Speaker 1: Hello, and welcome to the Royal College Pathologist CQI Awareness Month webinar series. My name is Maya Lagsdall, and I'm excited to be hosting these sessions where we have leading experts guide us through key CQI methodologies and skills for making change and improving patient care and safety. I'm pleased to introduce today's speaker, Dr. Jumoke Sule. Jumoke is a consultant microbiologist at Addenbrookes Hospital in Cambridge. She has gained experience in clinical audit and quality improvement over the years as audit lead for her laboratory and as clinical governance lead for Public Health England Laboratories. She contributes to certification of clinical audit at the Royal College Pathologists. So without any further ado, I'd like to kick things off by welcoming Dr. Sule. Jumoke, over to you.

Speaker 2: This session will emphasize the use of clinical audit as a quality improvement tool. I will be discussing four principles for quality improvement and how they apply to clinical audit. And these four principles are active engagement and partnership working, use of correct methodology, informed critical analysis, and facilitating and supporting change. Clinical audit became mandatory for doctors in 1998 when the Department of Health released the Healthcare Circular, a first class service. I've provided the definition of clinical audit from the Healthcare Quality Improvement Partnership, and I'll give you a few seconds to go through this. I would like to highlight the important phrases within this document, and these are that clinical audit is a quality improvement cycle, it involves measurement of effectiveness, and it requires taking action to ensure that improvement occurs. And if action isn't taken place, then it's unlikely that the audit will lead to quality improvement. Clinical audit has received bad press recently, and Oil and Keep, in their paper, have provided some evidence that national clinical audits over the period of 2004 to 2012 have not led to improvement, and they did not even hit the required targets. Rather, they state that clinical audit has become a quality assurance tool for trust boards rather than an improvement tool. I suggest that if clinical audit is done for quality improvement purposes, and this is made clear, then clinical audit should work for improvement. I would like to emphasise here that clinical audit has multiple purposes, and they're all really important. When undertaking audit, however, it's important to be very clear about what the objective is, and it could well be that at the front line, where audit is taking place, it's used as a quality improvement tool, whereas at a board level, it is used to provide assurance. The important thing is that when clinical audit is being done for quality improvement, then quality improvement tools need to be used. The Plan-Do-Study-Act model is a well-known quality improvement tool, and on this slide, I have linked the different components of the PDSA cycle to the principles of quality improvement for clinical audit that I will be discussing. Starting with the planning stage, active engagement and partnership ensures that all aspects of the clinical audit cycle are discussed and planned for. In the Do stage, the correct methodology for improvement should be used, and this should be right from the beginning of the audit cycle to the very end. In the Study stage, the critical analysis of results is really important because understanding the results will help to make the correct recommendations and actions for improvement. And this brings us to the Act of the PDSA cycle. Any changes are more likely to work if there's a culture of facilitating and supporting change. Let's start with active engagement and partnership working. Panek et al. have proposed this model of alignment to ensure that quality improvement activity is sustained. And even though this model relates to quality improvement, it equally relates to clinical audit activity as well. Ownership for clinical audit should always lie with frontline staff, with middle managers helping with coordination and resources. And senior managers provide the leadership and culture to make quality improvement happen. The starting point is that quality improvement or clinical audit activity needs to be strategically selected and aligned to both the interests of the clinical staff and the managers. So for frontline staff, they need to be provided with the incentives to do clinical audit, the time to do it, and the resources. The middle managers, it's important that they have quality improvement and clinical audit within their management objectives. And for senior managers, the regulatory bodies are a major incentive to ensure that clinical audit takes place, particularly regulatory requirements from the Care Quality Commission and other regulatory bodies. There are two extra groups I would like to add to this model. And these are the patient and public group and also the regulatory bodies. The patient and public are really important because we should be taking their views into consideration. And the regulatory bodies provide incentives to the senior managers to ensure that they are engaged in clinical audit. Another example of active engagement is that some trusts and the Royal College of Pathologists certify high quality clinical audits. And these are really useful for all members of the organisation. For frontline staff, they are able to provide evidence of continuous professional development for appraisal purposes. The same applies to middle managers. And for senior staff, they are able to demonstrate to regulatory bodies their engagement in clinical audits. There are also local benefits to partnership working. And this slide demonstrates an audit that was undertaken by the virologists within our department where they looked at the accuracy of reports that went from our laboratory through the electronic interface to our service users. And we serve four acute trusts and many GPs. And as you can imagine, there are many different types of computer systems. And this can clearly lead to errors in transfer of results. So this audit was done very soon after a change in computer system. And we did find some errors in the results as a result of faulty middleware. The re-audit showed evidence of improvements in the quality of the reports and by inference patient care. And there were major benefits by visiting our local GPs as this built up relationships and we were able to get feedback about our laboratory service. There was also a lot of shared learning, particularly as trainee led the audits and they were also developing their experience in quality improvement processes. And the audits were presented at a national meeting by one of our trainees. The next principle is using the correct methodology for improvement. And this is the methodology for the whole of the audit cycle. And that's from preparation to sustaining quality improvement. This slide is from the Healthcare Quality Improvement Partnership and emphasises the importance of what needs to be done in between, particularly reporting, analysing and taking the right actions. I emphasise building a review of exceptions and non-conformances, particularly in the clinical audit planning process. In this slide I have listed three different tools for root cause analysis. They're all very similar in their approach in that they explore potential factors that can lead to non-conformances or non-compliance with audit standards. The SWISG's barriers looks at different layers of the organisation to find out why the error or non-conformance has occurred. The Fishburne diagram is similar and it will take the spine and have different layers from the spine to explore each of the different potential factors. With the five whys, each potential factor will be explored and one would ask why until you get down to the bottom of the problem. I highlight the best practice in clinical audit tool as this can be used for people who are either new to clinical audit or it can be used as a guide to ensure that all the different aspects and methodology of clinical audit are incorporated into the cycle to ensure that it leads to improvement. Next I come to the critical analysis of the audit results. So in order to make effective action plans we need to ensure that we understand the data or measure, including variation, the organisational processes and pathway, so a process we call process mapping, and also internal and external influences. This slide demonstrates how process mapping was used to improve HIV resistance tests in turnaround times from 41% to 82% compliance. I highlight that the process was undertaken in two different laboratories, the virology laboratory and the genetics laboratory, and the improvement was made by changing the date that amplicons were submitted to genetics previously on a Friday to a Monday. Further review of the results during the re-audit revealed that majority of samples with a turnaround time greater than 21 days were submitted by external hospitals, so further work needs to be done to reduce the end-to-end turnaround time, and you'll note that during the process mapping this was only undertaken from the time the sample arrived at the laboratory and not at the time the sample was taken from the patient, so this is another area that one needs to think about. Following on from understanding the results, it's really important to get recommendations right, and I've highlighted on this slide a hierarchy of intervention effectiveness, and while education and training are really important, it's system-focused interventions that are more effective, and in the previous two audits I've referred to in my talk, it was the system functions change that led to improvement. The first, correcting the error in the middleware, led to the improvement of transfer of results across the interface, and in the second audit of HIV resistance turnaround times, it was a redesign of the process that led to the improvement. The last principle I'll discuss is facilitating and supporting change, and this relies on effective leadership and promoting a culture of quality improvement. Organisations must also have expertise in quality improvement methodology, and staff must be given time to train and the resources to carry out clinical audit and quality improvement. We've now come to the end of the talk, and in summary, clinical audit is very powerful when it is done properly. The same principles that apply to quality improvement also apply to clinical audit, and we must think about what we do with the results and exceptions or non-conformances. We can use tools like root cause analysis and process mapping to ensure that we develop effective plans for improvement.

Speaker 1: Thank you to Dr. Jamoke Sule for this interesting presentation, and thank you for watching. Remember to tune in next Thursday, 30th of May, for our podcast with Dr. Shuba Allard and Dr. Lisa Escort, where we discuss the importance of quality improvement in transfusion medicine. For more information on everything that's happening during CQI Awareness Month, go to rcpath.org slash cqiaware. This webinar was developed by the Clinical Effectiveness Department of the Royal College of Pathologists. This webinar was hosted by Maya Laxdall, recorded by Kate Stewart, and directed by Maria Morerifeo. Thank you for watching.