Audit glossary and training resources
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The National Perinatal Epidemiology Centre (NPEC) promotes high‑quality clinical audit and research to improve maternal and neonatal health. This page provides a glossary of key terms used in NPEC reports and a directory of training resources for health‑care professionals seeking to develop skills in clinical audit. The glossary ensures consistent understanding of perinatal and maternal terms, while the training section highlights public‑sector programmes in Ireland and the UK.
Clinical Audit Glossary
This glossary explains commonly used terms in clinical audit, quality improvement, governance and patient safety. It is intended to support a shared understanding of language used across clinical audit activities, reports and training resources.
The definitions are aligned with terminology used by the Health Service Executive (HSE), the HSE National Centre for Clinical Audit (NCCA), national clinical audit guidance and relevant Irish healthcare governance frameworks.
This glossary is provided as a general guide. Local policies, national guidance and relevant legislation should be consulted where formal definitions or governance requirements are needed.
General clinical audit terms
| Term | Definition | Source |
|---|---|---|
| Action plan | A documented plan that sets out the actions required in response to audit findings. It should identify what needs to change, who is responsible, when actions should be completed, and how progress will be monitored. | Based on: |
| Audit cycle | The structured process used in clinical audit. It usually involves selecting an audit topic, agreeing standards or criteria, collecting and analysing data, comparing practice with standards, implementing improvement actions, and re-auditing to assess whether improvement has occurred. | Based on: |
| Audit criteria | Specific, measurable statements that describe the aspect of care being assessed. Criteria are usually derived from clinical standards, clinical guidelines, evidence-based practice or agreed best practice. | Based on: |
| Audit finding | A result or observation identified through the audit process. Audit findings usually describe whether current practice meets agreed standards, where variation exists, and where improvement may be required. | Based on: |
| Audit lead | The person responsible for coordinating and overseeing an audit project. The audit lead may support topic selection, methodology, data collection, analysis, reporting, feedback and follow-up actions. | Based on: |
| Audit methodology | The planned approach used to carry out an audit. This includes the audit aim, standards, population, inclusion and exclusion criteria, data collection method, sample size, analysis plan and governance arrangements. | Based on: |
| Audit report | A written summary of the audit aim, standards, methods, findings, conclusions and recommended actions. An audit report should clearly show whether care met the agreed standards and what improvement actions are needed. | Based on: |
| Audit standard | The expected level of performance for an audit criterion. Standards are often expressed as a percentage, for example, that 95% or 100% of eligible cases should meet a specified criterion. | Based on: |
| Baseline measurement | The first measurement of current practice against agreed standards. Baseline findings provide a reference point for future comparison after improvement actions have been implemented. | Based on: |
| Benchmarking | The comparison of performance with agreed standards, peer organisations, national results or recognised best practice. Benchmarking can help identify variation, areas of good practice and opportunities for improvement. | Based on: |
| Clinical audit | A clinically led quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit clinical standards or clinical guidelines, followed by action to improve care when standards are not met. | Based on: |
| Clinical governance | The system through which healthcare organisations are accountable for continuously improving service quality and safeguarding high standards of care. Clinical audit is one of the tools used to support clinical governance. | Based on: |
| Clinical guideline | A systematically developed statement or recommendation designed to support healthcare professionals and patients in making decisions about appropriate care in specific clinical circumstances. | Based on: |
| Clinical standard | A measurable statement that sets out the level of healthcare outcome, process or care expected in relation to a clinical condition, treatment or prevention activity. | Based on: |
| Data collection | The process of gathering information for an audit using an agreed method and data collection tool. Data may be collected from healthcare records, electronic systems, audit forms or other approved sources. | Based on: |
| Data collection tool | A structured form, template, spreadsheet or electronic system used to collect audit data consistently and accurately. | Based on: |
| Data quality | The extent to which data are accurate, complete, consistent, reliable and available in time to support meaningful audit findings and improvement actions. | Based on: |
| Denominator | The total number of eligible cases included in a measure. For example, the denominator may be all patients, births, admissions or records that meet the audit inclusion criteria. | Based on: |
| Exclusion criteria | Characteristics that determine which cases should not be included in an audit. Clear exclusion criteria help ensure that the audit population is appropriate and consistently defined. | Based on: |
| Evidence-based practice | The use of the best available evidence, alongside clinical expertise and patient preferences, to guide healthcare decisions and service delivery. | Based on: |
| Inclusion criteria | Characteristics that determine which cases are eligible for inclusion in an audit. Clear inclusion criteria support consistency, transparency and accurate interpretation of findings. | Based on: |
| Indicator | A measurable element of care or service delivery used to assess quality, safety, performance or outcomes. | Based on: |
| Local clinical audit | A clinical audit carried out within a local service, department, hospital or organisation to assess care against agreed standards and support local quality improvement. | Based on: |
| National clinical audit | A clinical audit conducted across multiple healthcare organisations or services to assess care against national standards, identify variation and support improvements at service, regional and national levels. | Based on: |
| Numerator | The number of cases that meet a specific audit criterion within the eligible population. | Based on: |
| Outcome measure | A measure that reflects the result or impact of care for patients or service users, such as complications, mortality, recovery, experience or health status. | Based on: |
| Patient and public involvement | The active involvement of patients, service users, families, carers or members of the public in shaping audit priorities, interpreting findings, identifying improvement actions or supporting dissemination. | Based on: |
| Plan–Do–Study–Act cycle | A quality improvement method used to test changes on a small scale before wider implementation. It involves planning a change, testing it, studying the results and acting on what is learned. | Based on: |
| Process measure | A measure that assesses whether a specific care process, intervention or activity was carried out as expected. | Based on: |
| Quality improvement | A systematic approach to making changes that lead to better patient outcomes, improved experience of care and improved service delivery. Clinical audit is one method that can support quality improvement. | Based on: |
| Quality assurance | Planned and systematic activities that provide confidence that a service or process is meeting defined quality requirements. | Based on: |
| Re-audit | Repeating data collection after improvement actions have been implemented to determine whether care has improved and whether agreed standards are being met. | Based on: |
| Research | A systematic activity designed to generate new, generalisable or transferable knowledge. Research is distinct from clinical audit, which assesses care against existing standards or guidelines. | Based on: |
| Sample | The group of cases, records or episodes of care selected for inclusion in an audit. The sample should be appropriate to the audit aim and methodology. | Based on: |
| Sampling method | The approach used to select cases for an audit, such as consecutive sampling, random sampling or inclusion of all eligible cases during a defined period. | Based on: |
| Service evaluation | A process used to assess how well a service is working. Service evaluation is distinct from clinical audit because it does not necessarily compare care with explicit clinical standards or guidelines. | Based on: |
| Stakeholder | Any individual or group with an interest in the audit process or findings. Stakeholders may include healthcare professionals, managers, patients, service users, policymakers, data teams and quality improvement staff. | Based on: |
| Structure measure | A measure that assesses the resources, systems or organisational arrangements needed to deliver care, such as staffing, facilities, protocols or equipment. | Based on: |
| Variation | Differences in practice, performance or outcomes between services, units, organisations or populations. Clinical audit can help identify whether variation reflects patient need, service context or potential gaps in care. | Based on: |
Governance, data protection and regulatory terms
| Term | Definition | Source |
|---|---|---|
| Anonymisation | The process of removing or changing personal information so that an individual can no longer be identified. Properly anonymised data are no longer considered personal data. | Based on: |
| Confidentiality | The duty to protect information shared in the context of healthcare. In clinical audit, confidentiality requires that patient and service information is handled securely, appropriately and only by those with a legitimate role. | Based on: |
| Data controller | The person or organisation that determines why and how personal data are processed. In healthcare audit, the relevant healthcare organisation will usually act as data controller for data it collects and uses. | Based on: |
| Data minimisation | A data protection principle requiring that only the personal data necessary for the stated purpose are collected and processed. | Based on: |
| Data processor | A person or organisation that processes personal data on behalf of a data controller, under agreed instructions and safeguards. | Based on: |
| Data Protection Act 2018 | Irish legislation that gives further effect to the General Data Protection Regulation and sets out national provisions for data protection, including the processing of personal data in health and public service contexts. | Based on: |
| Data Protection Impact Assessment | A process used to identify and reduce data protection risks before personal data are processed, particularly where processing may involve sensitive data or higher risk to individuals. | Based on: |
| General Data Protection Regulation | The EU legal framework governing the processing of personal data. In clinical audit, GDPR principles such as lawfulness, fairness, transparency, purpose limitation, data minimisation, accuracy, storage limitation, integrity and confidentiality are relevant. | Based on: |
| Governance | The structures, policies, processes and accountability arrangements that support safe, effective and transparent clinical audit activity. | Based on: |
| Healthcare record review | A review of existing healthcare records to answer one or more questions. A healthcare record review may be used for different purposes, including clinical audit, research or incident review, depending on the purpose and governance arrangements. | Based on: |
| Health Information and Quality Authority | HIQA is an independent authority that works to improve health and social care services in Ireland through standards, monitoring, health information guidance and other quality and safety functions. | Based on: |
| Incident review | A structured review undertaken after a patient safety incident to understand what happened, how and why it happened, and whether learning can improve safety at service, organisational or national level. | Based on: |
| Look-back review | A review used where a group of people may have been exposed to a specific hazard, to identify whether harm occurred and determine what further care, communication or action may be required. | Based on: |
| National Centre for Clinical Audit | The HSE National Centre for Clinical Audit supports the development of an end-to-end process for clinical audit in Ireland, including guidance, training, resources and implementation of recommendations from the National Review of Clinical Audit. | Based on: |
| Open disclosure | The open, honest, compassionate and timely communication with patients and, where appropriate, relevant persons following patient safety incidents. | Based on: |
| Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 | Irish legislation that provides for mandatory open disclosure of certain notifiable patient safety incidents and includes a statutory definition of clinical audit. | Based on: |
| Peer review | Professional assessment of healthcare processes, services or quality of work by colleagues or peers, with the aim of supporting learning and improvement. | Based on: |
| Personal data | Information relating to an identified or identifiable living person. In healthcare audit, personal data may include identifiers, demographic details or information contained in healthcare records. | Based on: |
| Pseudonymisation | The processing of personal data so that the data can no longer be attributed to a specific person without additional information. The additional information must be kept separately and protected. | Based on: |
| Special category data | Personal data that are more sensitive and require additional protection. Health data are special category data under GDPR. | Based on: |
Training resources for clinical audit
The following programmes are delivered by public organisations and provide high‑quality, English‑language training in clinical audit and quality improvement.
- NCCA Fundamentals in Clinical Audit – e‑learning (HSE, Ireland): An online programme on the HSeLand platform. A new three‑hour interactive module launching in April 2026 teaches how to define audit topics, apply ethical and GDPR considerations, collect and analyse data and develop quality‑improvement plans.
- NCCA Advanced Clinical Audit course (HSE, Ireland): One‑day virtual course for staff with audit experience, focusing on advanced methodology, stakeholder engagement, data analysis and sustaining improvements.
- Royal College of Physicians of Ireland – Performing Audit course: An online CPD course teaching how to plan, design and conduct a clinical audit, differentiate audit from research and quality improvement, describe the audit cycle and make recommendations. Mandatory for first‑year specialist trainees; awards 3 CPD credits.
- HQIP Introduction to Quality Improvement for Healthcare Professionals (UK): Free online module introducing definitions of quality and improvement, with tools such as clinical audit, statistical process control, process mapping and plan–do–study–act. Includes interactive activities and a certificate on completion. A companion module for patients and the public explains how to participate in quality improvement.
- NHS England e‑Learning for Healthcare – Research, Audit and Quality Improvement: An online programme developed by the Academy of Medical Royal Colleges and Royal College of Anaesthetists. It teaches healthcare professionals to interpret the validity and reliability of healthcare data, covering clinical trials, reviews and audits, and offers first steps for those planning research or audit projects.