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You’d need to write a proposal to the hospital’s director outlining every bit in details.
The purpose of your audit, how do you plan to implement the change, if it requires any funding Where’s it coming from, what’s the inclusion and exclusion criteria, what is the expected outcome of it and submit for approval.
Once it has been stamped and approved, you can go ahead and start. The first cycle is collecting data without implementing changes. Then you start the protocol and collect your data again. This is also called as reaudit. Or second cycle.
After you’ve got 2 sets of data, interpret it in charts and compare the results. You’d see a trend that shows there’s improvement and present it to the department in which you conducted your audit
Audits can be absolutely about anything
Anything you notice in your workplace where the said standard is not being done. It could be even something about the 5 moments of hand hygiene. In first cycle, you notice they aren’t doing it well. As a result, transmissible infection rate in patients and others is higher. Give a talk about the importance of hand hygiene over a week, hold seminars or teaching sessions with the department and tell them it’s important to maintain hygiene at all times for safety.
After educating, redo your survey and check the data if people are getting less sick.
This is a closed loop audit. Because you have found a problem and also made amendments to solve the problem and it has worked