Clinical Audit Project Plan

CLINICAL AUDIT PLAN
Please complete this project plan before starting your project.
1. Short Title of Audit:
2. Details of Audit Lead (Who is the person responsible for completing the audit?)
Audit Lead: Name: Designation:
Contact details: E-mail: Phone:
3. Details of Audit Sponsor: (Who is the person responsible for overseeing/supervising the project and/or
audit lead as required)
Audit Sponsor: Name: Designation:
4. Date plan completed:
5. Rationale for Audit:
Why is this audit needed and what are the expected benefits?
6. Based on your audit rationale how would you classify this audit?
This is an external must-do  This is an internal Trust must-do 

(e.g. National audit or contractual requirement (e.g arising from Trust objectives/ risks/ incidents /
such as CQUIN) complaints/ NICE guidelines compliance etc)
This a Division/Service priority  This is an individual clinician interest 

(e.g. part of Divisional or Team Service (e.g. personal interest, personal development or as
improvement priorities) part of an educational or training programme)
7. What standards will be audited?

List the audit standards being measured for compliance
Define the measurable standards to be audited, identify any known exceptions to the standard and
include a target for compliance e.g. All patients on CPA will have a documented care plan (exception
patients not on CPA); 100% of CPA patients will have a signed care plan (exceptions patients who
decline/lack capacity)
Page 1 of 4 v0.6 Jan 2016

8. Do the audit standards cover the practice of one or more professional groups?
This is a Multi-disciplinary audit  This is an Uni-disciplinary audit 
9. What methods will be used?

How will you carry out the audit e.g retrospective case note review, sampling method?
10. What is your planned sample size? (Total sample size and if relevant any breakdowns by
Teams/Services/Divisions to be included in your audit sample)
Name of Service or Team and Division Planned Sample Size
Total Sample Size:
11. What is your planned project timetable
Project Activity Person Estimated

responsible Completion Date
Audit tool and or other audit material to be completed by:
Data collection to be completed by:
Data inputting to be completed by:
Data analysis to be completed by:
Audit report to be completed by:
Improvement action plan to be completed by:
Please note if this is a re-audit you should refer to the original project plan and audit tool to re-use
methods which will ensure comparability of results.
Page 2 of 4 GFSPL/L-1/QD/P-58
Completing Clinical Audit projects at ART Fertiltiy Clinics.
1. Contact the clinical audit team to discuss the project.

2. Complete the Clinical Audit Project Plan and return to the audit team along with any other relevant
information you may have at this stage such as your draft audit tool.
3. The project plan will be submitted for approval to the Quality Department via email.
4. Once approval has been obtained, send the audit team your proposed audit tool (or questionnaire or
data collection form) if you have not already done this.
5. Your project will now be registered on the Clinical Audit Programme.
6. You can now start your audit and remember to keep us updated of your progress especially if your
planned timescales slip.
Remember - on completion of your project clinical audit findings must be documented in a brief report and
disseminated for wider organisational learning. An action plan must also be developed to improve practice
where compliance is below target and a re-audit planned once the actions have been implemented and
embedded into practice. Any areas of risk identified by your audit should be escalated to your line or
service manager for advice on any immediate remedial actions.
(Report and Action Plan templates are available for completion)
Clinical Audit Stages (HQIP – Healthcare Quality Innovation Partnership)

Stage 1 - Preparation and Planning (including for re-audit)
This involves selecting the topic of the clinical audit, ensuring that it is a priority agreed by all those
involved in the process and that the standards by which current practice is measured against are evidence
based. A clear project plan needs to be developed, making sure structures, responsibilities and timelines
are in place and that it is properly resourced with all relevant participants. Any financial costs associated
with running the clinical audit should be identified and agreed, with those responsible for enabling
necessary changes in practice committed and providing the necessary leadership.
Stage 2 - Measuring Performance
A detailed methodology and data collection process is designed and tested, including a sufficient sample
size and a clear and concise data set. Data are analysed using appropriate statistical measurements and
reported in a way that maximises the impact of the clinical audit by ensuring that results are
communicated effectively to all key stakeholders.
Stage 3 - Implementing Change
Once the results of the audit and recommendations for change have been published, an action plan should
be produced to monitor implementation of these recommendations.
Stage 4 - Sustaining Improvement (including re-audit)
After an agreed period, the audit should be repeated. The same strategies for identifying the sample,
methods and data analysis should be used to ensure comparability. The re-audit should demonstrate that
the changes have been implemented and that improvements have been made. Further changes may then
be required, leading to additional re-audits.
PLEASE RETURN YOUR COMPLETED PROJECT PLAN ELECTRONICALLY to

Dr. Richa Jagtap, Co-Medical Director | Dr. Parul Katiyar, Co-Medical Director |
Mr. Christy Daniel, Quality Manager
CLINICAL AUDIT TEAM
Dr. Richa Jagtap, Co-Medical Director | richa.jagtap@artfertilityclinics.com
Dr. Parul Katiyar, Co-Medical Director | parul.katiyar@artfertilityclinics.com
Mr. Christy Daniel, Quality Manager | christy.daniel@artfertilityclinics.com
Dr. Shrestha Sagar, Fertility Consultant | shreshtha.sagar@artfertilityclinics.com
Dr. Surleen Kaur, Lab Manager- Embryology | Surleen.kaur@artfertilityclinics.com
Mrs. Paemila Raikhan, Nursing Coordinator | Paemila.raikhan@artfertilityclinics.com
Ms. Saloni Egbert, Zonal Manager- Ops | saloni.egbert@artfertilityclinics.com
Dr. Nalini Mahajan, External Member, Fertility Expert | Nalini.mahajan@artfertilityclinics.com

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CLINICAL AUDIT PLAN

Please complete this project plan before starting your project.

1. Short Title of Audit:

This is an external must-do  This is an internal Trust must-do 

This a Division/Service priority  This is an individual clinician interest 

7. What standards will be audited?

Page 1 of 4 v0.6 Jan 2016

This is a Multi-disciplinary audit  This is an Uni-disciplinary audit 

9. What methods will be used?

Name of Service or Team and Division Planned Sample Size

Total Sample Size:

11. What is your planned project timetable

Project Activity Person Estimated

1. Contact the clinical audit team to discuss the project.

Clinical Audit Stages (HQIP – Healthcare Quality Innovation Partnership)

PLEASE RETURN YOUR COMPLETED PROJECT PLAN ELECTRONICALLY to

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