Quality Improvement and Development Team Blog

Members of HQIP's Quality Improvement and Development Team will blog here regularly, reporting on initiatives to support clinical audit at a local level:

• 4 May 2012: Clinical audit in orthopaedics
• 4 April 2012: Bart's and the London Trust Clinical Audit Competition
• 20 March 2012: Antipsychotic prescribing in dementia care
• 24 February 2012: Junior doctors and clinical audit
• 8 February 2012: More from the North West
• 28 January 2012: Planning for new challenges
• 13 January 2012: Data Sharing and Information Governance seminar
• 19 December 2011: Interesting questions
• 15 December 2011: Keeping in touch
• 8 December 2011: Effective end to the 2011 RCA Network meetings
• 2 December 2011: Celebrating good practice and Ensuring Data Quality
• 29 November 2011: Excellent events from RCA Networks
• 23 November 2011: Venues, SWANS and Clinical Governance

4 May 2012: Mandy Smith: Clinical audit in orthopaedics

On Tuesday 1 May I attended the annual meeting of OICAN (Orthopaedics International Clinical Audit Network), hosted by the Robert Jones and Agnes Hunt Orthopaedics Hospital (RJAH) in Oswestry, Shropshire. Delegates included orthopaedic surgeons and other clinicians from both general and specialist orthopaedic hospitals, clinical audit and clinical governance leads and patients.

 Audit networks based on clinical specialities can develop a very clear focus on the key issues that matter to their patients. The delegates heard speakers from two of the major national orthopaedic projects - the National Joint Registry and the National Hip Fracture Database - and there was a particular emphasis on the ways in which these projects can and do lead to real improvements in patient outcomes. In fact in fact the analysis of data on outcomes was a theme throughout the meeting, with presentations on the National PROMS project in Orthopaedics, on the Epsom Orthopaedic Centre's outcomes programme, and how one of the local trusts has reduced morbidity and mortality by carrying out a detailed continuous audit of unexpected deaths following orthopaedic surgery.

Another theme which recurred during the day was the close relationship between quality and cost. Good quality orthopaedic care costs less - it results in shorter inpatient stays, fewer post-operative infections, fewer readmissions or revisions and better outcomes for patients. Trust Boards are increasingly taking this message on board, and the Chief Executive of RJAH spoke about how they have used the HQIP board guidance (http://www.hqip.org.uk/boards-and-clinical-audit/) to develop their own processes for considering clinical audit reports and quality improvement projects at board level.

Congratulations should go to Cormac Kelly (who leads the network) and Alison Whitelaw for their work in organising the event.

4 April 2012: Liz Smith: Bart's and the London Trust Clinical Audit Competition and National Audit Forum 2012

My colleague Alex Bird and I were recently asked to judge and award prizes at this event (Friday 30 March) to celebrate the Trust's national and local clinical audit programme.

Competition was stiff with 23 entries for the ‘trainee' category and twelve for the ‘speciality/team' group.  Judging competitions on behalf of Trusts is an enjoyable, if sometimes challenging, part of our varied roles.   All thirty-five projects were sent to us in advance along with the Trust scoring matrix and after much deliberation we agreed the following results:

Team prize: Child Development Team "Family Satisfaction with the CDT and Specialist Children's Services".

Trainee: Fiona Riddoch "Clinical audit of urine free cortisol requesting".

There was also a Trust nominated prize for the best Speciality Audit Programme 2011/12 which was won by Maternity.  Well done to everyone who submitted a project, the final results were very close in both categories.

On the day itself we heard presentations on the implementation of local change as a result of national clinical audits. We were inspired by some of the amazing outcomes and re-engineering of services that have come about as a result of national audit results being used as part of wider processes, including the new build on the Royal London site and the Trust's merger with two other east London organisations.  We felt that this work, particularly the MINAP project, should be shared more widely with the local community.  We understand that Bart's Health is building on the success of the day and already planning another event later in the year.

Mandy and I are happy to be involved with your local trust clinical audit event provided we have dates well in advance!

20 March 2012: Mandy Smith: Antipsychotic prescribing in dementia care

One of the speakers at the YEARN (Yorkshire Effectiveness and Audit Regional Network) meeting last week was Mubashir Fazlee, a pharmacist currently on secondment to South West Yorkshire Partnership NHS Trust. His subject was the ongoing project which the Trust has undertaken to improve the quality of care provided to patients with dementia, which links to the POMH-UK (Prescribing Observatory for Mental Health) Topic 11 clinical audit on the use of antipsychotics in dementia.

In 2009, the Department of Health published a report on the use of this type of medication in treating patients with dementia entitled ‘Time for action'. The report highlighted the substantial clinical risk involved, with a conservative estimate of 1,800 extra deaths and 820 extra serious adverse events such as stroke per year. The South West Yorkshire Partnership project, ‘The Right Prescription', was aimed at reducing the level of prescribing both in primary and secondary care.

A baseline audit showed that many of the problems which had been identified nationally were also of local importance, but what was particularly interesting was the way in which the local clinical audit team had contributed to the quality improvement interventions which have been put in place. One of the key steps was the introduction of local guidelines and a flow chart and checklist to assist clinicians who had to assess patients or review their medication. The clinical audit team were involved in the development of this documentation, which means that as well as being useful for the clinicians, it should also be easy to audit in the future.

The project team took a creative approach in getting their message out to the widest possible audience, including patients and carers. A simple but effective approach was to supply paper bags to pharmacies printed with project information, advising anyone who had concerns to talk to their GP. A more sophisticated approach was to include a QR code which anyone with a Smartphone can scan to get access to the information on the project website.

You can find out more about the project on the website here: http://www.southwestyorkshire.nhs.uk/useful-information/antipsychotic-drugs/

24 February 2012: Mandy Smith: Junior doctors and clinical audit

It was good to see some junior doctors presenting the outcomes of clinical audits at the recent Clinical Audit and Improvement conference in London. Shortly after that event, I went to Bristol, where the Severn Foundation School hosted the second annual National Foundation Doctors Presentation Day. This event is supported by the UK Foundation Programme Office and a number of other national organisations (including HQIP). It brings together doctors in training from across the country. I was very happy to sit on the judging panel which heard 23 presentations of clinical audits, research and other quality improvement projects. Other judging panels considered the 35 clinical audit posters and 32 posters of original work which had made it through an initial review into the final competition.

The range of topics under consideration was very wide. The projects included clinical audit, research, and also some of the more creative approaches which junior doctors are taking to help themselves, setting up peer-led groups to provide mutual support through some of the more thorny aspects of modern medical training. This did not make judging easy, but it did make for a fascinating day. First and second place in each of the three categories won both cash and a trophy in the form of an engraved Bristol Blue glass paperweight. As the overall standard of the presentations was so high the judges also commended a number of other projects for their combination of technical quality, relevance, impact on services and for the obvious enthusiasm of the presenters for their projects.

First prize for the oral presentations went to Dr Daniel Hill, who looked at the possible effects on theatre staff from the smoke which is generated by diathermy. This smoke is as mutagenic as cigarette smoke, and his study showed that the amount generated in a UK plastic surgery theatre could amount to the equivalent of up to 30 cigarettes a day. His survey of UK plastic surgery units revealed that only 66% of them had smoke extractor devices available, and that they were not always used. The Health and Safety Executive recommend the use of specialist smoke extractors but clearly the theatre staff themselves need to be aware of the potential risk they may be running from this unusual form of passive smoking.

Second prize went to Dr Karen Grewal, who had developed a scoring system to help GPs identify women who should be referred for ultrasound investigations for possible ovarian cancer. Delayed diagnosis is often a problem with this disease, but a case controlled study had shown a pattern of associated symptoms. The purpose of the scoring system was to enable GPs to apply this research, and aid GP led investigations.

Highly commended presenters included Dr Pei Gee Chew, who carried out an audit of the use of HS Troponin T against NICE guidelines, Dr Andy Caldin, who looked at measures to reduce the number of unnecessary admissions to A&E from nursing homes, and Dr Philippa King, who looked at the acceptability of home based care for children with bronchiolitis. The judges also commended Dr Harry Cutler and Dr Amrit Samra for their innovative approach to peer led support for foundation year doctors compiling their e-portfolios - the official record of their achievements and competencies.

It is inspiring to see junior doctors who are willing to take the driving seat in improving not only their own training but also the safety of their colleagues and patients and the quality of the care they provide.

8 February 2012: Mandy Smith: More from the North West

The North West Mental Health Network started its year on Monday 30 January with a meeting to develop a work plan for the group. The final document included several things which all networks need to do on a regular basis to make sure they are still effective and fit for purpose, such as reviewing the Terms of Reference. At a time when many organisations are changing and merging and individuals are changing roles and responsibilities, it's also important to review and update the membership list.

One of the key technical areas which the group identified was NICE Quality Standards. They plan to collaborate, both on reviewing the standards during the consultation phase, and on developing methods for monitoring compliance. The group has concerns about some of the standards which have already been published. As Ema O'Neill-Jones from the NICE audit support team was at the meeting she offered to take some of the comments back to her colleagues in the Quality Standards team. All of the members of the group will be responding to the current consultation on Quality Standards - it runs until 13 March. It was announced on NCAF here: http://www.hqip.org.uk/ncaf/pg/announcements/view/50365 and you can find all the details on the NICE website here: http://www.nice.org.uk/aboutnice/qualitystandards/qualitystandards.jsp.

The first Greater Manchester Clinical Audit Network meeting of the year also had attendance from NICE - Sally Sutcliffe from the audit support team spoke about the updated audit template which is now in use. We will be working with Sally and the other members of the NICE team to produce a simplified version of this template which trusts can use to create their own audit templates on the Clinical Audit Knowledge Exchange (CAKE) - a topic which I will be coming back to in future blogs. Sally also mentioned the current NICE consultation on indicators for the Commissioning Outcomes Framework - again you can see the announcement on NCAF (http://www.hqip.org.uk/ncaf/pg/announcements/view/51073) and get more details from the NICE website here: http://www.nice.org.uk/aboutnice/cof/ConsultationOnCOFIndicators.jsp.

Members of the network discussed plans for future meetings. As well as inviting speakers from national organisations such as the CQC and NHSLA, the discussion focussed on the importance of sharing the expertise that already exists within the group - one of the key functions for all networks.

Finally, I had the opportunity to catch up with some of my former colleagues from the University Hospital of North Staffordshire. Recently they achieved level 2 in their NHSLA assessment, and the assessor was very happy with the evidence they presented to show compliance with the clinical audit standard (now standard 2.1 - see the updated ‘Statutory and Mandatory Requirements for Clinical Audit here http://www.hqip.org.uk/assets/LQIT-uploads/Statutory-Mandatory31-1-2012.doc). The assessor was particularly impressed with their use of project briefs as part of the audit planning process. HQIP has asked the Senior Clinical Auditors (Clare Fleming and Vicky Lewis) to write up a case study of their experience which will be on our website ASAP.

28 January 2012: Mandy Smith: Planning for new challenges

When it comes to supporting local clinical audit networks, Liz and I split the country between us. Liz looks after the East of England, London and the south, while I take the Midlands, Yorkshire and Humberside and the north. Several of the networks in my patch have had meetings in the last couple of weeks, and as always there have been some interesting discussions. National clinical audit is always high on the list for debate, but each of the networks had had other issues to raise, many connected with plans for the coming year.

At YEARN there was feedback from their successful conference in November, which I mentioned in my first blog, and a discussion about the implications of the NHS operating framework for 2012.

At CASnet (for the East Midlands) the meeting took on a new format, following a network wide consultation. As well as a brief business meeting to discuss future plans, there were two facilitated discussions on topics of current interest. The first, led by Marina Otley and Roger Simpson, was on the approaches which the members of the network take in compiling their clinical audit programmes. A lot of the discussion focussed on the HQIP guidance, and I was happy to be able to tell the group that many of the concerns that they had about the old version of the guidance have been addressed in the new version, which is now out on the website (http://www.hqip.org.uk/clinical-audit-resources-3/). 

The second session, led by Sian Thomas of the East Midlands Internal Audit Service and Stephen Ashmore of CASC, was about the tricky question of costing clinical audit. In the current financial climate, how can we demonstrate that clinical audit is good value for money? To what extent should clinical audit be used to save money? I was happy to contribute some examples of audits which have saved money from our case studies (http://www.hqip.org.uk/case-studies/). Roger Simpson is interested in developing ideas for costing clinical audits and will be posting a discussion thread on NCAF.

Most of the old SHA regions have just one clinical audit network, but the North West has four. The Liverpool and Merseyside group met yesterday, and items on the agenda included their plans for a conference on 2 March - contact Jacqui Parry at Liverpool Womens Hospital for more information (jacqueline.parry@lwh.nhs.uk). The meeting was hosted by Aintree Hospital, and started with the presentation of an audit of nephrology referrals by one of their junior doctors. Debi Moorcroft, the Clinical Standards Manager at Aintree, gave a summary of the work which the trust is doing to develop clinical audit. It was very encouraging to hear about their determination to see that clinical audit achieves its full potential - particularly when other trusts are cutting clinical audit resources.

If you don't already attend the meetings of your local network, think about joining - there is much to be gained.

13 January 2012: Liz Smith: Data Sharing and Information Governance seminar

As part of its commitment to improving the National Clinical Audit and Patient Outcome Programme (NCAPOP), outlined in the HQIP four point plan published in November 2011, we have arranged a series of free quarterly seminars covering a range of topics related to improving aspects of the NCA programme.  Although originally aimed at project providers and contractors, the QID would like to bring these sessions to the attention of local clinical audit teams as we feel that some of the topics covered would also be useful at a local level.  We understand that there are still some places available, on a first come first served basis, for the inaugural 2012 event covering Data Sharing and Information Governance to be held on Monday 20 February between 9am and 1pm at the Wellcome Trust, Euston Road, London.

Further details of this, and future events, plus booking details are available on NCAF here:  http://www.hqip.org.uk/ncaf/pg/event_calendar/view/50388

Attendance at these half day events will not only give local clinical audit staff access to top class speakers but also the opportunity to meet and network with some of the national clinical audit project suppliers.

With our best wishes for 2012 - we look forward to continuing our work with you.

19 December 2011: Mandy Smith: Interesting questions

When I am not out on my travels a proportion of my time is spent dealing with queries that some in to HQIP. Some are straightforward, but some are more challenging and I certainly don't attempt to answer them all from my own clinical audit experience. The aim is to find someone who has expertise in a particular area and then share the reply with my colleagues at HQIP so that we all learn a little more.

Sometimes a query comes in which highlights the need for us to update the information on the website. A recent example was a query from the Clinical Audit Manager of a hospital trust in the North West. She asked about the way the CQC would use audit data - particularly data from national clinical audits - in compiling risk profiles for trusts. Her query was based on information given to her by one of the NCAPOP audit providers, who had told her that they submitted data on participation to the CQC.

There is a partial answer to her question on the CQC website, as the CQC have published a series of data source documents which list all the sources they will look at when compiling risk profiles. There are separate documents for each healthcare sector, and the CQC is updating them regularly. You can link to them through our updated summary of statutory and mandatory requirements for clinical audit.

All of the documents state that the CQC will use ‘national clinical audit datasets' in compiling risk profiles, but it is not clear whether this just refers to the NCAPOP projects, or to all the clinical audits on the Quality Accounts list, or to any national clinical audit which the CQC are aware of. If you search through the document for acute trusts you will find specific reference to some of the NCAPOP audits - for example, the Sentinel Stroke Audit - but also references to the last national priorities data collection on participation in clinical audit, which the CQC made for the year ended 31 March 2010.

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15 December 2011: Liz Smith: Keeping in touch

Now many of us are lining up on the runway to Christmas, it is the time of year when we traditionally think about keeping in touch with people.  The Quality Improvement and Development team have, this year, noticed a lot of organisational and departmental changes affecting Clinical Audit staff.  To enable HQIP to keep in touch with you please ensure that we are notified if your contact details, particularly email address, change.

To do this please go to http://hqip.org.uk/registration/ and enter your up-to-date details. This will ensure you receive the eBulletin at your new email address and that the information we have for you is up-to-date.

Unfortunately, you will need to amend your NCAF details separately. You can change your email address by logging in with your old details and clicking on ‘Settings' at the top of the page.  If you belong to a regional network please also remember to update your contact details with your local chair. 

Finally Kate, Alex, Mandy and I wish you an enjoyable Christmas break and look forward to working with you again in 2012.

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8 December 2011: Liz Smith: Effective end to the 2011 RCA Network meetings

Earlier this week I attended the South East Clinical Effectiveness Network (SECEN) meeting.  This is one of the longest standing regional networks, and having been a member myself for many years, I know the group well.  They are so keen to meet that in the past, when other venues were unavailable, the meetings have even been held in pubs!  However, on this occasion we were given generous hospitality by a survey software company in Central London.  The packed programme, apart from my HQIP update, included presentations from Jane Moore, NICE Implementation Consultant for London (a former HQIP colleague, and another SECEN member), Nick Johnson, HQIP's professional body consultant,  and  James Thornton, HQIP Communications Manager and Viv McGlashan (Royal Berkshire Hospital) who gave a mini - workshop on how to promote Clinical Audit both within organisations and externally.

Nick Johnson has now attended almost all the regional network meetings across the country and met a good number of the Clinical Audit community and other interested parties.  Nick says that although the on-line professionalisation survey closes on 9 December 2011, he is still happy to receive direct emails from those who have additional comments to make.

My final event for 2011 was at the South Central Clinical Audit Network meeting at Bracknell. Whilst standing on Waterloo Station looking forlornly at the ‘delayed' message for the train I was expecting to catch, I was joined by Kirsty Maclean Steel, NICE Clinical Audit lead.  We made the best of our unscheduled wait by having a good catch up and arrived at the venue just in time for our agenda slots along with a welcome coffee and mince pie (first this year!).  Among other items, SSCAN members were very interested in the recently published schedule of mandatory and statutory requirements and felt that this document could give them some evidence to challenge proposed changes within their organisations.  Members were also interested in the CAKE application, and agreed to log on to the website to learn more. 

The joint chairs, Jen Knight and Kat Young, put a great deal of effort into arranging the SSCAN meetings so it was disappointing to see so few people there.  This may be a reflection of the current changes that many teams are experiencing but is certainly not an indicator of the value to members of attending network meetings regularly.  Kat and Jen have arranged an interesting programme for 2012 including items on regulation and assurance. It would be good to see more people from the South Central area attending the next meeting on 1 March 2012.

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2 December 2011: Liz Smith: Celebrating good practice and Ensuring Data Quality survey

To celebrate the first full year of the two London Clinical Audit networks, set up by HQIP in 2010, a pan London ‘Sharing Good Practice' event was held in the Great Hall at St. Bart's Hospital.  It was an event worthy of the magnificent surrounding with the portraits of august benefactors looking down on us. How healthcare, and subsequently life expectancy, has changed over the intervening years.  I expect in the 16th and 17th centuries care for the sick was mainly focussed around the feeding of nutritious meals and cleanliness - which also resonates with us today.

Following on from the normal network meeting and guest speakers there was the viewing and judging of 14 excellent posters.  I was delighted to be asked to be a judge along with Kirsty Maclean Steel, Clinical Audit lead at NICE.  Kirsty and I decided not to mark the actual presentation design, as not everyone had equal access to professional poster making, but only marked the content.  We were pleased to learn that one poster had recently been submitted at an international conference in Berlin, and even more pleased to know that it was the Clinical Audit facilitator herself, and not a clinician, who had done the presentation.  Well done Alexa for raising the profile of Clinical Audit in Europe. We were also delighted to be joined by two members of the South London and Maudsley patient involvement network who had submitted a poster on improving food and dining for in-patient units.

After much deliberation Kirsty and I chose in first place the Bart's and the Royal London project led by Senior Physio., Cystic Fibrosis Service, Charlotte Wells on ‘Meeting physiotherapy needs of adults with CF in a challenging time'.  In second place was the CNWL Camden Provider Services project detailing the work and outcomes achieved in ‘An organisational approach to monitoring improvement' by Fiona Sutherland and Adam Backhouse.  We later learnt that Fiona and Adam had used learning from the HQIP conference to create and monitor their new process.

The success of the two London networks is down to the excellent chairs, Emerald Toogood and Dawn Nortman, their enthusiastic members and the organisations which host the meetings.   The QID team are delighted to see them flourish and will support their on-going development.

This week also saw the close of the Ensuring Data Quality Workshop impact analysis survey.  Many thanks to all those people who have taken the time to feed back to us how they have implemented the learning from the workshops (held in July and September).  It is only by receiving feedback that we can gauge the value of our workshops and support tools, which in turn enables us to develop further events and products. 

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29 November 2011: Mandy Smith: Excellent events from RCA Networks

The last few weeks have brought a flurry of events organised by regional clinical audit networks. The North West Mental Health Network (NWMHN) conference was hosted by Mersey Care Trust at their offices in Maghull. The organising committee had put in a lot of work to develop an entertaining programme which included a role playing / observational exercise on the problems and pitfalls of presenting clinical audit findings. It was a challenge for those of us called on to play the parts - although I rather enjoyed the role of ‘stroppy consultant who doesn't want to listen'. There was an excellent display of posters, with prizes awarded by votes from the audience. First Prize of went to the audit on ‘MRSA in a Mental Health Trust' (5 Boroughs Partnership NHS Foundation Trust), and the runners up were audits on ‘Screening Uptake in Women with a Learning Disability in Salford' (Greater Manchester West Mental Health NHS Foundation Trust) and ‘Out of Hours Workload of Psychiatry Trainees' (Mersey Care and Cheshire and Wirral). 

Although the event was organised by the Mental Health network, the event was open to the other north west networks and I will be meeting the chairs of all four networks in the North West in January to discuss the possibility of a full region wide event next year.

The Yorkshire and Humber Effectiveness and Audit Regional Network (YEARN) conference is a much anticipated annual event and the turnout was excellent - particularly now, when many trusts seem to be reluctant to allow staff time out to attend events. The audience included both clinicians and clinical audit staff, and this was reflected in the variety of presentations which included examples of good quality local audits. Karina Gajewska from the Yorkshire and Humber Public Health Observatory presented findings from their review of Quality Accounts, but sadly Dr James Kingsland, National Clinical Commissioning Network Lead, was unable to attend to give his presentation on Clinical Commissioning - something I am sure we are all waiting to hear more about.

Again there was a poster competition and the winners were Mathew Bell and Ana Megias-Bas, Hull and East Yorkshire Hospital NHS Trust for ‘Audit of the Approval process of restricted antibacterial agents'. Second prize went to Dr Muhammad Sharafat, The Mid Yorkshire Hospitals NHS Trust, B. Carrigan (specialist registrar), R. Srinivassa, A.Thickett and R. O'Leary (all consultant anaesthetists) for an audit of the use of routine blood tests on ITU.

This morning I attended the Midlands Effectiveness and Audit Network (MEAN) event at City Hospital, Birmingham. Like YEARN, MEAN has been running a regular programme of events for some years. Updates from the network, from NAGG and from HQIP were combined with workshops on the NHSLA audit criteria by Sally Suleman-Fereday (Senior Assessor, DNV Healthcare & Biorisk UK) and on implementing evidence based care by Chris Connell (NICE Implementation Consultant).

Linda Chadburn (Chair of NWMHN), Helen Blenkinsop (Chair of YEARN) and Val Bailey (Chair of MEAN) and all their colleagues on the respective steering groups deserve congratulations for the work they put in to organise these events, and HQIP is committed to continuing to support them.

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23 November 2011: Liz Smith: Venues, SWANS and Clinical Governance

I attended and presented at two Trust's Clinical Governance events this week.  Both were held in church buildings - it was good to see theses spaces used for conferencing but even better to see, were the very large audiences for both events and Trust commitment to Clinical Governance.

At the first event, held by East Sussex Healthcare, I was particularly heartened by a consultant urologist's excellent presentation on the National Continence Audit and how they were using the results to improve care especially as services vary between the Trust's two sites.

The second event at Moorefield's Eye Hospital, demonstrated their newly developed in-house, on-line Clinical Audit project management tool; this should benefit the Trust which has 21 sites.  Three hundred people attended the session with a wide range of professions and Board members present.

It is always a pleasure to go into organisations to promote the work of HQIP, and usually come away amazed at some of the work being achieved.

Following on those two events, I also attended the South West Audit Network (SWANs) meeting which takes place at an agricultural auction house venue.  I feel that SWANs is well named.  Members are serene and graceful on top but paddling furiously to cope with growing pressures and demands against a backdrop of reducing staff levels.  There was a lot of discussion about national clinical audit and members were pleased that HQIP will be working with the clinical audit community to improve the quality and effectiveness of projects over the coming weeks.

The schedule of statutory and mandatory requirements, published by HQIP last week, was well received (well done Mandy).  There was also some interesting discussion about HQIP using too much ‘modern technology' such as NCAF and Twitter.  My feelings are that we use a wide range of communication tools, and what is easier than the fortnightly e-bulletin popping into your in-box with ‘what's hot and what's not' in clinical audit and quality improvement. 

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