What is the difference between a clinical audit and a quality improvement project?

HQIP defines clinical audit as a quality improvement cycle that measures practice against agreed standards and acts on the gap, so an audit is one form of QI. A QI project more broadly tests a change and measures its effect, sometimes without a pre-existing standard. NHS England's 2025/26 CST portfolio grades them as a single domain and treats them equally.

Does a QI project count as research?

No. The HRA's Defining Research table states that research is designed so results can be generalised from the sample to a wider population and aims to generate or test a hypothesis, whereas service improvement measures change within the service only. Each has its own governance route.

Does an audit need research ethics approval?

Audit is not research, so it is managed under local clinical audit governance rather than research ethics review. HQIP requires audits to comply with local policy on registering and reporting, and to escalate any ethical or information governance concern to the appropriate clinical lead.

What earns level A in the CST quality improvement and clinical audit domain?

NHS England's 2025/26 guidance states level A is being involved as lead in all aspects of a surgically themed clinical audit or QI project that has demonstrated change, such as a second cycle or closed audit loop. Level B is the same in any specialty, and level C is a contributor to a project that demonstrated change.

How is research graded in the CST portfolio?

Through the presentations and publications domain. In the 2025/26 guidance, level A includes first authorship of a PubMed-cited publication that is not a case report or editorial letter, level C is named co-authorship of one PubMed-cited publication, and level D includes a cited collaborative authorship.

Is the 2027 CST portfolio guidance published yet?

Not as of 11 September 2026. The NHS England portfolio guidance page is the 2025/26 edition, last updated 23 October 2025. Check the page again when the 2027 application window opens, because domain wording and evidence requirements can change between rounds.

What does a closed-loop audit mean?

That the cycle was completed: a standard measured, a change implemented, and practice re-measured to show whether it improved. HQIP states the audit cycle is not complete until evidence has been obtained that the action plan resulted in an improvement in the quality of services.

Audit vs QI vs Research: CST Management Station Answer

Clinical audit measures practice against an agreed standard and acts on the gap, quality improvement changes a process and measures whether it improved, and research generates new knowledge that can be generalised beyond the patients studied. The Healthcare Quality Improvement Partnership and the Health Research Authority supply the definitions, and NHS England's Core Surgical Training portfolio guidance decides how each is graded. The CST panel asks this question to find out whether you know which one you did.

Key takeaways

HQIP's Best Practice in Clinical Audit, April 2020, defines clinical audit as a quality improvement cycle that measures the effectiveness of healthcare against agreed and proven standards and takes action to bring practice in line with them.
HQIP's four stages of the cycle are preparation and planning, measuring performance, implementing change and sustaining improvement, and HQIP states the cycle is not complete until there is evidence that the action plan improved the service.
The HRA's Defining Research table, October 2022, says research is designed so results can be extrapolated from the sample to a larger population, audit measures against a standard, and service evaluation measures current care without reference to a standard.
NHS England's 2025/26 CST portfolio guidance grades quality improvement and clinical audit as one domain: level A is leading all aspects of a surgically themed audit or QI project that demonstrated change, such as a second cycle or closed loop.
Research is graded through the presentations and publications domain, where level A includes first authorship of a PubMed-cited publication that is not a case report or editorial letter.
No 2027 edition of the portfolio guidance had been published by 11 September 2026; the 2025/26 page, updated 23 October 2025, is the current one.

What is the principle that separates audit, QI and research?

The principle is the question each one answers: audit asks whether care meets a standard, quality improvement asks whether a change made care better, and research asks something nobody yet knows.

The HRA's Defining Research table states that audit is designed to answer whether a service reaches a defined, predetermined or pre-established standard, and that it measures against a standard.

The same table states that service evaluation and improvement answer what standard the service achieves, measuring the current service without reference to a standard, or comparing the current service to the previous one after an improvement.

Research, the HRA states, is intentionally planned using a documented methodology that allows results to be extrapolated from the study sample to a larger population, and aims to generate or test a hypothesis.

What is the HQIP definition of clinical audit and its cycle?

HQIP defines clinical audit as a quality improvement cycle that measures the effectiveness of healthcare against agreed and proven standards, then acts to bring practice in line with those standards.

HQIP's Best Practice in Clinical Audit, published in April 2020, sets out four stages, and the CST panel expects you to be able to place your own project on them.

Stage 1, preparation and planning: a clearly stated improvement aim, evidence-based standards, a named clinical lead, and a stakeholder group that signs off the method before data collection
Stage 2, measuring performance: a data set defined by the standards, a documented sample, and nothing collected that the standards do not need
Stage 3, implementing change: an action plan owned by named people
Stage 4, sustaining improvement: HQIP states the cycle is not complete until evidence shows the action plan improved the quality of services, and the group decides whether to repeat the audit

HQIP also states that if the named lead is a junior doctor on rotation, a more senior clinician should oversee the project so that it is completed. Say that at interview: it is the reason your consultant's name is on the letter.

How does NHS England's CST portfolio grade audit and QI?

NHS England's 2025/26 CST portfolio guidance grades quality improvement and clinical audit as a single domain on a scale from A to E, with the top grades reserved for leadership of a project that demonstrated change.

Level A: involved as lead in all aspects of a surgically themed clinical audit or QI project that has demonstrated change, such as a second cycle or closed audit loop
Level B: involved as lead in all aspects of a clinical audit or QI project that has demonstrated change, in any specialty
Level C: involved as a contributor in a clinical audit or QI project that has demonstrated change
Level D: involved in a clinical audit or QI project
Level E: none or other

Two things follow. A QI project counts exactly as an audit does, and a single-cycle audit with no re-measurement cannot reach A, B or C, however well it was presented.

The evidence the guidance asks for is a letter from the supervising consultant with their name and GMC number, the presentation slides or project summary, and a letter of acceptance from any meeting where it was presented.

How does the portfolio grade research?

Research has no domain of its own in the 2025/26 CST portfolio; it is graded through the presentations and publications domain, where authorship and the type of paper decide the letter.

Level A: first author of a PubMed-cited publication, or in press, that is not a case report or editorial letter; or the top prize for an oral presentation at a national or international meeting
Level B: an oral presentation at a national or international meeting, a first-author prize-winning poster, a first-author PubMed-cited case report or editorial letter, or a published book chapter
Level C: a named co-author of one PubMed-cited publication or one in press
Level D: a first-author poster at an accredited meeting, a regional oral presentation, or a cited collaborative author on a collaborative publication
Level E: none or other

The guidance asks for the article PDF with its PubMed identifier, or an acceptance letter from a PubMed-catalogued journal, and for presentations the slides, the acceptance letter or programme, and a certificate of attendance.

The domains sit inside a portfolio station worth 45% of the total score, alongside 45% for the management and clinical station and 10% for the MSRA, as NHS England's applying-for-core-training page states.

How would a worked scenario run in the station?

A typical CST portfolio question: tell us about your audit, then, was that actually an audit? A strong answer walks HQIP's four stages and names the standard.

Step one: name the standard

For example: I audited VTE risk assessment within 24 hours of admission on the surgical ward against the NICE standard, with my consultant as senior lead.

Step two: give the measurement

Say the sample and the result as numbers: 60 consecutive admissions over four weeks, 38 assessed on time, 63%.

Step three: describe the change and who owned it

A prompt added to the clerking proforma and a five-minute teaching slot at handover, agreed with the ward manager and the pharmacist.

Step four: close the loop and reflect

The re-audit of 60 admissions three months later showed 52 on time, 87%, and the proforma change was adopted across the department. What I learned was that the change stuck because the ward owned it.

That answer earns level A because it is surgically themed, led in all aspects, and demonstrated change with a second cycle, and it survives the follow-up because you can say why it is an audit and not a service evaluation.

What is the interviewer listening for?

The CST panel listens for a standard named, numbers given twice, a change owned by someone, and honesty about your role.

The correct label: audit, QI or research, with the HRA or HQIP reason you chose it
The standard and its source, whether NICE, a college guideline or a local policy
A baseline and a re-measurement, said as a fraction and a percentage
The intervention and the people who owned it, not just the poster
Your actual contribution: lead in all aspects, or contributor, matching the letter you claimed
What you would do differently, said briefly

What is the trap in this question?

The trap is calling a one-off measurement a closed-loop audit, or claiming the lead on a project where you collected data for someone else.

HQIP states that the cycle is not complete until evidence shows improvement, so a project without a second measurement is at most level D in the CST portfolio, and the panel will ask for the re-audit figure.

Overclaiming is worse than a modest project. The portfolio evidence is verified against the consultant's letter, and Good Medical Practice 2024's fourth domain, trust and professionalism, is the standard a discrepancy is judged against.

A subtler trap is calling a service evaluation an audit. If there was no predetermined standard, the HRA's table says it was evaluation, and the honest label still earns credit for the change it produced.

What is the escalation route when a project stalls?

Escalate a stalled audit to the consultant lead first, then to the clinical audit department, and register it there at the start so the trust's governance carries it across your rotation.

HQIP requires every clinical audit to comply with local governance arrangements, including registration and reporting, and to escalate any ethical or information governance concern to the appropriate clinical lead.

The HRA table states that each project type has its own governance requirements to arrange before starting, so a project that turns out to be research needs research ethics review rather than an audit registration.

How does this topic link to the portfolio domain?

This topic is the portfolio domain: quality improvement and clinical audit is one of the five domains in the 2025/26 CST guidance, and presentations and publications is another, so the grading rules above are what the panel scores against.

The guidance states that assessors have 15 minutes to review the uploaded evidence before the candidate joins and is asked about two achievements, and that the portfolio score combines the assessor's score with the answers given.

Candidates upload an index page with a letter from A to E for each domain rather than a self-assessment score, so the letter you claim is the letter you will be asked to defend.

How this comes up at the CST interview

Audit, QI and research come up at the CST interview twice: as a definitions question in the management station and as a discussion of your own evidence in the portfolio station.

Practise your project as a four-stage story with two sets of numbers, and practise saying which label it deserves and why. coresurgeryinterview's 299-question bank includes portfolio-station questions on audit and research with AI-marked spoken practice: /Question-Bank/Sample-Questions.

Audit vs QI vs Research, and How the Portfolio Grades Them