ENGAGING CLINICIANS IN QUALITY
IMPROVEMENT USING NATIONAL CLINICAL AUDIT
Dr Dominique Allwood
Public Health Registrar
Improvement Science Fellow
E: Dominique.allwood1@nhs.net
Tw: DrDominiqueAllw
The Project
Background
• Despite being well organised and reasonably well funded, large scale audits are
undervalued as a potential resource to support improvement
• The Francis Inquiry report highlighted the need for trusts to focus more on quality
• HQIP commissioned ISL to undertake a project to understand more
Aim
• Project aimed to better understand the barriers and facilitators in using NCA to
support local quality improvement
Method
• Thirty participants contributed their views through interviews or focus groups
conducted in 2013
Participants
Themes
1. Technical and
Practical Issues
2. Communication
3. National and
local alignment to
quality
improvement
•
•
•
•
•
•
Analysis
Interpretation
Presentation
Recourses
Knowledge
Skills
• Content and purpose
• Engagement
• Motivations and incentives
• Structures, systems, staffing and culture
Key Findings (1)
• There is a need to clarify the content and purpose of some national
clinical audits so that local healthcare providers understand the
relevance and importance of audit and can use this data to make
improvements to services
• Support with how to analyse and interpret data and present findings
to others in user-friendly ways would help people to engage better
with audit findings
• Incentives to drive improvement could act as both barriers and
facilitators. Recognition of good practice was seen as a powerful
motivator while financial incentives received a mixed response
Key Findings (2)
• The right resources, knowledge and skills are needed to encourage
engagement with clinical audit. Face to face events were seen as one of
the best tools for building understanding and sharing best practice
• Organisational structures, governance, staffing and culture all had a
strong influence on the take up of clinical audit and on whether data was
used to encourage improvement
• More could be done to engage clinical leads with HQIP. Participants
would like to see greater involvement of clinicians and input from
patients in the design and reporting of clinical audits
1. Technical and practical issues
Analysis
Presentation
Knowledge
and skills
Methodology
Timeliness
Education,
training and
ability
Access to
skills
Time
Interactivity/ IT
systems
Events
HQIP
Conference
Interpretation of
data
Prioritisation
Uncertainty
Customisation
Presentational
skills
Interpretation
Change
Workshops
Peer groups/
networks
Engagement
Data vs.
information
Guidance
and tools
Duplication
Interpretative
and analytical
Comparisons –
case mix,
adjustment
Participate in
learning
Data collection
Sharing best
practice
Professional
bodies and
audit suppliers
2. Communication
Content and
Purpose
Communication
and reporting
Engagement
and Dialogue
Data collection vs. audit
Between clinical audit leads
and clinical teams
Between HQIP and local
audit teams
Between clinical audit leads
and local audit team
Between HQIP and clinical
leads
Between suppliers and trusts
Between HQIP and suppliers
External reporting
Interpretation
Audit vs. improvement &
Improvement vs. judgement
Evidence-based standards
vs. aspirational targets
Relevance
Mechanism for improvement
3. National and local alignment to quality improvement
Incentives and
motivations
Awareness
Recognition, competition,
clinical excellence awards
Regulatory – appraisal/
revalidation, Quality Accounts
Staffing of clinical audit teams
National Clinical Audit
Buy-in from Boards and Medical
Directors
Financial – BPT, resource
allocation
Public disclosure
Audience
Ownership
Organisation
Culture and organisations
HQIP
Leadership
Stages
Understanding
why there is a
need to change
• Engagement with content, relevance and
relationship to recognised standards
Understanding
what to change
• Technical elements of analysis,
presentation and interpretation
Understanding
how to change
• Prioritising, action planning and learning
from others, implementation
Discussion – variation in views
• Some areas focused on more heavily
• Mixed views in many areas
• Whether factors were barriers or facilitators
• Perspectives on mechanisms that drive improvement
• Processes and practices of individual, organisations
• Focus, timeliness, output, content and presentation of audit and support provided
• How much suppliers should be responsible for vs local clinician ownership
• Presentation, interpretation and summarising
• Highlighting areas for improvement
Recommendations
• Commissioners of audit (HQIP)
• Suppliers of audit
• Both commissioners and suppliers of audit
• Provider organisations
• Individual clinicians and audit teams
Recommendations (1)
Commissioners of national clinical audit: HQIP and NHS England
• Consider developing a strategy that places national clinical audits in the context of a vision for
improvement
• Consider a balance of data on clinical effectiveness, patient experience and safety when
commissioning audits
• Further work could be undertaken to evaluate the effectiveness of specific mechanisms and
drivers for improvement
Suppliers of national clinical audit
• Audits should include clear objectives about quality improvement, explanation of the purpose
•
•
•
•
of data items
Linking to evidence-based standards and differentiating non-evidence-based targets from
descriptive data
Consider ways to provide real-time feedback to support continuous improvement
Customisable outputs that can be manipulated for local analysis.
Involvement of clinicians and patients in design and reporting
Recommendations (2)
Both commissioners and suppliers of national clinical audit:
• Consider a dual approach to interpreting data focusing on:
• ensuring data is analysed and presented in a way that is meaningful with adjustment to
allow valid comparisons
• supporting the user population to gain the relevant skill sets to interpret the data
• Explore streamlining data collection methods and alignment with informatics developments
• Resources and opportunities for clinicians to discuss findings, share best practice, and
compare performance
• Strengthen communication strategies to improve engagement and recognition
• dialogue with clinical leads, medical directors and clinical commissioners as well as the
media
• Highlighting and celebrating improvements and providing support to manage local and
national media.
Recommendations (3)
Provider organisations:
• Support clinical audit teams and clinicians to undertake national clinical audit and focus on
ensuring adequate skills and resources (skills in collection, interpretation, analysis and
presentation of data, quality improvement, change management, and clinical leadership)
• Trusts should ensure appropriate processes are in place use national clinical audit
proactively in improvement and share best practice for management of national clinical audit
processes and ensure this is integrated within the quality agenda of the organisation.
Recommendations (4)
Front-line staff: clinicians and audit teams
• Greater ownership of and engagement with national clinical audits may be fostered by
increasing understanding of local and national approaches to improving quality and the role
of audit in the broader development of knowledge and skills for measurement and
improvement of quality from undergraduate training onwards.
• Clinicians should explore available resources to support them in using national clinical audit
for improvement and utilise forums to learn from and share good practice
• Strengthen relationships between the medical director, clinical audit teams, and clinical leads
and managers