Guidance for audit evaluators

Audits submitted to the College for evaluation are initially reviewed for completeness by the Clinical Effectiveness Department. In some cases, additional data may be requested at this stage; if this is not provided the evaluation cannot proceed. After initial review of the audit, the Clinical Effectiveness Department will select two (sometimes three) evaluators of the same specialty of the audit.

The evaluation process is managed online via hyperlinks sent to evaluators by email.

Although evaluators are welcome to make particular recommendations, they should do so with the understanding that other evaluators may offer other opinions. When evaluators disagree on their conclusions at the end of the process, a third evaluator will be selected.

Evaluation process

The purpose of the evaluation process is to provide audit authors with an expert opinion regarding the quality of the audit under consideration. The evaluation should also supply applicants with explicit feedback on how to improve the quality of their audit.

  • When an audit application is submitted online, the Clinical Effectiveness Department will review the application to see if it satisfies all the criteria set by the College.
  • If any criteria are not met, the applicant will be contacted and asked to provide further information.
  • If the criteria are met, the application will be sent to two (sometimes three) independent evaluators for online evaluation.
  • Once the evaluators have entered their decision and any comments online, an email will notify the Clinical Effectiveness Department that the process is complete.
  • Each evaluator is sent an email asking them to review the application objectively and independently of each other.
  • An application for evaluation will be sent to the evaluator again after seven days, to remind the evaluator to complete the evaluation form.

Role of the evaluator

The evaluator’s role is to check that the criteria and standards are met appropriately for their specialty.

An evaluator has ten days to evaluate an audit application. If for any reason the evaluator cannot commit to the work, they should inform the Clinical Effectiveness Department as soon as possible. Another evaluator then may be selected.

An evaluator may evaluate an audit more than once in the following situations:

  • When evaluating an audit for quality of initial audit. This evaluation confirms that the audit design meets  the  standards.  Areas for  further  development  will  be  highlighted  by evaluators as an educational feedback. Email feedback is issued to the applicant detailing the outcome of the evaluation.
  • When evaluating an audit that has completed at least one audit cycle for certification of high quality. (College certificates are issued as a PDF to all participants on positive evaluation).
  • When evaluating the resubmission of an audit. An audit that did not meet all of the standards on first application can be resubmitted once the issues raised by evaluators have been addressed. The resubmission will then be re-evaluated, usually by the same evaluators.

Evaluators’ comments should be as specific as possible, referencing page numbers where appropriate. This will assist the author in his or her revisions. Please focus on the content of the report rather than on issues of editorial style.

Outcome of the evaluation 

  • If two evaluators decide the audit is of an acceptable standard, an email confirming this will be sent to the applicant and all participants in the audit team.
  • If the evaluators’ decisions are different, the submission will be reviewed by a third evaluator.
  • Further information may be sought from the applicant and clarification may be sought from the evaluators. The applicant and all participants will be informed of the outcome by email.
  • If two evaluators decide that the required standard has not been met, the applicant will be advised of the outcome by email and will receive constructive feedback on the areas for improvement.


The role of evaluator requires integrity, as they may review confidential information and this confidentiality must be maintained. This means that when the evaluator is responsible for personal and confidential information, they must take reasonable steps to be protected against improper disclosure.

The Clinical Effectiveness Department is open to any comments or suggestions you may want to make in order to improve the evaluation process.