Deborah Kirkham is an ST5 trainee in genitourinary and HIV medicine in Health Education North West. She is currently taking time out of programme in London as a National Medical Director’s Clinical Fellow at NHS England and the BMJ. Twitter: @deborahkirkham
As a genitourinary medicine (GUM) and HIV specialty registrar with six years of postgraduate training under my belt I have seen some key developments in the sphere of service improvement. When I started as a Foundation Year 1 doctor, the concept of quality improvement (QI) was not widespread and audit remained the key player. The improvement landscape has evolved quickly and audit is now often viewed as inferior to QI.
The “Learning To Make a Difference” project was a joint venture running from August 2010 to September 2011 between the Royal College of Physicians of London and the Joint Royal Colleges of Physicians Training Board (JRCPTB). It involved Core Medical Trainees (CMTs) in their first two years of broad medical speciality training participating in a QI project. The success of this pilot led to the incorporation of QI project completion into the requirements for successful sign off of CMT, but this was only implemented in 2014. The current GUM “Annual Review of of Competence Progression” (ARCP) requires participation in audit but there is no mention of QI. It is understandable therefore as an emerging addition to training programmes that QI has not yet become embedded in hospital departments across the NHS.
In GUM there is a strong culture of audit both locally and nationally. The British Association of Sexual Health and HIV (BASHH) has a national audit group and national audit programme. The British HIV Association (BHIVA) has a national audit schedule and releases regular reports as well as publishing findings in peer reviewed journals. However, we know that although audits are good at identifying areas where practice is not achieving set standards it is not always the best tool for facilitating the changes required to improve that practice. This is confirmed by research in a paediatrics department which found that over a six year period only 27.8% fulfilled the criteria for a full audit and only 22.2% of audits were re-audited (http://adc.bmj.com/content/89/12/1128.full). It is easy to see how audit can often turn into a simple exercise in data collection. (http://careers.bmj.com/careers/advice/Quality_improvement)
The key difference with QI compared to audit is that the focus is on identifying a problem, engaging with stakeholders to try out solutions, and using continuous measurements to identify what is working and what unintended consequences there may be. The data collected is to support the improvement process as opposed to being the raison d’être of the project.
Although there are undoubtedly individuals with a passion for QI within GUM and HIV medicine, they appear to be the exception rather than the norm. At this year’s BASHH conference only one abstract out of 254 mentioned QI methodology and similarly at the BHIVA spring conference only one abstract out of 208 described QI methodology. We appear to be excellent at identifying what the problems are, but less well equipped to address them in a logical, consistent, and sustainable manner. Encouragingly in September 2015 BASHH launched the Trainees Collaborative for Audit, Research, and Quality Improvement Projects (T-CARQ)
(http://www.bashh.org/BASHH/Education/Doctors_in_Training/BASHH/BASHH_Groups/Doctors_in_Training.aspx?hkey=8b7f91a3-36b0-423f-8373-61d68c14fb12). This may be a sign that the wheels of change are turning and trainees are leading on the promotion of QI within the specialty.
Searching through BMJ Quality Reports, sexual health and HIV are not well represented. There was only one report about sexual health which describes improving the sexual health of patients in stroke rehabilitation (http://qir.bmj.com/content/4/1/u207288.w2926.full?sid=4f6c6935-e453-4ebf-8a4b-9fe6827590a0), and another single project about HIV which discusses the improvement of data management in the Portugese HIV surveillance system (http://qir.bmj.com/content/4/1/u209037.w3663.full?sid=db3683f4-a460-4c36-be0c-732523ed4664). There were no results at all for the keywords “GUM” and “genitourinary,” and no mention of common infections like chlamydia, genital warts, herpes, candida, or bacterial vaginosis.
There are some barriers to the initiation of QI projects in sexual health. Many departments are small with only one or two consultants, and may not have any junior doctors working within them. This can be problematic for two reasons: firstly, small departments may not have staff availability to invest time in developing new ways of service improvement, as well as keeping up with all the mandated national audits; and secondly, it is often junior doctors who do the majority of work in both audit and QI projects. Furthermore, a department without juniors may not be aware of the benefits of QI methodology. Larger departments on the other hand may feel tied to audits by tradition and expectation.
Happily there is lots of opportunity for QI in sexual health. The robust multidisciplinary team working lends itself to the methodology of QI where stakeholder engagement is vital for the success of projects. The patient group is typically young with ideas and opinions that can easily feed into projects. While clinical outcomes and clinician experience is important the specialty of sexual health is perfect for focusing on patient experience. QI has a great opportunity to really make a difference.