This paper seeks to study the process of clinical audit to improve tubercolosis (TB) diagnosis in Cuba, Peru and Bolivia. It aims to present the lessons learned in implementing clinical audit in the three specific study sites and highlight what may be relevant to low‐income settings in general.
The lessons are based on observations and qualitative data collected from 22 health centres that completed a minimum of two audit cycles in the three study countries. Local audit committees selected audit criteria, collected relevant data, compared their performance against the agreed standards and proposed ways for improvement.
Lessons for the development of clinical audit for TB diagnosis in the study countries include the difficulties in setting achievable standards based on appropriate criteria; the need to establish clinical guidelines and routine data; and the need to address patients' beliefs and attitude. Lessons for the development of clinical audit in low‐income countries include the need for preparation (e.g. through clinical guidelines) before introducing quality improvement tools and the importance of a visible relationship between audit activity and patient care. Crucially, local clinicians struggle in developing evidence‐based audit criteria that should be developed at national level.
The lessons learned presented here are derived from interviews, document analysis and participant observation. Such techniques are liable to observers' and informants' bias. Similarly, conclusions drawn from an inquiry into contextual factors also threaten their external validity. The paper used chronological analysis and explanation building to overcome these limitations.
In low‐income countries, audit needs to be fully integrated in the national and local disease control programmes. The lessons presented here provide practical guidance for those considering developing or improving clinical audit in low‐income countries.
Clinical audit has major potential for improving health care delivery in low‐income countries within existing resource constraints. The lessons presented here have relevance to audit across the entirety of health systems in low‐income countries.
