5 signs your audit programme isn't working

Most providers have an audit programme. Fewer can say what it's actually changed.

An audit programme that's working produces evidence of improvement‚ actions closed, practice changed, risk reduced.

One that isn't working still produces paperwork. It just doesn't produce much else. Here's how to tell which one you've got.

1. The same findings show up year after year
   If last year's hand hygiene audit flagged low compliance on a particular ward, and this year's audit flags the same thing, the audit did its job‚it found the problem twice. What didn't happen is the improvement. A repeat finding isn't proof the audit is broken. It's proof the action plan that followed it was.

2. Actions get logged but nobody checks they happened
   Most audit tools have an action column. Fewer have a column for "did this actually get done, and did it work." An action plan with a due date and an owner looks complete. Whether it closed the gap is a different question, and it's the one CQC and NHS Resolution actually ask.

3. The programme is built around what's easy to count, not what's risky
   Documentation audits are quick to run and quick to score. Auditing whether clinical decisions were appropriate, or whether a consent conversation actually happened the way the notes say it did, takes longer and is harder to standardise. A programme weighted toward the former and light on the latter will always look tidier than it is.

4. Audit results and incident data live in separate systems, and nobody's cross-checking them
   If your complaints log, incident reports, and audit findings are reviewed by different people at different meetings and never compared side by side, you'll miss the pattern where all three are pointing at the same underlying issue. That's usually the first thing an external reviewer finds, because they're the ones actually putting the three together.

5. Your audit plan was written once and hasn't moved since
   A risk-based audit programme should shift with your risk profile — a new service line, a staffing change, a near miss, a regulatory update. If this year's audit calendar is last year's audit calendar with the dates changed, it's being run as a compliance exercise, not a governance one.
   

   What a working audit programme actually looks like
   
   None of this means adding more audits. It usually means fewer, better-targeted ones, with a genuine re-check built in: did the action happen, and did it work. That loop, audit, act, re-audit is the part that gets skipped most often, and it's the part that actually produces the evidence boards and inspectors want to see.
   
   If you're not sure where your programme currently sits against that, it's worth an honest look before your next inspection does it for you.
   
   Get in touch and the Harbour Governance team can help you review your current programme against what CQC and NHS Resolution actually expect to see.