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Active Hospitals


At a local level clinical audit links into both clinical effectiveness and clinical governance. Firstly, clinical effectiveness aims to identify and appraise existing evidence of best practice.

Once identified, if necessary, local practice may be amended to ensure that it is conforming to best practice.

A clinical audit project might be undertaken to ensure that:

  1. best practice is being followed
  2. patient physical activity outcomes are improving

“Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria…where indicated, changes are implemented…and further monitoring is used to confirm improvement in healthcare delivery.”

Principles for Best Practice in Clinical Audit (2002, NICE/CHI)

We suggest that a minimum of one physical activity related audit per pathway per year is performed. Use this Clinical Audit Project Proposal Template to plan your audits.

The Active Hospital project aims to increase physical activity levels during and following hospital admissions. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria of recommended physical activity levels from the Chief Medical Officer (CMO) and condition specific guidance (1, 2).

Aims of the audit process are to monitor outcomes related to those guidelines and where indicated, implement changes at an individual, team or service level. Audit monitoring will be used to confirm improvement in healthcare delivery and physical activity outcomes. The ideas for audit, in the form of the precise audit questions, standards and outcomes that are being used, need to reflect patient and clinicians views about primacy of topics and outcomes.

An Audit cycle can be used to confirm improvement in healthcare delivery and physical activity outcomes.

Outcomes of the audit should be discussed with the Patient and Public Involvement group, as they offer an opportunity for lay representatives to provide input as advocates for patients.


Audit Matrix

You can use this matrix as a guide and checklist to help you with your Governance framework.

Clinical Audit Project Proposal Form