Chief Executive's Blog: HQIP, clinical audit and quality improvement

Welcome to the HQIP CEO Blog, where HQIP's Chief Executive, Robin Burgess, will give regular updates on the latest news and events regarding HQIP, clinical audit and the wider spheres of health and social care quality improvement.

LATEST BLOG ENTRY:

Launch: NHS Wales National Clinical Audit and Outcome Review Plan 2012/13

I had the pleasure of attending an event in Wales last Thursday, the Clinical Audit and Effectiveness seminar which officially launched the NHS Wales National Clinical Audit and Outcome Review Plan 2012/13. This formal plan for the promotion of clinical audit from within government, which HQIP was involved in helping produce, alongside people involved in direct delivery of care in Wales, is a welcome step forward for Wales, and one which England could usefully follow. Of course HQIP produces its own strategy for our work in England, but the added value of this jointly produced document is that everyone in health service delivery, alongside health policy leads in the Welsh Assembly Government, have all collaborated to set out a high level vision of how clinical audit fits into a broader integrated plan for healthcare in Wales.

The exciting thing about this strategy is the link between clinical audit and quality improvement, it is explicitly stated and emphasised and a way to ensure audit findings are acted on is created. Audit is seen as firmly being what we believe it to be: a quality improvement process in itself, not simply the spur to one. It's all very well assuming that the production of high quality data about variance in delivery of care will automatically improve quality, by local people acting on the findings in some sort of spontaneous way.  In Wales they have recognised that the findings of the measurement phase of national audit need to be supported by targeted quality improvement activity on the ground. They are doing this by encouraging functional and organisational links between the audit teams and their quality improvement teams within their local health boards; and by assisting local change through deployment of the Welsh quality improvement organisation, Thousand Lives Plus, to help local providers enact change when audit findings encourage it.

HQIP has clearly identified that there is a gap between the findings of the national audits we commission and change activity. Some NCAs drive change effectively by simply producing good data, but there is a good case to be made for applying specialist QI capacity to support and facilitate local clinicians and managers to enact changes or improvements in services suggested by the data. In some trusts in England that capacity is there and they apply the learning from NCAs quickly and well; but it is not always the case and they may need some additional help. We believe its time this extra capacity was in place. The Welsh have recognised this and are taking the right steps, through a tightly integrated programme, to support local change activities, both through organisational restructuring on the ground and by application of specialist QI support external to the individual provider. This achieves the location of audit activity within a broader spectrum of health service activity, rather than seeing it operate within an audit ‘bubble'. To break out of the bubble requires governmental action and vision, to lead and direct provider activity. We support the Welsh in this programme and believe it will lead to greater improvements in use of audit findings.

Read the NHS Wales National Clinical Audit and Outcome Review Plan 2012/13 here >>

Presentations from the day are available here >> and abstract booklet here >>

We have also created a specific Welsh page on this site were we can share further information on the their plan and share other items of interest.  Click here to visit >>

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Registry/national clinical audit development in Europe

We will shortly add a detailed report about our conference held last week (26-27 April 2012) on registry (or clinical audit, as we call it here) development across Europe, and presentations are available, but I wanted to use this column to give a quick personal view on this event.

HQIP had been interested in getting involved in developing registry practice in Europe for some time, but the conference came about because we are involved in the European Society of Quality in Healthcare (ESQH), whom we saw as a conduit for this. However the specific spur was the very similar role played by the Danish lead at ESQH (and then ESQH president) Paul Bartels, in registers in his own country, as I do.

The development of registry practice is much the same in Denmark as it is in the UK, and we soon realised we had much in common and a shared agenda. So, at Paul's suggestion, we set to work to organise this event at high speed, to also form the content of our annual Summit for national clinical audits, since there is so much to be gained from sharing practice.

The event went well and we filled the venue, with a 1:2 mix of European and British delegates, all with practical experience of running projects of this type or responsibilities to do so. Although you would expect me to say this, I think the event was a real success.

The quality of the discussion, and the quality of the programmes being discussed, was a stimulus to us in HQIP as there were things described (especially in the Swedish and Danish systems) that we know we can consider doing here.

We are grappling with the same issues Europe-wide, and looking for similar solutions; we can all learn from each other. I came away excited, pleased (in that we had organised it and, with ESQH, shown the leadership needed), energised, and also challenged. I am sure the majority of delegates went away with similar feelings.

We will work with key colleagues in Europe to keep the discussion going and look for opportunities to work together, involving ESQH as part of that - we see this as the beginning of European work. I have viewed some international work on quality as a little remote from our practice, lacking in discussion as it often is of data and evidence; but through this event we have created a channel of discussion useful to us and also to many others involved in the same approaches.

I would like to take the opportunity to thank all staff at HQIP who worked so hard on this event - notably Becky - Rebecca Beaumont.

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24 April 2012: Harmonisation of accreditation schemes

HQIP is an agency focused on a variety of related methods of quality improvement in health and social care - and one of the main ones of these is accreditation of clinical services.

A couple of years ago, with the Academy of Medical Royal Colleges, we created a model of how the disparate clinical accreditation schemes (typically run by Royal Colleges) could be harmonised and aligned under a single accredited system. This would mean that anyone seeing the mark of accreditation could take a view of what it meant and how valid this was in terms of assurance it provided.  

However, whilst the model received strong support, notably at the National Quality Board, there were no funds available to take it forward. Yet the interest in accreditation does not diminish, with new schemes in pilot stages and some schemes increasing their profile, so the need for an integrated approach remains.

The relationship of such schemes with regulatory minimum standards remains unclear, and the precise position of accreditation as a quality improvement methodology as part of a national architecture of quality, remains in debate, partly because such an architecture does not yet exist. Individual schemes may negotiate their own relationship with CQC and other regulatory processes, but there is clearly a need to speak collectively with regulators, commissioners and government.

HQIP hosted a meeting this week (working with the Royal College of Psychiatrists) of colleges from medicine, nursing and allied health to discuss these issues. There was opportunity to hear about the best research into effectiveness in accreditation and best practice internationally.

Overall, it was clear that much remains to be done and that a collective approach is welcome and supported. It was agreed that HQIP, working closely with the Academy and the other disciplines, would take a lead in engaging with regulators, commissioners and the Department to cement accreditation's place in their thinking as the vital tool it is in driving improvement. This was clearly illustrated by the international review of literature, by David Greenfield at the University of New South Wales, which was presented on the day.

If anyone not present at his meeting wants to stay involved, please contact Eve Riley, our Development Officer on accreditation at eve.riley@hqip.org.uk.

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19 April 2012: Clinical engagement in audit

One of the most interesting and complex issues in the development of clinical audit is the exact role and active participation of clinicians.

HQIP, as an organisation with clear interest in the engagement of clinicians of all disciplines, has consistently argued that we see both national and local clinical audit as being part of clinical governance: a process to review the effectiveness of clinical care and to continually drive change and improvement. All audit should be of value to clinicians and where audits fail in this regard then that is clearly a moment to review the utility of that specific activity or type of activity.

Most local audit (other than by junior doctors) is instigated and led by clinicians, is linked into clinical governance and trust strategy and as such generally meets the criteria for its utility given above. If there are issues, it's with junior doctor audit or with national audits.

HQIP has done a lot of work to make junior doctor audit more relevant. It's still the case that a proportion of junior doctor audit is still largely a wasted opportunity because the cycle is not complete, it feels like a tick box exercise, and little change results.

This is often where local Trusts have failed to do the very sensible things recommended by HQIP in its joint guidance with the Foundation years programme. There is a role for Deaneries here and we have started engaging with them afresh to talk about these issues, including some training being organised for Yorkshire and Humber. We are keen to ensure that throughout the country there is a common standard of practice and the same old ways do not continue; there is no reason why junior doctor involvement in audit should remain a problem. If any Deaneries want to do more then please contact us.

At national level, we know that there is concern from some clinicians about some of the national audit programme; they share some of the views of local audit staff about the real value of such large, ongoing data collections, especially where practice seemingly varies little from year to year. Also, many would like the opportunity to opt-out where the performance is consistently better than most.

We hear these concerns and raise them with the Department. Yet it needs to be remembered that every audit programme we commission is designed and led by keen, enthusiastic clinical experts, and approved by the professional body or specialist society concerned prior to roll-out, and then refined in practice.

If local clinicians want to tell us about issues they have with national audits, then use our new feedback mechanism. Clinicians can also raise concerns directly with the audit concerned, or via their professional body or specialist society: the channels are there.

It is perhaps a reflection of reality that there is a diversity of opinion about the desirable features of these projects which our recent consultation on the ideal principles of national audits was designed to address. The second version of this is out now for consultation.

More pertinently, local Trusts don't get much help in acting on the findings of national audit. We publish a range of material to help people do so and the audit providers help to a degree as well; but more needs to be done. We think there is a real need to resource this area, perhaps from the centre, to develop Trust responses. One thing we will be doing is to host some work to help clinicians respond to audit findings. This will be carried out this the autumn, with the involvement of Dr Paul Barach, an international expert of quality improvement.

More generally, many clinicians are not actively involved in audit as much as they should be. Revalidation, as it becomes a reality, will help address this, but there is still room as part of specific development work in individual disciplines. For this reason we have appointed two new clinical fellows, Dr Maeve Lawrence and Dr Rish Prasad, to help promote audit amongst GPs, looking to develop ways to enable GPs to learn about audit, in the training and as part of their ongoing practice.

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28 March 2012: Transparency and patient reporting

Last Friday (23 March) saw the official launch of the National Joint Registry's patient report. Many national audits produce material directly aimed at patients, and the new NJR publication joins this list - although the report has been out for a while.

The launch and the scope of the report mark this out as quite a significant addition to the roster of patient reporting. It is very much a product of work by those with experience of joint replacement, working with the clinical and analytical team, to make difficult information available for a wide, lay audience. It's a big, ambitious and comprehensive template for what patient friendly reporting should or could look like.

The engagement of patients in audits of all types remains challenging. Their engagement in the governance of all national audits is a given these days; increasingly patient organisations are also prominent in the management of the audits, and the assessment of patient experience and perception of outcomes is also a requirement in national audits we are commissioning. The demands of the transparency programme are to require reports to be put in the public domain for patients to use.

Yet still there are national audits which don't report openly; access to their reporting is via closed websites, or is sent to clinicians only. This type of project will not be able to be included in the Quality Accounts list and will not receive national funding. If any national audits collect data that is not in their open reporting but it is in their reporting to clinicians, this will have to change - not least of all because FOI requests will open it up anyway.

We are working on some E-learning for patients and some more practical guidance on involving patients in audit; our own in-house patient group is a massive help in this, and they have just elected an independent chair. They, alongside other national patient bodies will be invited to join our new advisory group, announced via our e-bulletin and website. We will also be producing some guidance on patient consent and information in regard to data on them collected for national audits, for local staff to give to patients to inform them, to add to what is on our site already.

Of course there is still lots to do; but we are confident the principle of involving patients in audit is much more established in 2012 than it was in 2008. There are practical issues in recruitment of committed patients who can shoulder the burden of demand participation places on them; but the principle, and the mechanics of how to do so, are much more in the open and understood than four years ago. It's progress, and the NJR report is one further marker of this.

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16 March 2012: The role of audit in patient safety

In recent years patient safety and protection has emerged as one of the dominant themes of quality improvement, and whole conferences devoted to QI are dominated by consideration of avoidance of serious events and prevention of deaths and accidents. This is of course a hugely important topic; but its not all there is to QI. Ensuring your work is of high quality and meets quality standards and guidelines is also a major part.

It is the case that clinical audit and registries are largely not seen as having much to say about patient safety and protection. Text books of patient safety entirely fail to mention its contribution. Yet audit does help and this week we have seen a very significant example of this delivered with world wide impact. This is the publication this week in the Lancet of a study based on National Joint Registry (NJR) data about metal-on-metal hip replacements. The potential risks of these products have been known about for some time at an anecdotal, case report or research level, but their impact at a mass level needs careful examination of large blocks of data about a significant body of patients over time.

Two years ago, after previous less definitive warnings from the Australian equivalent register, the publication of findings from the NJR in this country led to the withdrawal world wide of a particular brand of hip joint - the ASR. In recent months, some other data has led to their use only in a segment of patient receiving hip replacements. This week a study entirely based on the massive volume of cases reported to the NJR over time has shown definitively that metal-on-metal hips should not be used in any cases.

This is patient safety and protection in action via audit. Its about marshalling large data sets to identify clear definitive risk, and pinpointing this with scientific rigour and accuracy. Through this action thousands of patient at risk will be protected, and if they need action because of implants they previously received, they will be able to obtain the attention they need to remedy any problem. Without this register, this would not have happened.

Its very easy to critique national projects as collecting lots of information for dubious benefit, as my last blog discussed. People forget the vital role of these registers in using those large data sets to identify and prevent harm. They don't just collect; they drive policy and practice. National registers are a patient safety mechanism of demonstrable power. Their data volume and quality makes them incontestable.

But audit does not just ensure safety at the national level. Many local audit projects look at aspects of patient safety; we covered this in the review of the literature available on our website by Loughlan, but day in and day out at the local level, that evidence based is added to and we always welcome examples of studies which reflect this. Identifying unwise and unsafe practice is one feature of audit that is not often cited. Let's celebrate it, knowing that many thousands of people will be the beneficiaries. 

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8 March 2012: Why I think national audit quality is improving

HQIP is currently consulting on a set of standards for quality in national clinical audit. This is designed to achieve consensus to enable a sensible discussion of what quality is.

As I have said repeatedly, judgement on quality depends on your perspective. For some, the NCAs are not even audits, just research; some others think their quality suffers because they are not enough like research projects. Others again emphasise the degree to which people act on the findings, taking a view on quality based on how the projects are used, rather than how they collect, analyse and promote their data. It's a minefield of competing priorities; and we need consensus to make balanced, informed judgements on what quality means and what quality is.

My own views are that the quality of NCAs is improving across the board. You can express your own view via our Stakeholder Survey 2012, which is currently underway (please do have your say if you've not done so already) - and also the Principles of Quality in NCA Consultation, which closed this week (thank you to all those that provided feedback).

The survey again asks for progress on NCAs (or otherwise) since HQIP's inception in 2008. As I say, I do think national audit quality, as a whole, is now much higher than in it was four years ago. I base this on HQIP's factors for consideration set out in our ‘HQIP Guide to Assessing and Improving Quality in Clinical Audit' guidance.

That document reviews a range of factors that could be taken into account in determining quality. On two of these, 'does the topic have substantial value' and 'is there a clear purpose for the audit' - these are assessed prior to commissioning by the Department of Health and NAGCAE (previously NCAAG) and on these HQIP does not have a role in the degree to which a bid meets these.  Again though, my own view, in the main, is that most NCAs meet these criteria.

In regard to cost, HQIP achieves substantial economies within the commissioning and contracting process, ensuring value for money as far and often as possible. We hold bidders to strict cost envelopes. The wider question of whether the cost is justified by impact is a more complex one. A substantial economic analysis would be required. However it's demonstrable that if an audit achieves improvements in mortality and morbidity, or avoids revisions and readmissions, then there is potential to recoup the relatively small cost of collecting and analysing audit data. This is a research question that could usefully be answered.

Are they led by professional bodies?  Since HQIP started we have systematically moved ownership of these projects to professional bodies. This criteria is largely met.

Methodological quality - well here is one for debate. The audits are subject to far greater challenge in regard to their methodological quality at commissioning stage, at review and during ongoing contract oversight. NAGCAE has rightly emphasised this and they play a significant role in ensuring quality in this regard is improving, as does HQIP. In key areas, such as case ascertainment, information governance, reliability and data quality, there have been substantial improvements year on year. Are they all perfect? No.  Are most of them adequate for the primary task of driving improvement? I'd say yes.

If you spend time talking with projects about how they address methodological and quality issues, there is a real commitment to continuous improvement. When I look at the progress of the National Joint Registry (NJR) for example, the audit with which we have most engagement, the quality of the data is simply vastly better than five years ago. All the audits are wrangling with quality issues all the time and finding improvement solutions - whether it's their ability to detect outliers, case mix adjustment, their data release and linkage systems, or their consideration and awareness of ethical issues. There is greater awareness of these issues and attempts at addressing them progress all the time or we, NAGCAE and the Department would not be able to renew them. It's an ongoing, Forth Bridge kind of improvement process.

Reporting of findings? They are all better at reporting, and they report in more detail than in the past. NCAs have had a lot of guidance in this regard - and requirements built into their contracts. They are much better at using the media and they get more impact - look at an example like the last Dementia audit report in December, which received a phenomenal amount of media coverage. New requirements regarding transparency and speed of reporting, and for patient reports such as the one NJR has just issued, will further increase this area of improvement. Are these reports more accessible? Yes they are all far more widely available, distributed and read, not least of all via our website.

Do they involve patients in governance? Much more so, and more routinely than in the past.

Do they routinely measure outcomes? Yes, far more than previously.

Do they drive change at the local level? How well do they fit with local needs? Well, this is the area where there is probably even more debate to be had. There is a body of local feeling that some audits are not appropriate for their needs, and are, in essence, research exercises collecting data that has little impact on local practice. As said above, the decisions on funding are made by the Department after taking advice about the exact shape each audit has - its balance of data, the standards it uses and so on. There is no doubt that some of the national projects are more akin to research projects - this is something I have acknowledged from the start because this is what we are asked to commission. There will always be a tension between the perceptions of those focused on the slightly different beast that is local clinical audit from the one that is national audit. On some people's criteria, the programme is less well regarded because of this. It's a matter of perception.

However there is one area where I think there has been inadequate progress, and that is the implementation of findings at the local level from national audit.

In some cases there is little to work on, as the last point suggested, but in far more others, there are plenty of useful findings waiting to be implemented. Why is this the case? It's down to a vast range of reasons, too great to list here, but one is that there is clearly a lack of capacity or staff, to work at the local level with trusts to put in place the change programmes needed to implement the recommendations.  In many Trusts, with some audits, the audit is of excellent quality and action flows from the report - stroke care is the best example. It's not always the case. We think there is a need for Trusts to get help from the centre. This should involve those who lead the audits in professional bodies, but it also needs people skilled in quality improvement and change programmes, skills not always present in the teams that lead the audit, nor at the local level. I think this is the main area in which the overall impact of national audits has not improved enough in the last five years.

This is a long blog on a difficult subject, and one on which we all have views. Debate will of course run and run, but it is important we recognise were improvements have been made and it is crucial we continue to identify where improvement is still needed - and take positive action to make those improvements, wherever it is we fit into the national clinical audit picture.

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24 February 2012: NCAF 

When we first started, we worked with the Department of Health to come up with ideas for a new kind of forum for those working in clinical audit, to be able to talk with each other and share views, and represent themselves collectively. Hence NCAF was born, using social networking software to provide an online space that avoids travelling and enables better sharing of documents and information.

Three and a half years on, and its clear that NCAF still offers this capacity and is used well by many people to do all the things listed above. The majority of use is respectful, useful and professional.

However it is also true that the use of the Forum is sometimes not, as we aspired it to be, professional. It is a matter of some shame that on a website which seeks to contribute to promoting the professionalism of clinical auditors some people choose to use NCAF in a highly unprofessional way. It is sad that I have to use this public blog to comment on the behaviour of those in the audit field in a negative way.  I am not saying that people should not use the forum to criticise HQIP, or me in particular; it is right and proper that the Forum is used as a place for expressing views, both negative and positive, of HQIP, me, or anyone else closely involved in audit. However, all too often, what is posted is not constructive, its deliberately and wilfully critical, and these criticisms are not substantiated or evidenced - such as that we deliberately delete critical posts; that we are somehow profiting from audit when we are not for profit and this is evident in our published accounts. It is also the case that some people posting use false names and are not even prepared to use their real ones.

The number of people acting in this way is low, at a hard core of about eight people, but they disfigure the site and give a very negative image of what clinical auditors are like: the impression is of rudeness, lack of balance and churlishness. There at times appears an almost irrational vituperation of what HQIP is trying honestly to do on the behalf of clinical audit and those who work in it.

This has to stop. People are welcome to make criticisms of us: please do - indeed we are inviting people to review the quality of our work via a systematic review that starts next week, and your identity will be invisible to us when you do. But if you are going to post on NCAF and leave your comments for ever on the site, you have to be prepared to say who you are, make constructive remarks, evidence what you say, and be prepared to justify your comments. I will systematically invite anyone posting direct critique of me, with whom I have not met, to meet me personally to discuss their views and find out why they feel the way they do. But I want everyone using the site to start behaving in a professional way, posting sensible critique under their own names; to be mature, like any other profession using a professional site should be. NCAF is not Facebook; this is the public window into the world of clinical audit, and at present, it is pretty ugly viewing.

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13 February 2012: CAI event reaffirms audit value for health and social care

Last week saw the annual Clinical Audit & Improvement meeting on audit both local and national. HQIP sponsored and subsidised places, and the meeting offered a great opportunity for communication, sharing best practice, hearing updates, and networking. Speaking as objectively as I can, I would say that we remain pleased to be associated with an event which has proved durable and which continues to attract a good audience - including people from Italy, Ireland and the Channel Islands as well as England and Wales.

Highlights included a splendid reaffirmation of the value of national audits based on continuous data collection, with a presentation by the Hip Fracture Database. There was general agreement from the floor that this audit was central to enabling England to be an international leader in quality of treatment for hip fracture; this is an audit which has strong stakeholder support, drives change, is methodologically adequate, and delivers improvements in outcomes.

There was also a HQIP workshop on the application of audit approaches in social care - as I have talked about before, this is a major development opportunity for HQIP and we are pleased to see such welcoming of the approach from social care people present. There was real enthusiasm to see us do the work we are - and recognition of how much the sector needs it!

Quality, Improvement and Development team lead Kate Godfrey started the process of sharing the revised standards and curriculum guidance for training in clinical audit; there was complete welcome for these documents, final versions of which will be issued taking into account valuable points made.

Elsewhere, there were valuable presentations on legal issues, junior doctor audit, and how that is being improved, and how audit contributes to patient safety.

The Department of Health sent over a presentation which I was happy to deliver, which set out the key issues at national level. Once again transparency was highlighted, but more importantly, the Department emphasised the importance of audit, both nationally and locally. They were keen to stress how local providers must ensure they enable an adequate level of resource is present to meet the need for audit work - both local audit and national audit. It was very pleasing to see them make the case for local audit in this way. In the near future HQIP will be working to promote to providers how they must ensure that this capacity is not weakened in the pressure to make economies - audit is a mandatory function that simply can't be removed.

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26 January 2012: Realising national policy commitments - subscription funding and the transparency agenda

This week and last, you will have seen major announcements about the national clinical audit programme; one about subscription and one about transparency. We have been working on these issues for some time with the Department, helping them to realise national policy commitments for the move of some audits to a new model of funding and to present audit data in an open, granular way.

Subscription: the clinical audits moving to subscription are all long established, well regarded projects. They form part of the core datastreams used to measure the effectiveness of these clinical services. These are mainstream audits and it is right that NHS trusts support their operation as part of their core service delivery. The inclusion of payment within tariff for this ensures the ability to do so is covered and means that no Trust should need to make cuts, for example in the staffing of clinical audit teams, in order to pay for this. This would be a false economy.

Over time we will work with the Department to determine which other audits, if any,  should also move to this form of funding and the first place to hear such news is here, on this site.

Transparency: the announcements mark profound changes to the national programme. We will be requiring all funded audits to start publishing their results at the most detailed level of granularity that is possible, taking into account the robustness of the data and the risk of patient identifiability. It is entirely right that data is released that enables patients and the public to see the comparative performance of clinical teams, where the funding for such projects is from the public purse or such projects otherwise supported or facilitated by government.

Alongside this promise, we have added extra features: coming soon, an improved PARCAR participation database; and the new feedback system - because openness is two way, on the one hand national projects sharing information about local provider performance but on the other being open to comment and discussion about how data is collected and reported.

The last area in this announcement is about how national audit projects report their findings. We are issuing all national providers we fund with a requirement to produce reports that have common features and characteristics, and communicate well to patients. This is a further step in the direction of having one nationally integrated system of projects funded by the state. They will be easier to read and to understand as a result, and in visual terms the suite of audits will form a more coherent and linked set of reports to the same purpose of improving services.

As well as this, next week will see the issue of the consultation on the promised ‘Principles of quality in national clinical audit'. In addition to addressing the visual coherence of the communications aspects of the programme through the above, the methodological and governance functionality of the individual projects is gradually being brought to a common, agreed pattern. This includes of course the requirement to measure outcomes, which we have been building into audits steadily over time. The common level of granularity and a movement to use of patient consented data wherever possible are others. This new document will seek to gain overt public consensus on a raft of others as well.

It is time we collectively decided and agreed what are the features of good national clinical audit that should be present in both the ones we commission and others in the public domain. We hope very many of you will contribute to this exciting debate.

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16 January 2012: Breast implant crisis highlights crucial need for effective registry management

The new year promises much hard work from HQIP as we continue to advance the re-invigoration of audit on a variety of fronts.

We are pleased to be launching the new Good Governance Guide, adding to our range of materials aimed at providers to ensure they make best use of clinical governance in their work. That followed on from the first audit (Lung cancer) to be placed under the Transparency programme on data.gov.uk, and the launch of the in-depth patient guide to the NJR and last annual report. These are all firsts - groundbreaking new ways of showcasing audit data for a variety of audiences. We are proud of all of these.

Shortly to come are the revised education standards and curricula guide, the next annual Clinical Audit and Improvement conference (organised by Healthcare Conferences) in early February, and lots more, including a consultation on principles of quality in national audits and registries.

Of course, over Christmas, a storm broke in the form of the PIP breast implant issue, and the solution that everyone thinks would have prevented the storm breaking is the existence of an effective clinical registry.  Indeed it is fair to say that it reached the stage in the media where it was taken as read that ‘this would not have happened with a registry'.

Registers of course play a crucial role in identifying substandard devices - the National Joint Registry's work was the reason DePuy's ASR hip was taken off the market, worldwide, saving harm to many thousands of people - and so a very pleasing reaction.

However, it must be remembered that there is still a window whilst data builds up before any register identifies such hazards. It was very satisfying to see such universal endorsement and championing of what HQIP trades in, but also a concern that we had been talking about the need for a new breast implant register for some time and it took a crisis to make it come to the top of priorities.

National audits and registers are long term investments, and they need a strategic vision, not based on crisis, to see their long term potential but also that they need time. They are not a quick fix. We are delighted the Department of Health in England continues to have a strong commitment to the audit programme.

My last word this week is regarding an event on 26-27 April, a joint conference in London between HQIP and the European Society of Quality in Healthcare (ESQH), about national clinical registers across Europe - look out for further details shortly and keep the date in your diary.

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19 December 2011: Dementia audit illustrates profile of clinical audit >>

Anyone who had a television or radio on last Friday will have been aware of the release of the report from the national clinical audit of Dementia, led by the Royal College of Psychiatrists with partners. This audit explores the care and treatment of those with dementia not in specialist units but in general wards in hospital.

This report has some hard hitting messages about the need for better training, awareness and general standards in treating this group of patients with significant needs. I won't repeat these; the report is found on this site as a main news item.

As well as being very proud to be associated with this report in relation to a clinical audit of care of profound interest to so many, and having a hand in helping it achieve the publicity it did, HQIP is also very proud of the impact our reports are now having. This audit led the news on the BBC Today programme, described clearly as a clinical audit, not a ‘study' nor research, and had a presence high in the placing of news stories in various media. Its testimony to the increasing recognition of the power of clinical audit data, and the profile of clinical audit that was not there when we started just over three years ago. This is a conclusion backed by the evidence of ever increasing visitors to our website, both daily and periodic. We now have over 15,000 visits per month for the first time (and just under 10,000 unique users).

This is up from roughly 7,400/5,000 for the same period in 2010 and up from around 5,000/3,000 in 2009. Our daily user numbers have been steadily increasing too (now around 500 a day). People see the buzz about clinical audit; it has impact and can galvanise attention.

This profile is of course also testimony to the skill and dedication of our providers. This dementia audit is from a highly professional and credible school, at the RC Psych. This is also an example of a specific type of clinical audit, in that it collects a sample of data from a number of centres rather than collecting large volumes of outcome data on a permanent basis. Some question the value of audits like the dementia one. What the Dementia study shows is that the main purpose of clinical audit is change in practice for the better, and that simple, sample based periodic studies can achieve a phenomenal amount of impact. Whilst outcomes data is useful, we should not lose sight of the tremendous value of audits of the type of the Dementia audit in making the lives of patients better. That's what counts above all. Yes, all audits should have high methodological quality, and be rigorous, but most of all, more than all of that, they need to change the practice of care. The Dementia audit, I am sure, will do this, and as our elderly population increases, and dementia increases also, I intend that HQIP and our partners will have an impact on this most of all.

Happy Christmas everyone.

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12 December 2011: Focus on engagement >>

The engagement of clinicians in audit is a tricky issue. Those who work in clinical audit sometimes fail to understand the perceptions clinicians have of audit support staff and the audit function compared to their own. Interest in clinical audit amongst rank and file clinicians is very variable, with many seeing audit as a function of exciting potential and far too many seeing it as a very boring part of their working lives, up there with targets and trust reporting as the part of their job they least enjoy.

HQIP has done a great deal of work engaging with the clinical audit community, listening to their concerns, seeking to improve communication, creating dialogue  and enabling them, through the recent changes to the national audit programme, a greater say. But we need to balance this, reflecting that audit staff are only a part of the wider community that do, could and should get involved in audit. At the simplest level, the perceptions of clinicians about the value of various national audits is markedly different than that of clinical audit staff. Both need adequate voice and recognition.

Its vital that we continue to engage more and more actively with clinicians to promote audit and to get their interest, and hear their views. Colleges and professional organisations play a major role in securing their interest and this is why we are currently working with the Royal College of GPs to recruit two new clinical fellows to help support clinical engagement in that part of the clinician spectrum. These also ensure that HQIP has greater internal clinical capacity. Dr Yvonne Silove who works in the national audit team has brought a great deal to the organisation in this regard, as have some of our clinical champions. We will also be exploring the recruitment of a full time clinical specialist to help us reach out to doctors earlier in their careers to generate enthusiasm in audit.

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21 November 2011: Audit practice bolstered by international links

Last week, I was invited to Warsaw by the Polish Ministry of Health to attend an expert seminar on healthcare quality as part of their EU presidency period.  This event was combined with a meeting of the European Society of Quality in Healthcare, of which I am an executive member.  The seminar gave a very brief picture of some of the challenges facing many other European jurisdictions in improving their healthcare systems. Of course, despite our financial restrictions at present, many of the states of the East still face immense challenges in providing good quality healthcare, marked by the necessary architecture of quality I have referred to in previous blogs - standards, regulation, measurement and change programmes.
 
Nonetheless, the commitment to patient ownership and leadership is admirable.  In some settings, such as Poland itself, the lack of good handover and common IT systems means that the patient will often carry their notes between primary and secondary providers.  Where there are no existing systems, but a commitment to patient interest, quite radical solutions like this have been put into place.
 
It was a week of international liaison. Earlier on, I was visited in London by my equivalent for the Australian safety and quality commission, who play a similar role to us in improving audit quality and commissioning.  If you have read the latest eBulletin, with the major actions contained to improve and extend what we are doing, especially to improve national audit, you will know that we will be using the statement of operating principles produced by the Australians as a base document for a similar set of principles for national audits here.  We are currently adapting this document and it will be out for consultation as soon as it is ready.  We think this is crucial for defining what quality is for national audits, on a consensus basis.  Meeting my equivalent, and being able to discuss really significant common issues in audit development, and share ideas, experience and strategic goals, was invaluable.
 
Put alongside the visit to Warsaw, these two meetings illustrate the immense value of looking beyond the UK's borders.  With minimal cost enabled by on-line meetings, low cost airlines, free places, and sharing material with others, the practice of audit can only be enhanced and improved.

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11 November 2011: Social care: getting to grips with measuring quality

We are moving to the greater integration of health and social care and with that there are many challenges and one very good opportunity, which is to develop better ways of measuring and improving quality in social care settings. There is much scope for learning both ways between the two sectors on improving quality, with the person centred approach and staff supervision culture of social care being two examples that should travel into health. However healthcare is very good at measuring the quality of the care they provide and using that information as part of a dynamic cycle of quality improvement. Nothing really like this exists in a systematic way in the social care field, and with the integration agenda now so real, especially at the local level, social care should move to adapt the techniques HQIP promotes to the social care setting, not least of all because they effectively measure outcomes, demonstrate good quality care, mark individual professionalism, offer assurance to service users, and help support performance and outcome monitoring.

We have been consulting and discussing these issues extensively with policy, regulatory and opinion forming leaders in the sector over the last 12 months, and the next stage of this work is to produce a manual for service managers and practitioners about how the method can work in social care. Julie Fenner is working with us to produce this manual, which will be out in 2012, and we will be including lots of case studies of current good practice, examples, and practical ‘how-to' sections to enable the methodology to be used more actively within the sector.

We are also discussing how at a strategic level the Department of Health can explore the wider use of these approaches in the sector. We are exploring how the involvement of the social care sector in national clinical audit can be improved, and audit methods can be further trialled in the sector.

We are also pleased to see the inclusion of the need to conduct review of your practice in a  systematic way in the new Social Work Reform Board framework for the continuing professional development of social workers in England.

It's an exciting time, and it's a time for real cultural change. If you are interested in working with us on this area and helping us advance this type of work in social care, please contact us via eve.riley@hqip.org.uk.

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4 November 2011: Revitalising clinical audit and QI

You will all have seen a range of new material announced this week on our website. There will be a large volume of detailed announcements, products and consultations coming out in subsequent weeks. Much of this is about new activity in revitalising clinical audit, especially the national audits, but some is about the relationship between audit and other government policy and within quality improvement as a whole.

Within the audit area, the things we have announced mark out a new era, a step change perhaps - one where there is far greater engagement in informing policy by a wider range of stakeholders. We will be asking people to give feedback in a formal way about national audits, and to give their views about their inclusion in the new Quality Accounts list for next year. We will also be consulting on common principles that should underpin national audits, using as our starting point some really excellent work done in Australia. We will also be forcing the pace on transparency.

Turning to the broader context, on Monday I spoke at an event at the Royal Society of Medicine along with Mike Farrar and Martin Marshall which was looking at the overall organisation of QI - whether there was, or needed to be a ‘grand plan'.  As QI develops I think we need to be more strategic. The issue is the degree to which there should be a really strategic approach to deploying, evaluating and managing QI rather than a few uncoordinated organisations casting a wide handful of seeds of (unproven) ideas and hoping a few things work and take root.  

I believe in strategy, research and management, and with that co-ordination and partnership. HQIP is one of the major organisations in QI with a budget of nearly £18m Departmental funds to resource QI approaches but we still need to work alongside other organisations to deliver combined programmes within the wider, bigger world of QI beyond HQIP's contract business of audit. In the near future we will start raising questions about training in QI, for example. Watch out for this.

I have also taken part in a seminar led by the MHRA about how registries and audits can play a greater role in ensuring products don't enter the market without effective testing. There is no question that products should be subject to benchmarking review, such as registers provide, before they get used, and various partners such as NICE have a stake in this. Making this happen for a wider range of products is however, demanding.

NCAF will be running specific announcements and inviting comment on specific topics - but if there is interest in new discussion threads about any of the topics raised here, go ahead.

Next week's blog will focus on social care issues: and in subsequent weeks I will turn to learning from other healthcare systems.

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25 October 2011: Audit data - getting the best out of the excellent

Over the past two weeks I have very much been engaged with discussion about three related policy drives within government and how they can be achieved; the wider context of information for a variety of health purposes, including clinical quality, commissioning and public health; measurement to support achievement of better outcomes in health; and transparency, whereby data is more open and released more accurately and in better detail.

The types of data we commission or promote are directly related to this. Clinical audit data is of unrivalled quality to achieve these aims; it measures outcomes; it drives quality. We have to strive to ensure it is publicly released to the appropriate level of granularity too, and is well used for a variety of purposes. We are developing clear plans with national audits to ensure they meet these aspirations.

However the debate here is big one, and audit, registries and confidential enquiries are just one set of available data within these policy contexts. I have taken part in a series of events - firstly at the Kings Fund, chairing a Capita Conference on outcomes, and secondly participating in the information seminar that was part of the Francis public enquiry into Mid Staffordshire - that have really focused my mind on how much we who work in audit and registers need to relate to this wider context.

We have to remind everyone that these data sources we specialise in are crucial within these wider aspirations - major sources of good, reliable data, incredibly valuable to achieve these policy aims. We have to ensure that those working on broader strategies understand our collective contribution, and also our expertise and knowledge that we can use to help other data sources make the same impact. We have a vital voice on these matters that needs to be heard - in these national events certainly - but in trust board rooms, in clinical meetings, in college discussions - and internationally. We're world leaders; let's celebrate that.

You may like to pick up these issues for discussion on NCAF, our interactive networking portal, available via this site. A detailed discussion of views about information, outcomes and transparency as a whole, and our data's role within it, from HQIP will appear on this site shortly.

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13 October 2011: Feeding back on national clinical audits

This week has seen the national HQIP conference for those involved in supporting audit at the local level. We felt it went well and having read the evaluations and spoken with many delegates, the vast majority of you thought so too.

It was great to see Bruce Keogh to reaffirm how important audit is at the centre of the Department's priorities.

We included a lot of discussion of patient engagement - in recognition of how far we all need to travel in this direction. Thanks for all members of our patient network who attended.

Inevitably there was a lot of discussion about national clinical audit, and I was keen to say from the platform, that at HQIP we listen carefully to some of the concerns of those who feel that there are major issues with the Quality Accounts list and in the quality of some national audits. We have agreed with the Department of Health prior to the conference that HQIP will take over the process of agreeing which audits will be required reporting within the QAs, gathering views from various stakeholders to ensure the final list is a consensus based on various special interests. We will get this list out as soon as possible after the consultation is complete.

This marks part of a wider process of review of the national audits working with the Department. They share our view that collectively we have to agree a consensus view on quality in national audit from various perspectives. However some principles about quality are fixed - one being that there must be a move to open reporting from all audits at an appropriate level of granularity in an open way, with reports in formats and style for various audiences to understand and use - not just clinicians. We are working with every audit we fund to get to this point as quickly as is achievable.

Separately I attended and spoke at a Kings Fund conference on Information. I was keen to get over that information has to be seen not as separate, but part of a process. You can't reify information and discuss it out of context for its purpose. You collect what is useful, and audit data is only as useful as how much it is used to drive improvement in patient care and outcomes.  We have to get better at sharing information, certainly, as the conference stressed, but it seems to me too much information, in the wrong form, can be unhelpful too. Next week I am speaking at the Francis Enquiry on these very issues.

By the way I am helpfully reminded by one of our NCAF contributors, that NCAF is perhaps a great way to discuss any of the issues I raise in this blog. If anything I say here strikes a chord, you can always spark discussion in that media with others.

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7 October 2011: Improving routine data to benefit QI

I attended two interesting discussions this week, one to discuss what we could learn from the Swedish network of clinical registers, and the second to help define the research topics for the National Institute for Health Research (NIHR) Health Services and delivery research programme, which researches organisational aspects of NHS provision. Both brought together groups of interested stakeholders for what provided to be very valuable and high quality debates.

The first focused on how data is collected within the NHS for QI purposes and the issues of HES quality, data linkage, and the value of specialist databases, as well as transparency issues. I put in a lot of time preparing for this; from our mapping of audits and registers one of the important things to emerge was how far advanced we are in the UK, with well over 220 registers; and in comparison with the reporting level and data quality of the Swedish group we have a lot of good things going for our programme.

That's not to say we can't learn and we are in contact directly with the Swedish equivalents of HQIP to see in more detail what we might take from what they do. As a whole, the main thing that came through was the same as at the RCP seminar reported in a previous blog; how important it is that we improve routine data - such as HES - to align with collection of QI data for audit and research. We have to find ways to streamline data collection.

The research meeting was an attempt to synthesise the views of many stakeholders and advance these ideas into a more detailed review. I was very pleased to be invited to attend this and a previous event and to hear the ideas under discussion, many of which covered some of the same data issues. As the programme also covers social care, I was keen to see research into quality improvement in social care and methods used there currently as an aide to the work we are doing to promote audit in social care.

Anyhow, its our national conference of local audit staff next week, which I am looking forward to immensely. I look forward to seeing lots of you there.

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28 September 2011: Handover practice

On the 2nd September by invitation, and paid for by the project, I attended an international expert group on Handover, the conclusion of a three year project, funded by the EU, to improve handover practice across Europe. The project has funded some useful review work on systems and approaches, and has focused on training and protocols as the main ways of improving handover. Although the project has now ended, the team of European researchers have produced an online toolbox of resources and approaches, based on a model like our own NCAF, to enable people to share best practice on handover. This product will be refined and then made freely available. All materials are in English and it's a useful compendium of approaches, many derived from the UK but also useful work from Australia and elsewhere.

Issues of effective handover are important for all organisations, and especially those, who like HQIP promote methods of quality improvement. We have actively supported audit of case notes as one contribution to effective handover. However, inspired by this seminar, it may be that HQIP develops more work on this important topic in the future.

One side project, involving a team from Birmingham University led by Professor Lilford, has carried out useful modelling of the challenges of carrying out evaluations of the impact of quality improvement strategies, with the basic conclusion that such studies need to be very large and expensive to be able to show the impact of specific approaches in a crowded healthcare system. This is relevant to our own work in evaluation of audit, where any study to explore the impact of audit on practice will need to be very large.

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15 September 2011: Health Informatics Unit

I attended a really important and valuable seminar at the Royal College of Physicians today which celebrated the 10th anniversary of the Health Informatics Unit.

For ten years the team there has been doing first rate work promoting the importance of good practice in basic record keeping. Their work is simple, yet offers a real contribution to patient safety and quality. One of the main things they stress is the need for basic, routine collection of data, ideally electronically, that is rich enough in detail to also form part of the dataset needed for research and clinical audit. Over the years they have clearly identified the limits of the existing data sets collected in secondary care, and how, with the weaknesses of that data source, research and audit has to create new and additional data sources. The session usefully addressed the patient perspective and the opportunities for patients to see their own data and to collect it - and it was great to see two members of HQIP's patient group, Margaret Hughes and Phil Willan present.

However, patients, like clinicians, will wait a long time for any change from the centre, so the development of a single, high quality electronic collection of routine data with value for audit is still a long way off. In the absence of that, attempts by clinical communities to at least establish a single core data set within their speciality, to reduce the burden of recording and form a common platform on which to build audit and research, offer the only, albeit partial solutions. So it was really good to hear Will Dixon speak about the Arthritis UK Inbank project, which tries to do exactly that, establishing a common platform for arthritis research and audit and links between relevant databases in that area.

This is an exciting development and offers great opportunities for similar work in other specialties. HQIP is fully engaged with Inbank, through a link to the National Joint Registry, and cooperation with Arthritis UK on research. If other opportunities emerge to support joint data platforms with funding it would seem a good idea.

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14 September 2011: Westminster Health Forum

I was invited to speak at a Westminster Health Forum event on the 8 September.

Chaired by influential political figures, a great line up of speakers included the chair and medical director from Mid Staffs Trust as the theme was the implications for quality in the NHS arising from the public inquiry into inspection and regulation of NHS providers.

I spoke about the role of clinical audit and the need for professional leadership of quality data.  I was most struck by the succession of high profile speakers who endorsed the value of clinical audit and the key role of professionals in leading investigation and improvement of quality. Successive speakers - Fergus MacBeth from NICE, Niall Dickson from the GMC, Cynthia Bower for CQC, Linda Patterson from the RCP, all emphasised how important clinical audit now was, reflecting the important partnership work we have carried out with these bodies and their name checking of HQIP gave recognition of the profile of clinical audit and HQIP within it.

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Robin Burgess, Chief Executive, HQIP

Robin is responsible for the management and strategic oversight of HQIP.  He is an executive board member of the European Society for Quality in Healthcare (ESQH) and an individual member of ISQUA, the International Society for Quality.

Contact Robin via: robin.burgess@hqip.org.uk

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