at audit, you may wonder how it differs from research.

Research is trying to find out more about things.

For example, we now think it is best practice to use magnesium sulphate in severe PET.

This came from the MAGPIE trial which compared magnesium sulphate with alternative treatments.

It concluded that magnesium sulphate is superior.

So it is now routine in "best practice".

This was research.

No doubt, in the future, further research will be done to compare magnesium sulphate with new regimes.

But, for the moment, it is the "gold standard".

So, your unit will have a protocol detailing its use in PET.

Audit would be to investigate how well you were complying with the protocol.

It would not be trying to prove the merits of magnesium sulphate or find new and better treatments for PET.

Its aim would be to try to ensure that the existing protocol is perfectly applied in all cases of PET.

Inevitably, when you audit against a protocol, you will sometimes come to see that the protocol is out-of-date and needs revision.

That would be a separate process of collating the best information, writing and agreeing the protocol, training the staff etc.

And once the new protocol was "up and running" you would need to do an audit to make sure the implementation was perfect!

We used to distinguish between clinical audit and medical audit.

The first related to all the clinical things happening to patients.

The second was just the medical things that happened.

Doctors trying to assert their much greater importance!

Nowadays we tend just to talk of "audit", meaning "clinical audit".


The NHS Clinical Governance support team has produced a useful checklist for local clinical audit. 


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Basic audit cycle.

You design a chain of events.

1. Decide what aspects of the subject you are going to audit.

    i.e. set your standards.

            e.g. all newborn babies will have vitamin K.

2. Get out a representative set of notes, assuming this is a retrospective audit.

    Find out how many babies did not have vitamin K and the reasons for some not having it.

        i.e. analyse the data.

3. Draw up some conclusions.

    Decide how performance may be improved.

4. Present the data, conclusions and recommendations for change to a representative staff meeting.

    This will normally take place at a designated audit meeting.

    Decide on who will implement the changes and the time-scale

5. Decide on the timing of a follow-up audit to find out the effect of the changes.

This takes us back to the start, so the whole process can be redrawn as a circle.


This is the basic cycle, but we need to add bits to make it worthy of the MRCOG.

For example, we need to add some organisational bits like involving the audit committee.

And what about the number of patient notes needed for the audit to be valid.

And what do you do with missing information: lost notes, incomplete records.

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The College has produced a guideline "Understanding Audit".

It dates from 2003, but this is not a subject that changes much.

This includes a definition:

"Clinical audit is 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.

Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria.

Where indicated, changes are implemented at an individual, team or service level

and further monitoring is used to confirm improvement in healthcare delivery".

NICE has also produced a guideline that you should read.


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Most of the small textbooks designed for the MRCOG have sections on audit.

There is a stack of stuff on the internet.

For example, the United Bristol Healthcare Trust has assorted helpful advice.

It is only 6 pages long, so worth your attention. has a useful resume.

Don't get bogged down in  unnecessary detail.


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How do you do an audit?

Basically you select a subject of importance to patient care.

You get your colleagues to agree that it should be audited.

This implies their consent to making changes if the audit shows things could be done better.

There is no point in the exercise if it doesn't lead to things being improved!

Always think about involvement of patients.

This would not be particularly relevant for an audit on anticoagulant prophylaxis.

But it would be highly relevant to one on the management of stillbirth.

Early in my consultant career we had a meeting on this subject.

We had two parents speak.

One was a staff member and the father of the baby,

The other was a mother.

Their experiences were very moving.

They had a huge impact on the development of training and protocols.


The subject of your audit could be your protocol for anticoagulant prophylaxis at Caesarean section.

You identify the key aspects of the protocol.

You can't audit everything, so you have to be selective.

What are the really important things you want to ensure are done for every patient?

Then you compare actual practice with the ideal standards in your protocol.

Most clinical guidelines, e.g. from the RCOG, have a list of "auditable standards".

For example, the RCOG document on Down syndrome screening has lists of standards.

Look at the section on ultrasound.

It lists 11 standards.

Any of these could be incorporated in an audit. 

"Auditable standards" are a good starting point for deciding what to include in your audit.

You need to make out a proforma to capture the information.

This needs to be in a format that allows easy analysis of the data.

You need to decide on whether the audit will be prospective or retrospective.

The downside of prospective audit is that it may influence behaviour.

If everyone knows that the legibility of all notes will be audited for the next month, one might see a sudden enthusiasm for calligraphy!

You need to decide on the number of records to be audited.

Do you have to look at a particular timescale?

Could there be variations in performance at different times of the year?

For example, at times of new junior staff taking up their posts in the hospital.

You need the advice of the audit department on all these aspects.

They will usually give help with getting the data, even if this is only retrieving the notes for you.

Remember the old adage about "garbage in, garbage out".

Make sure that the data that is collected is accurate.

Be wary of delegation!

Analyse the data.

Accentuate deviations from what the protocol specifies.

Think of reasons for the deviations.

Think of remedies.

Prepare a presentation.

Get one or two senior colleagues to have a look at what you have produced.

You don't want people telling you that there are major flaws when you present it to an audit meeting.

Produce your final presentation.

This will include:

    the findings of the audit,

    the facts about bad performance with regard to the protocol,

    the facts about good performance with regard to the protocol,

    highlight the deviations.

    discuss possible reasons for them.

    discuss other relevant issues.

        is the protocol readily available?

        are staff adequately trained in its use?

    your recommendations about how things can be improved,

    your recommendations about who should be responsible for implementing the change,

        make sure that you discuss this with the Clinical Director and Business Manager,

            they might not be happy about you putting someone in charge they think unsuitable,

            they might be concerned about available resources that you have not thought about,

    the timescale for the proposed implementation of change,

            discuss this too with the Clinical Director and Business Manager to make sure it is practical,

    your thoughts on whether the protocol is still up-to-date or whether it needs to be re-written -see below.

Note, again, that audit is not primarily about re-writing protocols.

But, in the process of your audit you should have looked carefully at the protocol and realised that it needs to be revised.

Present the data to all of your colleagues at an audit meeting.

This could include your anaesthetists, not just midwives and obstetricians.

Agree the necessary changes.

Agree who will implement them and the timescale.

Agree any training needs and how they will be met.

Once this is implemented, you should have achieved optimum management of this area of care!


But how do you know?

You need to re-audit.

So, agree a timescale for re-audit.

This might be the same audit.

Or your analysis and discussion with colleagues might suggest things to add or remove.


Your scrutiny of this area might lead you to conclude that the protocol itself needs to be improved.

This is a completely separate exercise to audit.

If the protocol was so hopeless that it was going to be completely re-written, you might defer the audit.

What would be the point of auditing the implementation of a protocol you were going to discard?

How would you go about re-writing the protocol?

First, you need to scrutinise the existing protocol.

In what way(s) does if fail to represent best practice?

You could get guidance from:

    the RCOG guideline on thromboprophylaxis,

    the NICE guideline "Caesarean Section",

    textbooks or recent publications like "The Obstetrician and Gynaecologist".

You then set up a team from all relevant disciplines to re-write the document.

Then you send a draft to colleagues for comment.

You present the final draft to a departmental meeting.

You agree changes that will lead to the final version.

You publish and distribute the final version and get the staff trained.

You make sure the protocol is readily available in paper form and on the intranet or key computers.

Once it is "up and running", you have to make sure you are achieving what you set out to do with the new protocol.

And so you come back to audit!


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Other things that might be included in an exam question.

You need to be able to talk about general principles and what audit is for.

You need to be able to talk your way through designing an audit.

This could be a viva talking about how to do it.

You could have a preparatory station with an audit to design about a specific task.

You need to know about how clinical audit is structured within the Trust and the department of O&G.

Who is responsible for what?

What support is there for you from the audit department if you want to do an audit?

You need to know the five basic components of the audit cycle.

These are outlined in the RCOG document.

You'll find variations on the theme in Nice guideline and most of the other texts on the subject.

Make out your own version and put it on a card.

Always remember that audit is a multidisciplinary activity.

If you want to carry out an audit, you need to have your colleagues on board.

This is particularly important if you make recommendations for change.

Once the cycle is complete, you need to remember re-auditing and give a suggested time-scale.

Best of all: do some audits!

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