Just Say No!

Published: 01 Aug 2019

This is the season for medical churn.

Junior doctors move.

Most are moving up and some are moving sideways. Some are moving for further opportunities, some will be sampling primary care for the first time and some moving not knowing what direction to go in.

For consultants, it is a time requiring more vigilance.

After settling into the new job, there will be a meeting with the new educational supervisor and inevitably there will be a talk on the need to do something about audit during the attachment. This is usually when the heart sinks. The conversation goes along the lines of being told that when you settle in you can do an audit of something topical. If you are very lucky you will be told that an audit is needed into a particular area.

If the conversation goes as far as suggesting that you should get 20 sets of patients’ notes out and look at such and such, just say no! The only exception to this if your supervisor, working with the local audit colleagues, actively participates in the entire exercise, designing the questions and the data to be collected and leads on assembling the notes.

The reason why this comes about is that there is a requirement for all doctors to participate in quality improvement (QI) activity yearly. QI encompasses a very wide arrangement of activities, including but not limited to:

  • clinical audit, both national and local
  • use of registry and local data for improvement
  • reviews of adverse events, ranging from mortality and morbidity to a multitude of safety events of lesser severity
  • participation in accreditation activities and improvement falling out from these activities
  • reviews of litigation and coroners’ reports
  • local learning from national confidential enquiries and high-level investigations into safety and effectiveness

Then we come to the use of “industrial techniques” such as have emanated from emulating the drive to reduce variation in the motor industry (6-Sigma , Lean and the Plan, Do Study Act cycle popularised by the Institute for Health Improvement). In relation to the latter techniques, one would expect healthcare organisations to have learnt one such technique and trained many in the institution to take that on and bring others, particularly juniors, into such a roll out.

There are other approaches, although it would take mentoring to develop such expertise. These would include the use of Statistical Process Control (SPC) charts which track events over time. Again, further expertise is required in this area although there are add-ons to Excel to allow such charts to be developed. Remember, HQIP have an array of usual documents to help with QI .

Finally, a plug for the national clinical audit programme. The programme covers a very wide range of healthcare including mental health and primary care (diabetes and Qualities and Outcomes Framework information). The advantage here is that healthcare organisations submit data which is “cleaned” and reverts to the organisation. This is then used nationally. It remains, however, very valuable good local data, which, when used within the base organisation, does not need any particular information governance permissions as it is the organisation’s own data. Many local questions can be asked of this data, especially when one looks at the multiple improvement recommendations coming out from the national reports and Getting It Right First Time (GIRFT).

Remember that we all work in teams of various sizes. Involve the full team in the QI exercise. The greater the team is involved, the more help there will be to do the work and the more buy-in with the outcome.

In conclusion, remember there are many ways of doing quality improvement and, possibly, the least good is through local notes collection.

Professor Danny Keenan

Professor Danny Keenan
Medical Director, HQIP