Quality Improvement and Development Team Blog
Members of HQIP's Quality Improvement and Development Team blog here on initiatives to support clinical audit and quality improvement.
22 November 2013: Strength in numbers
The chairs of the four clinical audit networks in the North West have been working together for some time to improve the sharing of good practice across the region, and their hard work was rewarded with excellent attendance at the recent regional training event, supported by the HQIP networks fund. 70 delegate places were on offer, and 70 delegates turned up – something of a miracle these days, when the pressures of work can conspire to make it impossible to attend external events. It also reflects the enthusiasm of staff in the North West to improve their own practice, as well as that of their colleagues.
Nancy Dixon led the day, with a focus on good audit design and achieving real improvements in practice. Here are some of the comments from the delegates:
· Excellent content that has highlighted essential improvements we can implement to our processes
What did you find MOST USEFUL about this event?
· Everything, gave lots of good ideas & has given lots of improvements we plan to take forward
· Realising I don’t know as much as I thought I did about clinical audit! Learning new methods and ways to challenge when I don’t think audits are as effective as they could be.
· Action planning – what not to do when action planning which highlighted issues / problems in our organisation. We are guilty of all the things we shouldn’t do.
· Focus on action and help and tips on how to make it happen
· Reassurance that we are all in the same boat with audit and need to move on together
· Thought provoking group discussion
What impact will this event have on how you fulfil your role?
· Valuable education on evaluating audit design and realistic ways change can be made to services
· Provided me with useful ideas to revisit locally / feed back with team; less audits of poor design and focus on fewer but higher quality audits
· More certain / confident of my stance within the organisation & empowered to push challenging issues e.g. audit ownership, RCA of findings, strength of actions.
At a time when many trusts are struggling to provide training, this kind of event demonstrates how the networks can provide a valuable service to their members, and CASnet, MEAN and YEARN are all holding training events and conferences next week. As Don Berwick has said, ‘The best networks are those that are owned by their members, who determine priorities for their own learning.’ Support your local network!
6 November 2013: Moving forward from the Keogh Review
By: Mandy Smith
One of Don Berwick’s conclusions about the NHS was that ‘The current NHS regulatory system is bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies,’ The Berwick Report. These gaps and overlaps could hamper the implementation of the findings of the Keogh review, so NHS England has produced a document setting out the roles, responsibilities and accountability of each of the organisations which must play a part.
The ‘Keogh Quality Note’ is a useful summary of the current regime for monitoring quality and driving quality improvement. The bewilderment which Don Berwick felt is perhaps reflected in the fact that it takes 11 pages to set out this regime, and for an HQIP audience it might initially seem strange that a document which is all about improving the quality of services does not include the word audit. However this document isn’t about uncovering failures in quality, nor is it about deciding what actions need to be taken to improve quality – that work has already been done by the Keogh review itself. This document is about who is responsible for ensuring that improvements actually happen – that crucial stage in any quality improvement process which all too often is where clinical audits fall down.
The first level of responsibility for implementing the Keogh action plans lies with the NHS trusts that were inspected – with their staff and especially with their boards. CCGs and NHS England also have some actions to take, and other organisations such as NHS Improving Quality and the NHS Leadership Academy have supporting roles to play. The responsibility for holding trusts to account for delivery of their action plans is placed on Monitor and the NHS Trust Development Authority. Of course at some point the CQC, through the Chief Inspector of Hospitals, will need to re-inspect the trusts in question, but the document makes it clear that this is seen as something separate – not a part of addressing the questions already asked.
There is a lesson here for clinical audit. All too often, actions are taken following an initial round of data collection, but then nothing is done to monitor the implementation and effect of those actions until ‘re-audit’ 6 or 12 months later. No-one takes responsibility in the interim, so the drive to change looses momentum. So who plays the ‘Monitor’ role in local audit projects?
Next year we hope to run another series of regional workshops on action planning and change management, and this is one of the questions we will be addressing.
1 November 2013: The judges’ scores are in: your evaluation of the HQIP conference 2013
By: Liz Smith
Thanks to everyone who completed a conference evaluation form. Your feedback and comments will inform the post conference review process and also play a key part in planning for future events.
The overall evaluation was again very positive with 96% of respondents rating the venue, organisation and content of the conference as good or excellent. This is welcome news as choosing a venue both in terms of location and facilities, as well as designing the content and getting speakers, started back in February!
Our main challenge for future events is to ensure we deliver stimulating content to our varied audience. We will take note of the need to engage more with community and mental health services; make the conference more attractive to clinicians and map clinical audit and quality improvement into local commissioning.
In terms of the workshop options, we will work on providing more information about each session at the time of booking so people can make more informed choices. It was terrific to see two workshops presented by local clinical audit managers; thanks to them and the other workshop presenters for accepting the challenge.
The opportunity to network is always a key feature of our conferences. Delegates welcomed the opportunity to speak informally with many of the speakers, whom they found to be very approachable. An added feature this year was the opportunity for discussion between local provider and commissioner organisations with national audit providers. We were even able to introduce two delegates who had flown in from Dublin on the same flight but did not know each other!
The evaluation forms have given us a wealth of comments both good and some more challenging, and many ideas for next time. I hope that this comment reflects the conference overall.
‘Great venue, excellent hotel, made the whole experience very enjoyable. Probably one of the best, if not the best conference I have attended.’
24 October 2013: All aboard for the SEA workshops
By: Liz Smith
Last week saw the first Significant Event Audit (SEA) workshop in Bristol, which was delivered by HQIP in partnership with the Clinical Audit Support Centre (CASC). CASC Directors Stephen Ashmore and Tracy Ruthven have wide experience in primary care audit and are specialists in Significant Event Audit techniques.
This series of regional workshop has been designed for GPs and their practices, and other providers of community care. It was good to see a mixed audience of GPs, Clinical Commissioning Group staff and other specialists, including GP revalidation leads.
The session was wide ranging, including the SEA requirements for GP revalidation. Delegates were provided with an excellent manual for further study and local use.
SEA is a completely new area of learning for me and I came away with two interesting learning points: SEA allows individuals and teams to review what goes well for patients and families as well as investigating when care or procedures do not go to plan, and “don’t forget Maureen”, in other words when discussing systems and processes involve the whole team as they often have experience of the wider picture and can add considerable value. I liked the inclusiveness of the SEA process and the emphasis on the need to record discussions and outcomes especially if the project covers other providers of care.
There are still a few places available at other venues, but early booking is now essential.
22 October 2013: Do you believe in fairies?
By: Mandy Smith
For me, one of the highlights of the HQIP conference in Nottingham was an excellent workshop led by Tim Heywood from Public Health Wales and Rachel Fletcher of Aneurin Bevan Health Board. With backgrounds in the Welsh ‘1000 lives’ campaign, they spoke about the impact which the All-Wales training package is having on quality improvement. You can find their presentation here (day 2 workshop 6) and they have blogged about their experiences at the conference here.
Many of their ideas are challenging to some conventional (outdated?) views of clinical audit, and I was particularly struck by one of Rachel’s slides. This was the one that showed the ‘Change Fairy’ – the charming but entirely mythical creature that flies in between the first round of data collection and the second to wave her wand and make everything better. On reflection it seems to me that an awful lot of people in the NHS seem to believe in fairies. All of the people who believe that an audit is finished once you have presented the results of the first round of data collection. All of the others who think that an action plan is simply something you write down and hand in to your clinical audit department to get them off your back. All of the Board members who think that as long as you are measuring compliance with standards things must inevitably get better. All of the audit leads who think that all you need to do to make change happen is ‘Remind all staff that . . .’
Then again, maybe I’m overlooking the real Change Fairies in the NHS. The front line clinicians of all grades, specialties and professions who are flexible and accommodating and ready to try new approaches if they bring benefits for their patients. The clinical audit staff who use their expertise and experience to guide and monitor the audit process from problem to improvement. The clinical leads who dig deep into the data and think about systems and processes to come up with creative and workable solutions, and then provide real leadership to achieve implementation. The Board members who are willing to emulate their colleagues in Wales, where the ambition is to ensure that everyone from ‘ward to Board’ has had training in quality improvement.
Maybe there are more fairies about than we realise!
30 September 2013: Valuing what you have
By: Mandy Smith
Earlier this year I gave a presentation at a Healthcare Conferences event in Manchester on the Francis report, and following on from that Kat Young, the chair of the recently renamed NQICAN (formerly NAGG) asked me to give a presentation to their September meeting. Three reports - by Robert Francis, Sir Bruce Keogh and Don Berwick - have been published this year which have implications for clinical audit and my presentation is an attempt to summarise them. You can download the final presentation here.
With a little help from some slides from Liz, most of the presentation consists of direct quotes from the reports themselves. Liz and I have taken the presentation to some network meetings and will take it to more. The discussions which have followed the presentation have shown that each of the reports have reached conclusions which reflect the concerns of clinical audit staff working at the coal face of quality improvement. Liz has already blogged about some of the issues, but there are two strands which have been picked up on in network discussions which I would like to raise.
The first is on the value which each of the reports places on the role of patients and carers as key partners in quality improvement and quality monitoring. Many healthcare providers still seem to see engaging with patients as a luxury which they cannot afford, but we are committed to demonstrating both the value and the effectiveness of genuine patient and public participation in clinical audit. National Voices, the health and social care charity coalition, was part of the clinician / patient alliance which founded HQIP, and we have a well established service user network. There is a whole section of our website on information for patients and the public here
The second is the value of having skilled and experienced clinical audit staff. Keogh identified a critical shortage in ‘key skills in data analysis and interpretation available to trust boards and management teams', while the Berwick report states ‘most health care organisations at present have very little capacity to analyse, monitor or learn from safety and quality information'. This report also proposes a solution to the problem: ‘Give the people of the NHS - top to bottom - career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning'. The clinical audit staff who I meet on my travels are generally already committed to developing their skills and it is a continued source of frustration to many that their skills appear to be undervalued by their employers. As we continue with our review of our products and guidance, we need to look at how we can continue to help the people of the NHS acquire the skills they need, and value the expertise that already exists in their colleagues.
10 September 2013: Professional and geographical isolation: more thoughts on Francis, Keogh and Berwick and how HQIP can help overcome some of these issues.
By: Liz Smith
A theme running through the Francis and Berwick reports, and specially mentioned in the Keogh Report is professional and geographical isolation. Keogh states: ‘The trusts we reviewed tend not to be well-linked to professional networks and other centres of knowledge’.This is as true for clinical audit professionals as for clinicians, managers and organisations in general. Potential issues that can occur when this happens are the failure to follow current best practice and the inability to keep up with, and embed new ideas.
In general clinical audit and quality improvement departments are small. In recent times there has been a move away from centralised clinical audit departments in favour of clinical audit staff working with, and responsible to business units, divisions or services. Even in terms of geography and office accommodation; we have come across clinical audit departments that are physically situated away from the main building and organisational hub, or tucked away in very remote offices on the main site. The Francis Independent Inquiry Report noted that in general the poor sitting of some offices can be detrimental to an organisation’s work. Technology can only help so far in bridging the gap between clinical audit professionals, their office base and all the stakeholders in the organisation’s clinical audit activity.
It is disappointing that some clinical audit professionals remain isolated. Since 2009 HQIP has worked to ensure that there are regional clinical audit networks in place across England, working collaboratively with The National Audit Governance Group (NAGG), which represents the networks at a national level. We know that peer support from clinical audit professionals working in other similar organisations can be a real benefit both for an individual and their organisation.
My colleague Mandy Smith and I attend the regional network meetings to share recent relevant publications, the impact of national reports and inquiries, such as the three major reports this year, and their impact on clinical audit. We also give updates on HQIP, resources and training events. Subsequently, Mandy and I are able to feedback to our HQIP colleagues the issues facing clinical audit in trusts and other organisations.
You can keep up to date with current best practice in clinical audit by accessing the resources on the HQIP website. Guidance and e-learning on quality governance and quality improvement, public and patient engagement in clinical audit and a range of other relevant topics can be found and downloaded free of charge. All our guidance materials are currently under review, and we will be announcing new versions as they are published.
Keogh states ‘These trusts will need considerable and sustained external support from a range of external sources to improve. In particular, they need help to establish networks with leading organisations within and outside the NHS to help them to counter the effects of the isolation described above.’ Throughout the Berwick report there is reference to the ‘power of persuasive and constant learning’. This is clear evidence of the power of networks and shared learning.
Over the past couple of weeks we have been able to confirm further keynote speakers for the HQIP Conference. The programme should address some of the issues around professional isolation and supports the Berwick Report recommendations in terms of continuous learning. For local clinicians and clinical audit professionals this is a unique opportunity to be able to engage with the national clinical audit project providers as well as national guest speakers such as Sir Mike Richards, Chief Inspector of Hospitals. We are pleased that so many local clinical audit professionals are taking an active part in the conference presenting workshops and posters.
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2 September 2013: Ensuring data quality in clinical audit: your opportunity to influence change
By: Liz Smith
Many of you will recall the series of ‘Ensuring Data Quality in Clinical Audit’ workshops that we held in partnership with Healthcare Quality Quest in 2011. A theme running through all these events was poor and sometimes unreliable Hospital Episode Statistics (HES) data. More recently, the issue has also been raised with us at network meetings and on other occasions.
Of course, over many years HES data has been the data source for amongst other things countless national and local clinical audit projects and mortality reviews. The view now is that it does not meet the needs of modern health and social care services.
You may not be aware that NHS England is leading a programme to bring the NHS data service up to date and has launched a consultation to get a wide range of views to inform this process.
The process, known as the care.data programme, has three strands:
- Ensuring that the new service meets current information governance standards
- Expanding the range of care settings from which data is drawn starting with the linkages from all hospitals and GP practices and in time by adding data from all other care settings, such as community health services and social care. This will see HES data become a care episode service (CES).
- Enabling commissioners to have a better range of hospital data. At the moment, HES is mostly limited to demographic, diagnostic, and procedural information, the quality of which is variable. Serious gaps have been identified in OPD and A&E data for example, and there is little or no access to information about patients’ experiences of care, outcomes, hospital prescriptions, investigations, or observations.
This project brings together a number of themes about the quality of data, data analysis and the use of information that we have explored over the past few weeks with the Francis, Keogh and Berwick reports, as well as Caldicott2.
The care.data programme leads are seeking responses to their consultation from a wide range of stakeholders. Do use this opportunity to give your views on how the CES can truly support good quality clinical audit, care audit and quality improvement. Consultation closes on 16th September 2013.
23 August 2013: Product Review: update on recent review panels
By: Liz Smith
Following the announcement in June that HQIP would be carrying out a comprehensive review of all its guidance, last week saw the first two review panels take place. These events looked at our current good practice guides, templates and resources in relation to clinical audit practice, and public and patient engagement. An earlier call for volunteers resulted in panels of experienced clinical audit professionals and managers from a range of healthcare sectors, as well as other partners and stakeholders. Members of the HQIP Service User Network were invaluable on day two with their knowledge and experience of PPE in clinical audit.
Over the past five years we have published over thirty resource documents and e-learning modules. Most have a regular review as part of the Information Standard accreditation process but the current review is taking place to ensure that we have the most up to date resources available to support clinical audit and quality improvement across health and social care. It was interesting to see how practice in some areas had changed over time, and the review panels recommended the deletion of some products and the creation of new ones. Following the final two panels the notes from all four days will be transformed into action plans for each product. Work will then begin on the revision of existing documents and the creation of new products which will be distributed, as usual, for wider consultation.
We would like to thank members of both panels for giving their time and expertise, and special thanks go to those who got up very early and travelled long distances to be with us.
8 August 2013: Essential summer reading: The Berwick Report
Earlier this week saw the publication of the National Advisory Group on the Safety of Patients in England’s report ‘A promise to learn –a commitment to act. Improving the Safety of Patients in England’ (The Berwick Report).
Following on from the Francis Inquiries and subsequent Keogh Reviews, the advisory group were charged with looking at the lessons learned from these events and identifying the changes that need to be made across the whole NHS. Behind the inevitable sensational media headlines the report demonstrates a wealth of understanding and thought behind the problems and issues, and gives robust recommendations and ways forward.
Although clinical audit is not directly mentioned, data and the correct analysis and monitoring of data are. Quality improvement is one of the key themes and it is pleasing to see this underpinned in the recommendations. Berwick identifies that improvement requires a system of support and that the capability to measure and continually improve the quality of patient care needs to be taught and learned. His solution is to give career-long help to learn, master and apply modern methods of quality control, quality improvement and quality planning to all. I particularly like the definition of quality improvement in relation to healthcare– ‘to decrease variation within and among NHS organisations so that best becomes the norm’. This aim directly underpins HQIP’s vision to develop the skills of clinical audit professionals to make them quality improvement specialists, and to share best practice across all healthcare providers in all sectors. We are working with providers and commissioners, and other partners to ensure that we have up to date resources, guidance, e-learning and training in place.
Whatever your role in clinical audit and quality improvement we would urge you to read the whole report:
2 August 2013: Data, data everywhere: notes on the Keogh Review
Looking through the Keogh Review report and some of the individual reports on the thirteen hospitals inspected as part of the recent review process, it would seem that there are still some gaps in learning and best practice in Clinical audit and quality improvement in some organisations.
The amount of data submitted both locally and nationally to the inspection teams was truly mind-boggling. Two crucial points are that data must be accurate and that it must be analysed and reviewed. Themes and issues should be disseminated and escalated in a robust process that staff understand and are able to use. For example, many staff across several organisations reported that they did not have feedback on clinical audit projects and good practice was not shared.
It would seem that some trusts did not look in enough detail at the recommendations from the Francis Independent Inquiry report (2010). You will recall that that this report, rather than the later Public Inquiry, looked in some detail at clinical audit at Stafford Hospital.
In relation to clinical audit and quality improvement there are some key themes that run across both the Francis Inquiry and Keogh Review. Needless to say, responsibility for strategy and good practice starts with the board as part of its wider strategic approach to quality, governance and risk. Boards need to use the wide range of data sources available to them including clinical audit. There needs to be a realistic, robust and monitored clinical audit programme across all areas of care and in all specialities; clinical audithttp://hqip.org.uk/assets/LQIT-uploads/Guidance-0212/HQIP-CA-PD-001-220212-Clinical-Audit-Programme-Guidance.doc. Francis and Keogh also both recommend protected time for clinicians to engage in Clinical audit and to attend the appropriate meetings where clinical audit is discussed.
The Keogh Review report Ambition two reads-
‘The boards and leadership of provider and commissioning organisations will be confidently and competently using data and other intelligence for the forensic pursuit of quality improvement. They, along with patients and the public, will have rapid access to accurate, insightful and easy to use data about quality at service line level.’
Following on from the Francis Inquiries and Keogh Review we are delighted that Professor Sir Mike Richards, newly-appointed Chief Inspector of Hospitals at the CQC, will be leading a keynote session entitled ‘The future regulation of NHS-commissioned services post-Francis’ at the HQIP conference in October. This is a real opportunity to learn about and maybe even inform this process.
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26 July 2013: Clinical audit the "bigger picture"
My final event before the ‘summer break’ was an invitation to attend the ‘Raising the Standards’ afternoon of presentations and poster display at South London Healthcare NHS Trust. Again, it was a swelteringly hot day so the doors of the full Lecture Theatre at the Q E 2 hospital, Woolwich, were wide open.
Following presentations by, mainly junior, healthcare professionals representing a range of specialities I spoke about the work of HQIP and how Clinical Audit forms, and informs, part of Trusts’ overall business. I have found that it comes as quite a surprise to junior, and sometimes senior, staff that organisations have statutory and mandatory requirements to take part in clinical audit projects and that the regulators use Clinical Audit data as part of the assessment processes. http://www.hqip.org.uk/statutory-and-mandatory-requirements/. Audiences are always interested to know about how ‘Quality Accounts’ came into being, and how clinical audit is also part of this public reporting mechanism.
‘Raising the Standards’ was a good title for the event which covered several innovative topics, some of which were Quality improvement Projects (QIPs). I was impressed that some of the junior staff involved had already moved their work on by adding in extra sessions into junior doctor training. But to give their work longevity they need to ensure that their new teaching is incorporated in future training programmes; otherwise, when they leave the improvements may not be embedded. This is one of the reasons that all QIPs need to be registered and monitored centrally by organisations and that action plans are written and monitored for all types of projects.
To help organisations and clinical audit professional further develop their good practice we have included workshops on risk assessing clinical audit findings and ensuring organisational memory through audit and QI in the HQIP conference programme. There will also be a local ‘market place’ of good practice posters where delegates can learn from their peers and others. Booking for the conference is now open and going well: http://www.hqip.org.uk/conference-2013-booking-open/
The winner, by far, of the poster completion was the project on the placement of naso-gastric tubes which had a good action plan attached. The overall prize winner for the best presentation of the afternoon was Dr Pretin Davda who presented on the management of hyperkalaemia. Pretin narrowly beat an engaging presentation by Dr Edd Maclean who spoke about improving foot health for diabetic patients.
Again, well done to the Clinical Audit team for organising the event. The challenge for them, and others, is how to keep best practice in Clinical Audit and Quality Improvement on the agenda as the trust de-merges shortly and new organisations come into place.
Finally and, almost, best of all the event was kept exactly to time by the chair, so we all got to enjoy the late afternoon sun.
19 July 2013: What a perfect day!
By: Liz Smith
Last week when the country was sweltering under the hot, sunny skies my colleague Kim Rezel, HQIP lead for Public and Patient Engagement, and I were tucked away at North Middlesex Hospital judging clinical audit posters as part of a daylong exhibition and presentation event.
Kim and I, along with other judges, were impressed by the high standard of posters covering a very wide range of clinical areas and topics. During the viewing we were able to ask the teams questions, which is always useful. One issue that we were able point out is the need to have a robust action plan as part of the poster presentation, after all that is the most important information that needs to be put across!
Lunch was followed by an afternoon of presentations and prize giving. Well done to all those who presented, but special mention to the ‘Operation Warfarin’ team who have made significant improvements to patient safety and well as improving junior doctor learning. We hope that the team will consider submitting their project the Junior Doctor Clinical Audit and Awards event that we are co-hosting later this year with the Clinical Audit Support Centre (CASC).
Well done also to the Clinical Audit team for putting on such an excellent day. We know that planning such events begins months in advance and requires time and perseverance.
As we came out into the hot sunshine Kim and I felt that this had been a really valuable day both for the trust and HQIP and we are looking forward to returning next year!
12 July 2013: Altruism in Action
By: Mandy Smith
The YEARN (Yorkshire and Humber Effectiveness and Audit Regional Network) meeting last week was held at the NHS Blood and Transplant centre at Seacroft Hospital on the outskirts of Leeds. After the meeting, Marc Lyon, NHS BT clinical Audit Manager, had arranged a tour of the centre with presentations from some of his colleagues. It was an opportunity to see another aspect of quality of service in an organisation which has a unique set of challenges.
As well as auditing the clinical processes associated with blood donation and processing, NHS BT has to comply with the requirements of the MHRA as a pharmaceutical manufacturer. It runs national audits on organ donation and transplantation, and the National Comparative Audit of Blood Transfusion. One of the aims of this audit is to ensure that blood transfusion is only carried out when clinically necessary and appropriate, but as NHS BT is funded by the income it generates from supplying blood and blood products, the success of this audit can reduce its income.
Some facts and figures:
· NHS BT relies on some 2 million blood donations a year to supply 7,000 units of blood a day
· At any one time about 4% of the population are active blood donors
· Men can donate blood every twelve weeks, and women every sixteen. However some donors volunteer to donate platelets using equipment which separates the blood components during the donation. As only the platelets are removed, they can donate every two weeks.
The timing of the tour was very appropriate as we were in the middle of National Transplant Week. One of the topics we discussed with Jayne Fisher, one of the Specialist Nurses for Organ Donation, was the fact that under present legislation, a family can decide to refuse organ donation even though the potential donor has joined the Organ Donor Register. It was interesting to read on the BBC Health News website just later that day that this is now under review, but it will still be important for anyone who joins the register to discuss their wishes with their family.
Thanks to Marc for arranging the tour, and to Jayne, Shirley Nesbit from the Scientific and Clinical Training department who did the majority of the blood centre tour and Sarah Fawcett the Donor Centre Nurse for their time. And well done to the member of our party, already a registered donor, who stayed on to make a donation. If you would like to consider joining him, or like me you are a lapsed donor who would like to re-acquire the habit, you can find all the information you need on the NHS BT website
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5 July 2013: Delivering on Francis
By: Mandy Smith
The theme for the Healthcare Conferences Clinical Audit for Quality Improvement Event in Manchester on 2 July was ‘Delivering the Francis Recommendations’. I take a personal interest in the situation at Stafford Hospital. It’s just 13 miles from my home, and I drive past it every time I go to Stafford to catch the train down to London. I have friends who work there, and friends and family who have been treated there.
The Francis report itself makes it clear why clinical audit failed to uncover the problems at the trust. Local audit meant data collection, with no attempt to use the data to resolve failings or drive improvement. Stafford didn’t participate in many of the national clinical audits and no one questioned this. Re-audit didn’t happen. There was a complete absence of board leadership on quality, and a failure to recognise the need to monitor the impact of structural and organisational change on quality of care.
The report also sets out a clear recommendation for making sure clinical audit has impact:
The Board should institute a programme of improving the arrangements for audit in all clinical departments and make participation in audit processes in accordance with contemporary standards of practice a requirement for all relevant staff. The Board should review audit processes and outcomes on a regular basis. Midstaffs Public Inquiry Website
Several of the presenters at the conference spoke about the role of trust Boards, and by implication the senior management of non-trust NHS care provider organisations. Chris Swonnell from University Hospitals Bristol spoke about board assurance and the needs of non-executive directors, and Andrew Cockayne of Croydon Health Services spoke about ways of communicating complex information at board level. Other presenters spoke about the importance of acting on audit findings, and on engaging the whole organisation in the audit process. I was particularly struck by Liz Lees work at Heart of England NHS Trust on encouraging nurses to participate in and lead clinical audits.
Michael Spry, Clinical Audit Manager at Countess of Chester Hospital, and Jean Schofield, Clinical Audit Development Manager at Sheffield Teaching Hospital, both gave presentations on life at the sharp end of audit – Michael on records audits, and Jean on making improvements based on national clinical audits. Special mention has to go to Jean for delivering an excellent presentation despite spending part of the day in the local A&E after a fall at the conference venue. Luckily the 4 hour wait was not breached!
26 June 2013: SECEN - learning from the past to assure the future
By: Liz Smith
Aylesford Priory in Kent was the beautiful setting for the latest SECEN meeting. Having been a member of SECEN myself for well over ten years it was good to see so many acquaintances and new members present and to know that the network is still vibrant and well attended.
There was a packed programme including the election of James Shaw-Cotterill as chair. The current chair Sue Venables has stepped aside following her appointment to the role of General Secretary of NAGG. SECEN will now have two attendees at NAGG meetings at this important time for NAGG as it welcomes a new chair and reviews its future and partnerships. As we say congratulations to James, who will be able to bring his experiences of working in clinical audit in a community provider organisation to both the SECEN chair role and NAGG, we also give our thanks to Sue who has been SECEN chair for some years and through her determination, and that of others, has kept the network alive and well across Surrey, Kent and Sussex.
Apart from my usual HQIP update I was also asked to give presentation on the Information Governance Review 2013 and the Francis Inquiry Reports. It is useful for the small field team at HQIP to be able to brief clinical audit and quality improvement specialists on relevant sections in recent important publications and we are happy to be able to share this learning with others.
I have always liked the motto “Don’t wait for your boat to come in – row out and meet it!” This was certainly the theme for the afternoon workshop on career progression in clinical audit given by our colleague Nancy Dixon at Healthcare Quality Quest. Nancy described the wide skill set that clinical audit professionals develop and how these are transferable into other quality improvement roles, across other service and managerial roles, and into other jobs such as research. Nancy also outlined some good ideas for creating eye-catching portfolios, applying for jobs and preparation for interviews.
... and finally another goodbye...this time to Julie Sears, Clinical Audit Manager for Virgin Care, Surrey who has been a long standing member of SECEN and a keen supporter of HQIP and our work.
21 June 2013: SWANs meeting and a swansong
Following several busy days of events across London it was good to round off the week by attending the SWANs (South west audit network) event near Taunton. This required an overnight stay in my favourite chain of budget hotels and on this occasion I arranged to meet two network members who come over from Jersey. We had a good evening together discussing integrated health and social care systems on the island. I was surprised to hear that there are some pockets of deprivation on what seems an island paradise.
It is always a pleasure to talk at SWANs, which is unique in that much of its funding comes from subscriptions from participating organisations. This funding is complemented by resources from HQIP's clinical audit network fund. Having attended the ‘Everyone Counts’ pre-publication event the day before I was able to update the members with the latest news about the project.
As part of HQIP’s review of networks and member organisations, we reviewed and updated the membership list in light of the changes introduced in April this year. Most members, especially those in new organisations, reported increased workloads and some reduction in staffing levels. There was some concern expressed that quality improvement projects (QIPs), whilst being valuable both to staff in enabling them to bring about change and improve patient care and outcomes, were not being brought to the attention of clinical audit teams. These projects therefore may fall outside organisations’ processes and reporting. Some members did have good processes for monitoring QIPs in place and these were shared.
The SWANs chair led a discussion about the future direction of the National Audit Governance Group (NAGG) and how it could develop to meet the needs of clinical audit and quality improvement professionals across all providers and commissioners of NHS-funded care.
This meeting was also a sad swansong for SWANs' former chair Ann Burnett. Ann was instrumental in setting up the network over ten years ago and has seen it grow to its present membership of over sixty. As network chair she represented SWANs on NAGG before becoming NAGG General Secretary. Ann is held in high esteem across the clinical audit community and has supported HQIP in the development of resources and led conference workshops. We will miss Ann, but I am certain that she will be using her skills and experience to benefit patients wherever possible.
13 June 2013: A chance to reflect
By: Mandy Smith
The annual MEAN conference is a regular feature in the calendar for anyone working in clinical audit in the West Midlands. This year’s event was held at St Georges Hospital, Stafford – part of South Staffordshire and Shropshire Mental Health Trust – and Steven Hazledine from the trust gave a presentation on the advances made by the trust in audit reporting. I was able to give an update from HQIP which included much of the information which has now been released in the latest e-bulletin.
The majority of the day was given over to a workshop facilitated by Nancy Dixon of Healthcare Quality Quest, giving MEAN members the opportunity to hear the work which Nancy presented to CASnet which I blogged about in February. The workshop has obvious benefits for people who are new to clinical audit, but it also gives more experienced clinical audit specialists the opportunity to reflect on the way they approach their role. I have a favourite quote from the late great Professor Avedis Donabedian, one of the founding fathers of quality measurement in healthcare. He said ‘Doing one’s best and being self-critical, self-adjusting, constantly seeking improvement, is a fundamental trait of professionalism’. If you work in clinical audit you spend most of your time challenging clinicians to do just that – so isn’t it a good idea to occasionally try challenging yourself?
You can find out more about Donabedian here
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7 June 2013: Pan-London Clinical Audit Network: Quality Improvement and Sharing Best Practice event
By: Liz Smith
Behind the hustle and bustle of King’s Cross Station lies St Pancras Hospital which was the venue for the annual joint meeting for the North London and South and East London Clinical Audit networks to meet and share good practice as well as networking with their colleagues across the capital.
About 35 clinical audit staff and clinicians enjoyed a packed programme including Nancy Dixon’s (Healthcare Quality Quest) workshop on Quality Improvement. The programme gave lots of opportunity to view the wide range of posters covering both clinical audit projects and good practice in clinical audit processes. The posters were also supported with verbal presentations. The presentation that really impressed everyone was given by Jos Miles, from King’s Health, who outlined the trust’s processes for managing and reporting on national clinical audits from service areas to the Board. The unenviable task of poster judging fell to Nancy and Jane Moore, the NICE implementation consultant for London. Adam Backhouse and Steve Walters, the respective network chairs, got novelty ‘clinical audit prize winner’ coffee mugs made, the first won by Alannah Hayes from Kingston Hospital, who presented an audit of ‘Common Surgical Conditions: Using standardised templates to improve information given to patients on discharge’, which was carried out by a group of FY1 doctors during their General Surgery rotation. The second was won by Kerry Tauxe from South London and Maudsley NHS Foundation Trust for their Do Not Attempt Resuscitation (DNAR) audit.
Thanks to Adam and Steve for arranging such a really good day and also to the St Pancras Hospital staff for their hospitality.
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4 June 2013: Best foot forward – Kingston Hospital Clinical Audit Seminar
By: Liz Smith
I was pleased to be asked to be part of the judging panel for the Kingston Hospital NHS Foundation Trust Clinical Audit seminar poster competition. Ahead of the event, the small panel had the difficult task of choosing from a selection of really outstanding clinical audit presentations all displayed on eye-catching posters. Although the panel members judged separately there was consistency in the marking which led to a multi-disciplinary local audit – The Effectiveness of Diabetic Foot Care Assessments by the MDT- winning first prize. The project used both NICE and local standards but most crucially had a robust action plan.
The Kingston Hospital Clinical Audit seminar is an annual event and run on the lines of a top-level conference by Anne Jones, Head of Clinical Audit and Effectiveness and her enthusiastic team. As well as the poster displays and seminar presentations there was also a series of mini-workshops including one on risk rating clinical audit results. This session outlined the trust’s newly introduced process for a risk assessment approach to clinical audit results and included some hands on practice.
I came away impressed by the empowerment to influence change that the trust allows junior doctors and other healthcare professionals to use in making improvements to patient care. The Quality Improvement Project technique is well established and has allowed junior doctors to make some significant changes in for example the diagnosis and care of dementia patients.
I was not surprised to learn that the hospital has high levels of patient experience and satisfaction, and it was good to see that the trust is employing clinical audit and quality improvement as part of its patient experience strategy.
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20 May 2013: Clinical divisions showcase their best practice in Leicester
By: Mandy Smith
I was in Leicester last week for the University Hospitals Leicester Clinical Audit Leads Forum. Carl Walker, Clinical Audit Manager had arranged an interesting programme, covering diverse topics such as the interaction between clinical audit and medical revalidation, the way the respiratory team at the hospitals are using IT to support the audit process, and the challenges faced by those who take on the role of clinical audit lead. I was able to give an update on HQIP's plans, including the latest developments in the ‘Everyone Counts' project - you can find more information here: http://www.hqip.org.uk/everyone-counts/
The event began with the final stage of the annual clinical audit competition and presentations from each of the four clinical divisional winners. Again, the topics reflected the range of audit activity across the trust, both in local audit and in participation in national projects. The Acute division presentation was about the local improvements that have been made following participation in the MINAP, and those of you who were at the London LINAP workshop will have heard a similar report about the improvements made by the London Chest Hospital.
A presentation on the re-audit of antibiotic prophylaxis in fractured neck of femur patients showed not only an improvement in care but also the importance of doing more than simply changing policy. The improvement was brought about by publicising the change and re-educating colleagues.
Local concerns in one of the most culturally diverse cities in the UK were reflected in a presentation on audit of access to familial cancer susceptibility clinics - a very newsworthy subject given the recent publicity for Angelina Jolie's decision after discovering her familial cancer risk.
The winner - chosen by a panel vote - was a re-audit of patient warming and perioperative hypothermia. An initial audit against the NICE guidance (CG65) had shown shortfalls, so the trust acted by trialling a new system (Inditherm Patient Warming - see NICE MTG7). An audit of the trial showed both an improvement in compliance with the NICE standards, and the potential for significant cost savings. The new equipment will now be introduced across the trust, with repeated audits to ensure any problems are monitored and addressed.
If you or your organisation is considering putting on an event like this and you would like to hear from HQIP please do contact us.
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17 May 2013: Flying the flag for Community Care events
By: Liz Smith
Recently, I have spoken at two community care events that both highlighted excellence in care and learning within community health services. NHS Solent used their “Using Evidence-Informed Practice to Improve Community and Mental Healthcare" to share learning with staff, other external and university partners. The session on Pads and Pants; Continence Technology, was really thought provoking and raised some laughs too. It was encouraging to be with an organisation that supports this type of conference, and to see so many executive and non-executive directors taking a real interest in clinical audit and quality improvement.
NHS Community services in north-west and south-west Surrey, as well as some Surrey-wide, are run by Virgin Care who invited my colleague Sam McIntyre and me to their “Promoting Clinical Excellence Event 2013”. Virgin Care won the HQIP award 2013 for Partnership Working.
The standard of presentations and posters was very high, and Sam, who works on the HQIP national audit team, and I were able to take away learning about community care, community hospitals and care homes. In the relaxing atmosphere it was easy for delegates to network and learn. The hardest part of the day was admitting to the questions on the diabetes themed ice-breaker exercise which left only a few people standing following questions on exercise, eating, smoking and drinking!! This local event was well supported by the national Virgin Care team and non-executive directors who empower and support local staff to improve services for their clients and communities.
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15 May 2013: Keeping in touch in changing times
By: Mandy Smith
The last few months have been busy for everyone as we went through the preparation for and implementation of all the changes in the NHS which came into force on 1 April 2013. When so many organisations are changing their names, their roles or relationships and individuals are moving as well, it's very easy for key contacts to get broken or lost.
During times like these, the regional clinical audit networks can provide a valuable resource in maintaining links. By helping the networks, HQIP can ensure that we keep our contact lists as up to date and accurate as possible too.
Liz and I have been working through all the available resources to try and identify all of the NHS care providers and care commissioners who might be eligible for membership of the networks - we will then be asking the networks for their help. We will share with the information we have gathered and we will ask:
- how many of these organisations are in touch with the regional clinical audit networks?
- how many are active participants, and which have never been heard from?
We want to make sure that we hold up to date information on who to contact in the organisations, and for those who are not in touch with the networks we can try direct approaches to try and build new links.
You can help by making sure you keep both your local network chair and HQIP are informed if you or your organisation change names or contact details. Hope to see you at your network meeting soon!
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11 February 2013: Sharing good practice across the networks
By: Mandy Smith
CASnet, the clinical audit support network for the East Midlands, took a fresh approach to their meeting on Tuesday 5 February. With the support of the HQIP networks fund, they organised a training event for network members, and invited Nancy Dixon of Healthcare Quality Quest to run a workshop. The title was ‘Time to raise the game on clinical audit'. Nancy challenged the delegates to consider how they felt clinical audit was working in their own organisations, and to take a critical look at the way audits are designed. Working on practical examples provoked a lot of discussion.
The afternoon session was on achieving improvement, and again the delegates had an opportunity to review some examples of action plans. The chance to share common problems and debate issues with colleagues was much appreciated - as is so often the case at network events.
Carl Walker, Marina Otley and the other members of the CASnet team did an excellent job in finding a venue in Leicester and arranging the day. The event boosted attendance at the meeting and hopefully will encourage more trusts to stay in regular contact. If any other networks are thinking of inviting a guest speaker or putting on a similar event, the details of how to apply for funding are here: http://www.hqip.org.uk/clinical-audit-networks-fund/
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28 January 2013: Dashing through the snow to the National Foundation Doctors Presentation Day
By: Mandy Smith
The train service between the Midlands and Bristol is a bit more sophisticated than a one horse open sleigh, but still presents challenges when the weather is as bad as it was on Friday 18 January. Under the circumstances the attendance at the National Foundation Doctors Presentation Day could have suffered badly, but the weather didn't dampen the enthusiasm of the participants. The quality of the presentations was again very high, although it was noticeable that there were fewer conventional clinical audits and more quality improvement projects using a range of other methodologies. This reflects the shift in the content of the new curriculum which came into operation last July.
I was asked to be one of the judges for the oral presentations. The runner up in this category was an excellent example of a traditional audit. Dr Sarah Sanderson, Dr Mhairi Murdoch and Dr Anna Lowdon audited anaphylaxis management, following an incident which demonstrated that their colleagues were uncertain about the procedure and dosage to use when administering adrenaline in anaphylaxis. They undertook a case note audit and used a staff questionnaire to reveal problems with the equipment used and the documentation of care, and came up with some simple but effective ways of addressing the problems.
Anaphylaxis is a dangerous but relatively rare condition, and the winning project addressed a much more common problem. Junior doctors on call are often faced with having to make decisions about escalating the treatment of patients without detailed knowledge of the patient's circumstances. In the most extreme of cases, they may be guided by ‘Do Not Attempt to Resuscitate' forms, but guidance in less critical situations can be given by having ‘Ceiling of Treatment' documentation in the notes. The Royal United Hospital, Bath had introduced a pro-forma, but an audit of case notes on the elderly care wards by Dr Mark Dahill and Dr Louise Powter showed that the forms were not being used. They went on to use PDSA cycles to redesign the forms, and a second data collection showed both a significant increase in the use of the forms and in the perceived usefulness of this type of documentation.
Both of these projects showed that it is not the data collection or analysis that makes a quality improvement project effective - it is the changes that are made to practice as a result.
The prize winners in the poster competition were:
Audit / Quality Improvement - two prizes were awarded
- Dr Markand Patel, Dr Mark Harris, Dr Ian Tapply and Mr Robert Longman for an audit of guidelines for extended VTE prophylaxis in colorectal cancer patients (this project also won the BMJ prize)
- Dr David Ledingham and Dr Rakesh Modi for a series of audits of cardiovascular health monitoring in patients with psychotic illness in both primary and secondary care
Original work: Mr Matt Fell, Mr Filippo Boriani and Mr Umraz Khan for a comparative study of lower limb reconstruction following open fractures in Bristol, Italy and Pakistan.
Case reports:Dr Jane Ding and Dr Leonie Perera for a case study of a toddler with ‘watery wee' - whose symptoms had been caused by the inappropriate use of herbal remedies.
Congratulations to all the prize winners!
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