How to Boost Your Clinical Practice with Evidence-based Audit: Part 1

Carl Walker

November 15, 2017

With Clinical Audit Awareness Week approaching fast, NQICAN chair Carl Walker shows us how to make the most of an evidence-based approach to improving our clinical practice. Don’t rely on mere quality assurance when you have a chance to really make things better.

How did you start your career in healthcare? What drove you to support quality improvement in the way that you do?

From an early age, even at high school, I wanted to be a statistician. I based my work experience around that, and I moved schools so that I could do an A-level in statistics. I went on to study statistics at university, and that taught me how to use data to make decisions.

After I graduated from Coventry university with a Stats & Business degree, I saw a summer job being advertised at the local hospital and I've been here ever since nearly 20 years later. During this time I have had lots of different roles, but essentially, I've found my niche in getting a big drive out of helping clinicians improve what they're doing. Ultimately, it's about using data and measurement to improve patient care, and that's what makes me tick.

There are so many people I've worked with over the years across Leicestershire, and you're always getting new junior doctors and different consultants and medical directors to work under. It keeps life interesting and I don't think I've ever done the same day twice.

I've had my national role over the past 2-3 years, which has allowed me to cast my net over a wider area and it's a good way to put back into the system in terms of sharing my experiences and pitfalls. I get to share what works and what doesn't.

Many doctors in the public and private sectors alike are looking for ways to proactively improve their practice. To inspire our readers to make their own changes, can you give an example of how clinical auditing was done successfully in primary care?

Most of my experience is within an acute teaching hospital rather than in primary care, but I've had contact with GPs at various points over the years. We were looking at pathway audits for pre-admission, post-discharge etc.

One thing I will say is that it's quite difficult, or at least has been in the past, to look at whole pathways in audits. We're doing a scheme within Leicestershire, looking across it and trying to make projects easier and to break down the boundaries. We want to make the governance and sharing of information easier.

Effective projects that I’ve been involved with would be the readmission to hospital audits we’ve done in collaboration with primary care colleagues. In the past, we audited that readmission and then liaised with their GP to find out whether there was a care package put in place or whether they were aware that the patient had been discharged. We looked at whether there was anything we could have done to prevent that readmission and if we could have provided better information on how to treat and manage that patient in the home setting.

Communication via discharge letters and getting feedback about it was good for seeing whether we were giving good and timely information to our primary care colleagues. We examined whether GPs were getting told why their patient had been referred to an emergency or outpatient setting.

The best approach to clinical auditing is to look at and improve our practices to make sure that we are not just meeting current standards but also developing better ones. In your view, what are the main obstacles that prevent clinicians from striving towards improvement rather than the mere assurance of existing standards?

The main obstacle, without a doubt, is the lack of protected time to carry out quality improvement and make joint plans across the board. There's a lack of support in general, and primary care doesn't have an audit department that GPs can go to as such.

When resources are limited, you focus on the mandatory things that the CQC, NHS Improvement or whatever else it might be required from you. There's also a lack of expertise in terms of extracting information from systems and analysing it.

Primary care has better EHRs than the secondary care setting, but I understand that it's still quite hard to get information from those systems. That makes it hard to use it to drive improvement. Having better IT for accessing the data that's on their systems and using it to measure performance would help to tell people how they're doing.

There is a variety of different quality improvements tools available out there. Which are most appropriate for use in the private sector, and why?

I've had quite a few discussions about this recently, and the main thing is having systematic approach to what you're doing. There's a quote that says,"All processes will fail if you don't follow them from start to finish, no matter what you're doing". The same applies to quality improvement."

You can pick whatever model you want out of the many tools in the toolbox, as long as you carry out the audit or Plan Do Study Act (PDSA) cycle systematically. You can't just collect your data and present it back as an improvement. You have to look at where we're not making an improvement, find out what the standards are, put together a useful action plan, and then monitor the effects of this or that action to see if they have made a difference to patient care.

The model for improvement and the audit cycle are the two key ones that we promote for improvement work. It's all about defining what you want to achieve from the start, and identifying the measurements that will tell you whether you're doing what you should be doing. Learn as you go along to see how the changes are affecting things as you roll them out.