Medical audit--need for a positive commitment.
To assess the effectiveness of a case note audit in two dermatology units, the effect of policy changes in clinical practice, made following the identification of deficiencies in practice by an initial audit in 1987, were evaluated 2 years later by repeating the audit process, i.e. 'completing the audit circle'. The case notes of 200 new referrals of patients with psoriasis were audited, using a criteria set of 18 questions devised by a group of 66 dermatologists, in 1987 and again in 1989. Following the initial audit in 1987, policy changes were made at one centre (B) but not at the other (A). In the centre where no policy changes were agreed (A) there was no improvement in record keeping when re-audited in 1989. In centre (B), where a number of policy decisions were taken and protocols established, there was a highly significant improvement in record keeping (60% satisfactory completion of the criteria set in 1987 increased to 74% in 1989, P < 0.0001). Doctors in training grades performed best and were most responsive to the policy changes. The effectiveness of a criterion-based audit depends on a commitment to change, where indicated, and regular reinforcement of new policies at all levels of medical staff.