A TEAM QI APPROACH TO NATIONAL CLINICAL AUDITS
Effects of a team quality improvement method in a national clinical audit programme of four clinical specialties in Ministry of Health hospitals in Saudi Arabia — Saleh Alghamdi, Nancy Dixon, Fahmi Al-Senani, Zohair Al Asri, Shukri Al Saif, and Talal AlTahan
The clinical excellence strategy launchd by the Ministry of Health (MoH) in Saudi Arabia in 2018 included working with multiprofessional teams in hospitals to implement improvements needed in clinical practice using the clinical audit process. Audits were carried out in 16 MoH hospitals on four clinical subjects — acute myocardial infarction, major trauma, sepsis and stroke. Clinical expert groups, including Saudi clinicians and an international clinical expert, developed clinical care standards for the four conditions from analyses of international and Saudi clinical guidelines and the groups designed the audits. Multiprofessional teams in each hospital were appointed to carry out the audits. Several workshops were held to prepare the teams to carry out the audits. Data collected from each hospital for before-and-after change cycles of data collection were independently reliably tested.
All hospitals made substantial improvements in clinical practices. Of a total of 84 measures used to assess compliance with a total of 52 clinical care standards for the four clinical conditions, improvements were made by hospital teams in 58 (69.1%) of the measures. Improvements were statistically significant for 34 (40.5%) of the measures. The project demonstrated that well-designed and executed audits using evidence-based clinical care standards can result in substantial improvements in clinical practices in MoH hospitals in Saudi Arabia.
QUALITY IMPROVEMENT TEAMS
Effects of team-based quality improvement learning on two teams providing dementia care — Nancy Dixon and Lorna Wellsteed
The article reports on what happened to clinical teams that carried out a quality improvement (QI) project as part of structured learning about QI.
The objective of the study was to determine the effects of a structured team-based learning approach to QI on the performance 12 months later of two teams caring for patients with dementia. A before and after prospective study design was used. The setting was two inpatient services in National Health Service (NHS) Trusts in England, one providing orthopaedic surgery (Team A) and one caring for elderly people with mental health conditions, including dementia (Team B). Team A consisted of nurses; Team B included doctors, nurses, therapists, mental health support workers and administrators.
QI training and support and assessment of the performance of teams and team coaching were provided to the two teams. QI training integrated tools for teamworking and a structured approach to QI.
Team members completed the Aston Team Performance Inventory, a validated tool for assessing team performance, at the start of the QI work (time 1) and 1 year later (time 2). A year after the QI training and team QI projects, Team A members perceived themselves as a high performing team, reflected in improvement in 24 of 52 components measured in the Inventory; Team B was initially a poorly performing team and improved in 42 of 52 components a year later.
This study demonstrates that a structured team-based learning approach to QI has effects a year later on the performance of teams in clinical settings, as measured by a validated team performance tool.
STANDARDS FOR
NATIONAL CLINICAL AUDITS
Proposed standards for the design and conduct of a national clinical audit or quality improvement study — Nancy Dixon
The objectives were to find and synthesize available literature on explicit or implicit standards for the design and conduct of a national activity that involves measuring and facilitating improvement of the quality of patient care, such as a national clinical audit or a quality improvement (QI) study, and to develop proposed standards for the design and conduct of the national activity.
The literature was searched to identify key aspects of good practice in the conduct of national or international clinical audits, QI studies, performance or quality indicator measurements or equivalent national initiatives that have the purpose of driving improvement in the quality of care provided in a healthcare system. Key aspects of good practice in design or implementation of these activities were abstracted from the literature, and organized logically into standard statements according to the stages in the design or conduct of such an activity.
Thirty standards for the design and conduct of a national clinical audit or QI study were derived from the published literature. The standards are on structural, process and outcome aspects of any national activity that involves measuring and improving healthcare services. Most of the standards focus on measurement processes.
These proposed standards for a national clinical audit or QI study provide a way to assure the quality of these national activities. Those that meet accepted standards may be more effective in influencing participating sites to use the data produced to improve the quality of patient care.
CLINICAL AUDIT
Clinical auditing as a quality improvement process – a paradigm shift from audit and feedback — Nancy Dixon
Clinical audit is generally understood as a process involving collecting data about the clinical care provided to patients in a healthcare setting and providing feedback on the findings of data collection to the clinicians involved in delivering the care. Over twenty years ago, clinical audit in the UK was redefined as a quality improvement process that includes implementing changes in practice to achieve needed improvements in the quality of patient care. This shift in understanding of clinical audit recognizes that feedback alone is unlikely to produce improvements in care when the causes of shortcomings in current practice are beyond the direct and exclusive control of clinicians who are delivering the care. The UK model of clinical audit places more emphasis on systems interventions intended to achieve improvement and rapid repeat data collection to demonstrate the effectiveness of the interventions.
Research, audit and journal policies (Letter in Anaesthesia,
Journal of the Association of Anaesthetists of Great Britain and Ireland) — Nancy Dixon
Journal editorial boards could adopt a short list of characteristics of clinical audits or quality improvement activities for which evidence of ethical scrutiny by the author’s organization is required as a prerequisite for publication. The list could incorporate the list of situations or circumstances included in the current advice to NHS organizations. This is a more rational and less discouraging approach than imposing Research Ethics Committee (REC)/Institutional Review Board (IRB) review of clinical audits and quality improvement activities carried out in healthcare organizations.
What is clinical audit’s purpose: quality assurance or quality improvement? — Nancy Dixon
Clinical audit has become a key activity for healthcare organizations and professionals in England. The clinical audit process is frequently described as a cycle of steps that includes making changes in practice. However, some evidence suggests that clinical audit is not effective in producing improvements in the quality of patient care. The explanation may be that clinicians and managers are seeing clinical audit as a quality assurance process, which implies making small adjustments in practice to conform to standards, rather than as a quality improvement process.
WRITING FOR PUBLICATION
Writing for publication for the first time — Try the hunter style — Nancy Dixon
Healthcare practitioners who want to write for publication for the first time can waste time and energy by relying on writing behaviour learned in educational settings, characterized in this article as the ‘gatherer’ style of writing. The gatherer style is suitable for authors who are preparing literature reviews and similar types of publication. A ‘hunter’ style of writing is more appropriate when an author wants to describe work carried out, whether research, a quality improvement study, a clinical audit, a service evaluation or another project.
In the hunter style, an author works through a systematic thought process and makes key decisions about the work the author wants to describe, before starting to write. The thought process includes defining what journal readers want to read about, answering key questions about the subject being written about and organizing the ideas into a logical structure. Practical points about writing clearly also are provided.
Writing for publication – a guide for new authors
— Nancy Dixon
Health care practitioners who are inexperienced in writing for publication are sometimes daunted by the publication process and fail to submit their work on quality improvement to a journal. New authors can acquire experience in writing a paper by working through a systematic thought process that includes consideration of what journal readers and editors want and if the work is ready for publication. The most important part of writing a paper is to think through the key ideas and messages for readers and then to organize the ideas into a logical structure. Writing clear answers to 10 key questions is one way to start the process.
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