Angelika Zarkali is a core medical trainee in Health Education East of England. She is currently an FMLM national medical director’s clinical fellow at NHS England. She believes that clinicians should be the force of change and improvement in healthcare and is keen to share her experience in quality improvement.
Over the last few years, quality improvement has started to replace traditional audit in junior doctors’ training and curriculum. This was fuelled by evidence that most audits fail to deliver improvements in healthcare, with only 12% of doctors reauditing[1] and only 5% of doctors felt that their audits led to a change in clinical practice.[2] This means that doctors have more recently moved away from the traditional, unsuccessful model of tick-box exercise audits and on to quality improvement projects.
The Royal College of Physicians initiative “Learning to Make a Difference” introduced quality improvement projects to core medical trainees (CMT) in 2011 and was met with great enthusiasm. Sixty-four trainees completed 34 projects in the first pilot year.[3] All participants reported that running a quality improvement project was a valuable experience and 85% thought that they had made a difference in patient care with their projects.[3] Three years later in August 2014, quality improvement officially replaced audit in the CMT curriculum.
Similar changes are yet to happen in other specialties but there is growing awareness of the value and necessity of quality improvement among trainees. Many independent initiatives, such as BMJ Quality, the Network4, and the Institute for Healthcare Improvement[5] are growing in popularity among trainees. The Network, which was set up in 2010 by a group of junior doctors, has now reached 2883 members.[4] At the same time, more and more conferences dedicated to quality improvement are organised, such as Agents for Change, FMLM Regional Conferences, the Network Quality Improvement conference, are all well attended by trainees.
Quality Improvement has finally become fully integrated into junior doctor’s work and training. But will this positive trend for quality improvement continue in the future?
NHS England recently published The 5 Year Forward View,[6] which sets the vision for the future of the NHS. It describes a healthcare system that is facing major challenges and needs to change and evolve in order to meet these. It describes a NHS that focuses on prevention and integrated locally provided care, a system that strives for excellence along with rapidly translated research and innovation in clinical practice.
In working towards this vision, quality improvement can be a major lever for change. The 5 Year Forward View emphasises that “one size does not fit all.” Local initiatives are necessary to instigate change that is sustainable and these initiatives should be led by clinicians. The need for medical leadership is highlighted in the report with a pledge to “review and refocus the work of the NHS Leadership Academy and NHS Improving Quality.” Trainees should share this load with more senior clinicians and lead quality improvement in their hospitals. Junior doctors are ideally placed at the coalface, working around the clock to recognise areas where improvement is needed.
In addition, the report describes the need for innovation and investment in research, but one that moves away from distant, traditional models into translational research, which has a practical implication to patient care and can be easily incorporated into clinical practice.
Quality improvement projects are an ideal example of work that directly improves outcomes for patients, is led by clinicians, and is tailored to local clinical practice. Quality improvement is in perfect accordance with the ambitions defined in the 5 Year Forward View and the publication of this report is an opportunity and a challenge to all of us to fully integrate quality improvement to our work.
Health Education England, the medical colleges, hospitals, and GP practices should rise to this challenge and support junior doctors and allied health care professionals to lead and participate in quality improvement projects.
But it is also up to us as junior doctors to become leaders and improve quality of care for our patients. If you are in search of inspiration for your next quality improvement project, take a look at the five year ambitions for dementia, cancer and mental health, as described in the 5 Year Forward View!
References:
- Greenwood JP1, Lindsay SJ, Batin PD, Robinson MB, Junior doctors and clinical audit. J R Coll Physicians Lond 1997 Nov-Dec;31(6):648-51.
- John CM, Mathew DE, Gnanalingham MG. An audit of paediatric audits. Arch Dis Child 2004;89:1128-9
- Vaux E., Went S., Norris M., Ingham J. Learning to make a difference: Introducing quality improvement methods to core medical trainees. Clin Med 2012 Dec;12(6):520-5.
- The Network: http://the-network.org.uk/
- The Institute for Healthcare Improvement: http://www.ihi.org
- NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view. Oct 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf