How to do a QI/Audit?

After looking through the 4 prior sections and digesting the information you are now ready to start arguably the most critical phase of the audit/QI pathway- the HOW section. We will look at a QIP example and a clinical audit example. The audit example will be set out as a template that you could utilise the layout of for your own audit proposition to a supervisor.

For ease, we will look at this section in terms of 4 steps (conception/aims, data collection/method, data analysis/results and dissemination/conclusion) working alongside a clinical scenario.

Clinical Scenario:

 “You are currently the FY1 on a vascular surgery ward. During your rotation, you have noticed that as a clinical team collectively you are very poor in completing your VTE prophylaxis forms and thus prescribing appropriate medical/mechanical interventions.  To try and improve completion rates, you have created a QIP addressing the problem.”

Step 1: Conception

You have addressed the problem (poor completion of VTE forms) in your clinical area. Now it’s the part of the journey to make an idea a reality. Determine what the aim of your QIP will be by using SMART (specific, measurable, achievable, relevant and time-bound)

1a. Obtain a supervisor

In this case, you want to create a QIP to address the issue. Before starting you need to obtain a supervisor- this could easily be your clinical supervisor or alternatively, most departments have a clinician who is heavily involved in organising/running Audits/QI projects.

1b. Literature review:

A quick review of literature on research platforms is useful in giving justification to your QIP based on satisfying personal or practice needs. In relation to the scenario above- published information can show you the effect of similar interventions etc.

1c. + 1d. Registering

Before starting your work on your QIP you need to get it registered, normally either within the trust or department. Once these have been approved you can start!

Step 2: Data Collection

The purpose of a QIP is to change something. However, to determine if something needs to be changed in the first place we need to collect data.

Prior to starting our QIP we would do a quick Audit of the completion rates of VTE forms in the vascular ward. Using those results we can deduce any gaps and apply suitable interventions to reduce these. At this stage, it is normal to note what % VTE form completion you want by the end of the QIP to deem the intervention a success. You may have local /national guidance for this

Let’s say our first audit showed that only 30% of VTE forms were being completed. It is then important to come up with reasons why this is so low. One way to do this is to use a Fishbone Model also known as a cause and effect diagram. From working back from poor VTE form completion we use 6 categories (machine, methods, measurement, materials, manpower and environment) to deduce the causes that have led to our poor result.

From our Fishbone Model in our scenario, we can acknowledge one of the reasons for poor completion is a lack of awareness that this form exists. An intervention is created to address this problem. For example, a teaching session for clinicians to show them how to complete it, where to complete it etc. You would then audit VTE form completion after the intervention (teaching session) to see the impact it had.

You would continue this for as many cycles (implementation of different interventions) as you want. An example could include:

  1. Pre-intervention audit

Intervention 1: staff teaching session

  1. Post-intervention 1 audit

Intervention 2: posters in doctors’ office

  1. Post intervention 2 audit

Intervention 3 etc

Step 3: Data Analysis

At each stage of the cycle analyse the data available to see the effect and impact the intervention has. This will help you determine if another cycle is needed.

Step 4: Conclusions

Through your data analysis of your intervention, it can be determined whether the intervention was a success or not. As such allowing you to determine whether applications are to be made to the clinical environment it is good to relate this back to your SMART aim. You can submit to present these findings at local, regional, and/or national meetings.

Clinical Audit Protocol Example:

TitleChest x-ray follow up in COVID-19 patients
Supervisor(s) (Add those you have contacted that have agreed to join the project)Dr A Bernard123 NIHR Doctoral Research Fellow and Specialty Registrar in Respiratory medicine   Dr P Dinklage23 Senior Research Fellow, University of Leeds   Dr E Joy1 Associate Professor of Respiratory medicine      
Institute1. Department of Respiratory Medicine, Leeds Teaching Hospitals, Leeds  2. Leeds Medical School, Leeds University, Leeds  3. Department of Biomedical Imaging Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds  
Venue(s)Leeds Teaching Hospitals Trust
A1 What is the principal objective? To identify how many CXRAY’s are conducted for follow up of admission for COVID-19 from the 1st wave of infection  
A2 What are the secondary objectives if any? To identify if follow up is in line with guidance – (quoted guidance should sit here including if it has changed and when.)

To identify if those who have persistent changes on CXRAY (longer than 3 months) are followed up with subsequent imaging and how many times  
A3 What is the initial title of your Audit/QIP? An audit of COVID-19 and CXRAY follow up for those with CXRAY changes on admission  

M1 What is the methodology for this project?

Design

Retrospective Clinical Audit

Setting

Secondary care

Participants

Inclusion criteria 

We will include all patients admitted with positive COVID-19 PCR between April-June 2020. Patients must have had a CXRAY with changes identified on radiology report consistent with consistent with or indeterminate for covid. Patients must have had a CXRAY after discharge.

Exclusion criteria 

No follow up CXRAY

Indeterminate for COVID-19 on PCR

No CXRAY on presentation or within 5 days of admission for COVID-19

Incidental finding of COVID-19 while inpatient admitted for reasons other than COVID-19

Variables

Age, sex, admission date, discharge date, date of initial CXRAY with report, date of subsequent CXRAY with report, whether CXRAY changes had resolved, dead/alive, date of death

Data sources/measurement

Online hospital systems – PPM+, XERO viewer

R1 What will be the potential benefits of your project?

  1. Identification of follow up pathway for COVID-19 patients with persistent changes on CXRAY
  2. Determination as to whether follow up is in line with current guidance (stated local/regional/national guidance here with reference)
  3. Development of quality improvement if poor follow up is identified

R2 What are the potential risks of your project? There are no risks identified for this project. The data will be kept on a secure drive on local trust department computer in respiratory medicine and will be collected retrospectively

R3 How will the data generated be analysed?

Data will be extracted from hospital systems, input into a password protected excel document kept on the departments drive, and analysed using excel/stata/R/SPSS (delete as appropriate)

R4 How will the data generated be stored?

All collected data will be confidential and kept in accordance with the Data Protection Act (2018) and the General Data Protection Regulation (GDPR).

A secure and password protected master list of participants with their identifiable information (named “COVID CXRAY Follow up”) will be kept and stored locally on the NHS Respiratory department network; this list will contain the unique research ID numbers for each participant. A second password protected document of anonymised data will be stored in the same drive. They will only be identifiable with the complimentary but separate password protected master list. All project data will only be accessible to the project team.

D1 How will the results be disseminated?

Output from the audit will be presented locally at the departmental monthly meeting. Results will also be shown at regional and national meetings that accept respiratory medicine audit projects. There is scope to re-audit with a second cycle should results demonstrate a potential for change/improvement

D2 References         

Reference clinical audit guideline sources and any other relevant sources to provide evidence to conduct the project. Doing this well will pay-off on write up/presentations as can use same sources again for the write up

The above protocol you can utilise as a template for a project to then present to your supervisor if you have an idea already that you would like them to supervise you with. Now you are ready to complete the quiz to produce your own project!

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