[BLOG] Audits and QI; do they make you a better doctor?

In this month’s blog, Alisha considers the hurdles that junior doctors and medical students face when trying to get involved in audit and quality improvement projects. What benefits can be taken away from a successful project? And, how can a project best enable change and improvement?

What does the word ‘audit’ mean to you? For some it conjures up bad memories of the days before an ARCP or end of year review, trying desperately to put together a report; for others, it means hours of data collection and spreadsheets of meaningless statistics. I carried out my first audit in my final year of medical school, as part of a GP placement: needless to say, it did not fare too well – primarily because I lacked a basic understanding of what an audit was. It was not until I was practising as a junior doctor that I grasped the concept of quality improvement in the clinical environment, and perhaps more importantly, began to observe how partaking in audit projects could improve the quality of care for patients, and even ameliorate the working lives of healthcare professionals on a day to day basis.

If audits are able to cause a positive change, why do many have such a negative attitude towards them? Studies have shown that the majority of individuals working within the NHS see quality improvement as a necessary and constructive aspect of clinical practice, but the limiting factor in most cases is time. With the growing demands of an already stretched system, together with essential exams and modules in management, there is no period during the day in which there can be a true focus on quality improvement. And with the pressure to balance work with a personal life, how can junior doctors be expected to dedicate time to audit?

The main problem is that audit is first and foremost seen as a ‘tick box’ exercise. Come ARCP and job applications, audits play a large part in determining whether a candidate is successful. Some individuals carry out audits solely to help them progress to the next stage of training, and many students don't go beyond the first round of data collection, therefore limiting their ability to enact change. There are multiple reasons behind this. Junior doctors often rotate through 3-4 month rotations, making it particularly difficult to continue projects in one department or hospital. For some, quality improvement can detract from patients, and they feel that time spent on clinical audits take them away from dedicating time to ensuring patients have the best quality of care. Others had the desire to carry out a project, but did not have adequate support from their seniors, colleagues or audit departments.

Yet despite the above, healthcare professionals can gain numerous skills and attributes being involved in an audit, be it a local or national project. It enables a greater insight into the standards of care we should be aiming towards and a better understanding of statistics – as well as the opportunity to improve communication skills when presenting findings. In addition, and what may appeal most to junior doctors, is the ability to accomplish change in the everyday practice of themselves and their colleagues – be it in the completion of drug charts; the timing of ward rounds; or the type of treatment used in their patients. The possibilities for audit projects are truly endless – they do not have to be those suggested by consultants or denoted by the recent NICE guidelines, but anything that you see in your daily life that you feel is not measuring up. Once I realised this, I stopped Googling ‘ideas for audit projects’ at the start of my placements, and simply observed. There is room for improvement in everything we do, and we are the people who can make that progress.

So what do you think – as medical students or as practicing clinicians? Should audits play such a large role in clinical practice? Do we need to do quality improvement projects in order to be classed as a great junior doctor?

• Carry out a project in an area that you find interesting, or an aspect that you experience in your routine practice
• Approach a supervisor who will be actively involved and keen to enact change themselves
• Always try to ensure the audit cycle is completed – it can be handed over to incoming junior doctors or medical students!
• Working as a team will make the project more enjoyable and the workload manageable.
• Try to get your data presented – share with others the positive changes that you have made!

References/Further Reading

1. Webb SJ, Dowell AC, Heywood P. Survey of general practice audit in Leeds. BMJ 1991;302:390–2
2. Hopkins A. Clinical audit: time for reappraisal? J R Coll Physicians Lond 1996;30:415–25
3. Benjamin Andrea. Audit: how to do it in practice. BMJ 2008;336:1241