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Clinical audits and Quality Improvement Projects (QIPs) are words you hear get tossed around a lot once you start working in the NHS, and it's a good idea to know what they mean.
Audit: quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes.
Quality improvement: process undertaken to make a patient's experience and outcome better, achieved through a systematic approach.
To make it simple, an audit wants to make sure that the current practice is up to date, and that the way things are currently being done meets the expected standards. This is different from research, where you are looking for new knowledge to add to already established knowledge.
Why should I do an audit or QIP?
Audits and QIPs are a useful addition to any portfolio, no matter your level in the NHS. It can show commitment to a certain specialty, and lets you work with senior clinicians to see if a change needs to be put into place. Any change you can make is very rewarding in the long run. It improves the quality of care and increases those involved in the knowledge of how to approach certain situations. There are 3 types of audits you may come across:
- Trust (Internal)
National audits are mandated, and they must be completed. Different departments may be running several national audits throughout the hospital at any time. Just speak with your hospital's audit department to know if any are currently running that you could join.
Trust or internal audits are related to important audits the Trust is carrying out in order to review any incidents that may have occurred in the hospital, any re-audits that need doing, or any other local topics of importance.
If you are looking for doing a QIP for your IMT portfolio - look here for other things that may be useful - Internal Medicine Training : Planning your Portfolio.
Local audits and QIPs in the NHS are the audits you (as a junior doctor) wish to pursue or anything a senior clinician may want to look into that you can also join.
How to conduct a clinical audit in the NHS or overseas
- Choose a topic
Within your department, observe if you feel that any one way of completing a task or maintaining patient care could be better improved. You can also approach a consultant or a senior registrar in your department whether they have any ideas or plans for an audit which you can implement and work on. Another place would be the audit department of your trust. They might have some national audit happening or they will look for doctors when they are given the task.
- Finding the standard of best practice
Check with your Trust guidelines about how this task is meant to be completed. Apart from trust guidelines, there would be guidelines from Royal colleges, NICE etc as well.
- Collecting data
Your audit department, or medical records department would be able to help you in this regard. They can pull sample for you given your inclusion criteria and then also they can arrange for pulling medical records of the patients. Utilize patient notes, the hospital's online system, as well as A&E or GP notes (as appropriate) to find your relevant data. Making a google form to collect data is the most efficient system I found.
- Analyzing data against standard
Make graphs, bar or pie charts, to document any difference between what you are working on against the set standard.
- Presenting the results & discussing possible changes
Put together an action plan and how you'd work to ensure you and those working with you are following the new standards you wish to instill.
- Implementing changes that are agreed upon
Speak with department heads, nurse shift leads, and your own colleagues about the changes you want to implement and how best to go about making these changes.
Allow for 6 months or so of time to allow for the new changes to become the norm and then start the audit process again to see if the changes held.
How to choose and prioritize a topic for clinical audit/QIP
The guidelines produced and recommendations made by these agencies can often provide the basis for a clinical audit project:
- The Care Quality Commission (CQC)
- The National Clinical Audit and Patient’s Outcomes Programme (NCAPOP)
- National Confidential Enquiries
- The National Institute of Clinical Excellence (NICE)
- The National Patient Safety Agency (NPSA)
- National Service Frameworks (NSFs)
- National Audits
- The Royal Colleges/ National Professional Body
- Patient Safety Initiatives
Choosing a topic can be exciting but you have to remember the following questions in mind when you prioritize it.
- Does it have direct impact on patients?
- Does it involve areas of high risk?
- Is it cost effective?
- Will it impact a high volume?
- Does it involve direct patient involvement?
- Does it relate to your trust priorities?
- Does it relate to your department priorities?
- Is it an issue of local concern?
- Will it involve multidisciplinary team?
- Is there a high possibility of doing a re-audit?
The more yeses you get, the higher the topic priority.
Another approach to identifying audit topics is to focus on patient pathways for given clinical conditions. Every patient passes through a number of points on their journey between their first and last contact with the hospital, e.g., Admission - Assessment - Diagnosis - Treatment - Review – Discharge.
At each point on this pathway there are aspects of care that could be audited. For example:
- Have patient history and examination been properly recorded following admission?
- Were appropriate investigations carried out?
- Was the treatment appropriate and timely?
- What was the outcome?
- Is the content of discharge summary adequate?
Also consider the interface of this pathway with other organisations; for example, referrals in or discharges from the hospital. Care often falls down here because of problems in communication.
How can you be sure that you've set the standard that needs to be measured against?
- Specific- use exact and precise language
- Measurable- collect relevant data
- Achievable- don't try to do too much at once
- Relevant- keep to your audit's objectives
- Timely- stick to current practice
- Effective- change can be instated
- Research based- evidence should be reliable
Ensure Concise Methodology
This can be done by knowing what your sample is as well as the sample size, establishing clear inclusion/exclusion criteria, demarcating an appropriate timeline, and create a method by which you can identify the patients you need for your audit. After you've done that, you will need to propose your audit in your local audit meeting. Adjust things as needed after this meeting and proceed to collect data. When you're done, present your data and make sure you've answered all the questions that you initially set forth.
Check here for NICE guidelines and Nationale Clinical Audit.
Make a SMART Plan
- Specific- state exactly what you want to achieve
- Measurable- have milestones that you can show you've met
- Attainable- you need to be realistic about your goals
- Relevant- will what you hope to achieve relevant to the problem identified
- Time-bound- you need to choose a timeline that is realistic
The Golden Rules:
1. No standards mean no audit.
2. Make sure you have full approval
3. Ensure sufficient time
4. Share your results
5. Be SMART
Why are audits important?
Audits help you to understand how your department is working and what can be done to improve the approach and infrastructure of patient care. They also help you to become a better doctor because you take the time out to learn about the current guidelines and pathways for many scenarios.
How to conduct a Quality Improvement Project (QIP)?
As you can see in the photo below, QIPs are the bigger step after performing a audits in the NHS. The methods and process should be all covered by the audit department of your trust, they need your input and approach to begin with.
Hopefully you all are now confident about how to proceed with audits or QIPs in the NHS! Remember that your hospital will have an audit department that you can always go to in case you need any help or advice. Good luck!
Frequently Asked Questions
Definitely you can. Find your national guidance on your selected topic, collect the data on the current practice and then present the findings in your departmental session/teaching. Do seek help from senior doctors in identifying the rooms of improvement in your current clinical practice.
It will not be handed to you always. YOU have to come up with a plan and seek their help to formulate it fully.
- How to Choose & Prioritize Topics - UHBristol Clinical Audit & Effectiveness Team as seen on 30 May, 2020