Clinical audit as a framework for the consultation on the future of Libyan Health Services.

I read with interest the special article entitled ‘Consultation on the Libyan Health Systems: towards patient centred services’ (1). In my opinion, the consultation would be better conducted as a clinical audit, which has been shown to be an effective method to improve the quality of health services (2, 3).

Making recommendations for good practice before a thorough review of current services has been performed may lead to standards being set too high initially. Staff may consider such high standards unobtainable and would not be engaged. Instead, achievable standards should be set within an appropriate timeframe, which is the essence of a clinical audit.

The involvement of local staff in the clinical audit of current services will help engage them with the concept of the need for change and thereby motivate them. It will also provide an insight into the available resources and perceived barriers to change, allowing the setting of meaningful, realistic, measurable, and achievable goals, both short and long term. There is a good evidence that staff engagement correlates with improvement in the performance and innovation of the organisation (4). Once staff appreciate the need for change and adopt the concept as their own, it gives them a sense of direction and vision for the future.

Clinical audit is ‘a quality improvement process that seeks to improve patient care and health outcomes through the systematic review of care, and the implementation of change’ (5).

The process involves five stages (6):

Preparation and planning

Selecting the criteria

Measuring performance

Implementing change

Sustaining improvement including re-audit to close the cycle

The activity of studying the differences between standards and the current service delivery is known as Gap Analysis in business terms (7). However, this term has also been used by some of the Healthcare trusts in the UK (8) to refer to the baseline assessment of current practice, which is the first step in a clinical audit followed by action plan, implementing plan and monitoring.

The proposal of conducting the Libyan healthcare consultations as an audit would include the following steps:

Staff consultation to collect specific information with regard to the available resources in the hospitals, clinics and private sector based on the World Health Organization (WHO) framework block themes cited in the article (1).

Review of current practice to compare it with a set of specific standards of national and international practices.

Once shortfalls in current practice have been identified, clinicians should discuss the plans for the necessary changes with all of the people concerned and set priorities for every speciality.

Implementation of changes within a specific timeframe taking into account the resources required.

The plans for change of clinical practice should be monitored and reviewed periodically to ensure full implementation of the changes, reasons for non-compliance and underperformance to be identified, and new targets set.

Underperformance may be due to personal issues related to physical or mental health, or professional related to poor staff performance, lack of motivation, absence of feedback and an unpleasant work environment (9). There is evidence that the impact of clinical audit is likely to be greater when the baseline adherence to recommended practice is low and when feedback is delivered more intensively (3).

The author had the opportunity to review a survey on the state of post war Libyan hospitals and clinics commissioned by the WHO in 2012. It included interviews with the directors of the hospitals and health centres using many subjective questions on the degree of satisfaction with the available services. The results of the survey were not representative of what was actually happening on the ground and not surprising, given that it was conducted by external people on behalf of the local staff. This is an example of why the author reiterates that the clinical audit has to be conducted by the healthcare staff themselves.

However, the benefits of self-evaluation and review of current practice are now being realised. In fact, the author had the opportunity to attend a Libyan City meeting with health centre directors and managers to develop a new standardised questionnaire to collect objective data regarding current Libyan health services from all health centres, primary care units and hospitals.