Audits and QIPs

Audits and quality improvement projects (QIPs) are important aspects of clinical governance that aims to improve clinical practice through a cycle of appraisal, intervention and reviewing the effects of said interventions.

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What is it?

Audits and QIPs both fall under the umbrella of quality improvement, but are slightly different. Broadly speaking, audits are a more traditional method of comparing current practice against an established standard; while QIPs do not necessary have a set standard but can involve virtually anything. As far as I am aware, QIPs generally have shorter cycles and a more rapid turnover, and are therefore useful for areas that are still relatively far from the set target/which requires rapid improvement as it is pertinent to ensure patient safety; whilst audits are done less frequently and therefore useful to ensure standards are kept at a satisfactory level.

Throughout this article, I will use an example of the first audit I carried out as a junior doctor, on the compliance of ankle/foot X-rays with the Ottawa rules.

1. Any quality improvement process involves first evaluating the current practice. This is usually carried out through data collection, then comparing it to an established standard. In my case, I looked at all the ankle/foot X-rays done within the past month in A&E, and determined whether the clerking notes and radiograph order requests fulfills or adheres to the Ottawa rules.

2. The next step would be to rationalise the results. Is it satisfactory? Is it not? It is useful to have an idea of a target compliance you would like to achieve within clinical practice (of which 100% is for the most part overly optimistic and not practical). For my audit, the compliance was low and therefore indicated that there was plenty of space for improvement.

3. With that in mind, you want to design some interventions to improve this number (or maintain it if it is satisfactory). Some of the easier things to implement include delivering teaching sessions to educate the department, putting up posters etc. This is exactly what I went for during my first audit. However, once you get the hang of things or you happen to meet a particularly innovative/ambitious supervisor, there are essentially unlimited ways to achieve this same goal such as tweaking with the IT system to design proformas, requesting funding to open up new services, mobile applications to aid memory and many more.

4. Finally, you repeat step 1 after giving some time for the interventions in step 3 to work i.e. close the loop, and decide whether or not they have made an impact. These 4 steps essentially form the audit cycle, effectively a PDSA cycle (diagram below), that is the crux of quality improvement. Feel free to rinse and repeat the cycle as many times as you wish to demonstrate consistent improvement/maintenance of a high standard. Usually, this may be the point where you wish to then present your findings at an audit meeting, to demonstrate the positive impact you have made for the department.

Why bother?

Audits and QIPs are essential to help improve particular areas of delivering healthcare services to patients. For example, you may decide to conduct an audit on whether the NICE guidance for CT head scans in head injury are adhered to, as that can ensure patients who suffer from head injury get a scan when it is indicated, avoiding unneccessary scans and over-exposure to ionising radiation, and freeing up the scanner for other more urgent scans.

It can also be used to make your life better! As an example of how literally anything can be a quality improvement project, imagine the following: You may wake up one day and feel like you have been bleeped one too many times for menial tasks in the middle of assessing unwell patients the night before, and decide to embark on a QIP. You conduct a survey amongst your peers on how satisfied they are with the current bleep system. The results seem to show everyone is on the same boat as you. You then present the results to the managerial staff and propose a separate channel for nurses to contact doctors for non-urgent jobs. After a few cycles of ironing it out, you eventually arrive at a mutually agreeable method of achieving this. Now you can finally conduct your A-E assessment on the anaphylactic patient without missing a beat from nurses bleeping for the third time about Jane's sleeping tablets.

Audits and QIPs also form an essential part of appraisal and re-validation for consultants, and for trainees, a crucial part of career progression. As a foundation trainee, we are expected to be involved in an audit/QIP project once a year, which is assessed as part of our Annual Review of Competence Progression (ARCP) (*COVID may have slightly changed how they evaluate this). It also grants you points for job applications to pretty much any specialty, with most granting maximum points for a closed-loop audit presented at the national level.

Top tips for success

• Start early- you often need to give time for your interventions to bear fruit, and sometimes you need to wait for the right conference to present your findings, so allow plenty of time particularly if you are planning to use it for your applications

• Get a supervisor- whilst it may feel daunting approaching a consultant with what you think is a simple idea, you NEED a supervisor. They are often willing to offer advice, as it forms part of their own appraisal, especially if you already have a clear idea of what needs to be done and what you are trying to achieve.

• Register the audit- as with the above, registering your project with your audit department makes it more official. They may be able to offer advice or sometimes even help with identifying your target groups/help with data collection. They will also give you a nice certificate for all your hard work which is definitely a nice addition to your portfolio.

• Master Excel- almost no one uses paper sheets for data collection anymore. Microsoft Excel is your friend. Learn how to properly manage and organise your data with this software, and also to generate graphs and charts, it certainly goes a long way.

• Research =/= audit- a common misconception, research generate new data within the current pool of evidence, and audits evaluate current practice. In other words, audits compares current practice to established agreed standards, and research contributes to creating new standards/updating current standards. They often fall under different domains and offer separate points for your specialty applications as well.

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Comment below for any questions regarding audits/QIPs, or any interesting projects you have been involved with!