Dr Howard Ryland is a Registrar in Forensic Psychiatry at South West London and St George’s Mental Health NHS Trust. He was previously National Medical Director’s Clinical Fellow at the Academy of Medical Royal Colleges and the Vice-Chair of the Academy’s Trainee Doctors’ Group. He is a member of the Academy’s Quality Improvement Task and Finish Group.
The Academy of Medical Royal Colleges Quality Improvement Task and Finish Group. It doesn’t exactly trip off the tongue, but it certainly sounds important. And indeed it is. The increasing focus on quality improvement and patient safety has been heralded by an explosion in the number of publications over the last few years, where the literature was previously rather threadbare (Davidoff et al., 2008). Quality improvement (QI) has been steadily moving up the agenda, with the associated language imprinting itself on the common consciousness (The Health Foundation, 2010).
Audit has long been heralded as one of the pillars of clinical governance and something that all trainees should involve themselves in. Compliance has been monitored through the ARCP process, with minimum requirements imposed. Historically little attention has been paid to the rigour of the audit work undertaken or the usefulness of the outcome. This approach has drawn criticism of a tick-box exercise that encourages simple task completion, rather than fostering deep understanding of the core principles or underlying intentions of audit (Kidd, 2015).
The Academy’s group aims to draw on the burgeoning evidence and political will behind quality improvement and translate it in to effective training for medical trainees (Shojania & Grimshaw, 2005). Despite the focus on doctors there is a clear recognition that health systems are complex and involve professionals from a diverse range of backgrounds interacting. Instead of a simplistic approach that seeks to just mandate quality improvement in the way that audit has been, the Academy’s approach aims to address all aspects of the quality improvement experience. It aims to do this through dividing and conquering with its four sub-groups, looking at curriculum development, QI training, supporting infrastructure at multiple levels, and mapping resources/multiprofessional ways of working.
The work aims to address several key ‘elephants’, which have long been lurking unacknowledged in the medical training ‘room’. Firstly, what is the relationship between QI and audit? Is audit just a subset of QI or does it have distinct attributes? Secondly, how can a parity of esteem with research be achieved? Trainees tend to be heavily incentivised to undertake activities that fit neatly in to the narrow concept of traditional research. The production of papers on esoteric elements of basic science is often rewarded with career progression; yet the equivalent effort invested in the pragmatic implementation of evidence to improve clinical practice frequently yields minimal formal acknowledgement. Thirdly there is the question of engagement by senior clinicians. What will it take to get these key players on board with this concept? Fourthly, the diversity of patient involvement in QI has been explored and how may we work most effectively in partnership. Finally, the big one: How are people going to find the time to learn about and practice QI?
A showcase event on 3rd November 2015 brought out the main messages and central recommendations of the group. The importance of high quality patient care was powerfully underlined by James Titcombe, whose infant son tragically died in Furness General Hospital, prompting the Kirkup inquiry in to the maternity unit there, revealing serious shortcomings (Kirkup, 2015). He spoke eloquently of how his previous experience as a project manager for the nuclear industry had informed his current role as a National Advisor on Patient Safety, Culture and Quality for the Care Quality Commission (Titcombe, 2015). He described how those who reported incidents would be entered in to a raffle to win a iPad and a fitter who had admitted to breaking some insulation was given an award instead of being reprimanded. What if a similar culture existed in the NHS?
There was recognition that QI training is important and requires adequate resourcing. The hotly anticipated publication of the General Medical Council’s Generic Professional Capabilities may add greater urgency to the need to integrate QI learning in to curricula, but the focus at the highest level needs to be flexible (General Medical Council, 2016). Inevitably learning about QI will be incremental, with skills being acquired in a progressive fashion, starting in undergraduate years and developing throughout postgraduate training and beyond.
What is clear is that there is a huge range of diverse resources available, from intensive hi-fidelity simulation courses to democratic MOOCs. Hubs that bring these resources together would be of enormous benefit to all, guiding the bemused neophytes and networking the QI connoisseurs. However this is achieved, signposting will be key and there is a need to link up like-minded individuals, so that a process of effective mentoring can occur.
Other important questions were posed, such as how would the effectiveness of any changes be evaluated? When attempting to implement such a diffuse programme of educational change, how will it be possible to know if the desired downstream impact of improved patient care has been achieved as a result of these efforts?
The final report, entitled ‘Quality Improvement – Training for better outcomes’ is to be published in March, which will set out the group’s recommendations. This will represent a hugely exciting opportunity to enhance the training that doctors receive in QI and will represent another step towards bringing QI to its rightful place centre-stage.
Davidoff, F. et al., 2008. Publication guidelines for qulaity improvement in health care: evolution of the SQUIRE project. Quality and Safety in Health Care, 17(Supplement), pp.i3-i9.
General Medical Council, 2016. Development of generic professioanl capabilities. [Online] Available at: http://www.gmc-uk.org/education/23581.asp [Accessed 22 January 2016].
Kidd, L., 2015. The purpose of audit: to improve care or boost trainees’ CVs. [Online] Available at: http://careers.bmj.com/careers/advice/The_purpose_of_audit%3A_to_improve_care_or_boost_trainees’_CVs%3F [Accessed 20 January 2016].
Kirkup, W., 2015. The Report of the Morecambe Bay Investigation.
Shojania, K.G. & Grimshaw, J.M., 2005. Evidence-Based Quality Improvement: The State of the Science. Health Affairs, 24(1), pp.138-50.
The Health Foundation, 2010. How do you get clinicians involved in quality improvement? London.
Titcombe, J., 2015. Joshua’s Story: Uncovering the Morecambe Bay NHS Scandal. Anderson Wallace Publishing.