In the first article on audit write-ups, we covered the theory of audit and important aspects of the write up – namely what was done in the QIP, what was learnt from doing the QIP and how your practice will change having done this learning.
This second article covers how the QIP log entries are assessed and discusses the typical comments given by trainers. The feedback should inform you of what you have done well and should provide suggestions that may be useful to you when you do another QIP so that your quality improvement skills improves incrementally.
In the first article, the trainee audited oral emergency contraception (EC). She asked a specific question: ‘Are women issued with Levonelle or ellaOne by the practice receiving information about LARC within one month of EC prescription?’
How QIA/audit is assessed
After reading her log entry, I understood why she asked this question; how she gathered the data to answer the question; how she analysed the data; what conclusions she made about the acceptability of level of service being provided; and what actions the practice agreed to help improve standards.
My feedback to the trainee would include a comment on how well this reflection demonstrated her knowledge of quality improvement and audit in particular. Her write-up was a succinct presentation of her findings and recommendations. I also agree with her newly-discovered learning needs around EC prescriptions, and computer searches for auditing. These need to be written up as a PDP.
My feedback about QIPs includes certain specific comments aimed at meeting annual review of competence progression (ARCP) criteria. The ARCP expects trainees to be able to identify and tackle aspects of GP that have impact on patient safety using QI methodology.
The RCGP guidance on QIP states: 'During your primary care posts in ST1/2 you are required to complete a quality improvement project with the aim of improving patient care. Audit is a type of QIP as both look at the quality of care provided with the aim of improving it and both require measurements to demonstrate change. More generally, QIPs can be about making small incremental changes and measurements which may be done weekly to test the impact of the changes.
'In contrast an audit has set criteria, each with their own defined standards, and has two sets of measurements over a longer time period, to demonstrate a baseline and then improvement. Completing a QIP allows change to be tested both quickly and successfully and is easier to do in a short time frame, for example in a 4-6 month trainee post. The QIP should be written up in the relevant section on the Portfolio and your supervisor will both assess and discuss this with you.'
Project title and why it was chosen
Trainees should explain what case, data or event triggered them to look at their chosen area. They should comment on the likely impact of their QIA on patients, and review the guidance or evidence that is relevant to the area (e.g. a literature review).
To score well, trainees give the QIP a clear and unambiguous title. In our example, our trainee gave her audit an appropriate and understandable title – you knew she was looking at EC and LARC. There must also be a link to personal and/or practice needs.
Our trainee discussed how EC was a learning need for her and that there was also a practice need about providing more information about LARCs. Her audit helped the practice understand how it could improve its level of EC care by discussing LARC more systematically with a 'hooked' and interested group of patients.
Had the trainee chosen a topic that was not a priority for the practice, I would have asked if she could identify other, more urgent areas of practice where she has questioned whether we are doing the right thing in the right way, perhaps from reviewing recent complaints or significant events.
The trainee was able to describe accepted best practice in her QIP. Preferably information about best practice is from a literature search and the trainee cites multiple sources. In our learning log, there is room for improvement.
The trainee cited NICE CG30 (2005). She demonstrates an acceptable understanding of current recommendations but would have scored more highly had she summarised key aspects of the clinical topic, citing several literature sources.
Trainees should discuss what they are trying to accomplish; how they will know that a change is an improvement; and what changes they could make that would result in an improvement in patient safety or patient care. A good QIP has SMART (Specific, Measurable, Achievable, Relevant and Time defined) aims.
Our trainee discusses how she set her audit standard after discussion with the team; how the data search was done; the data analysed; the findings presented to the practice and how she walked the practice through the EC template and IT (econsult and Gov.uk Notify) to attach patient information leaflets (PILs) on LARC to email or text patients.
Her suggested changes would increase the number of patients receiving PILs, potentially improving their understanding of LARCs and increased uptake of LARCs could improve patient care.
If a new protocol, for example – how to use Gov.Uk Notify to text PILs to patients – is written, then it too could be uploaded. If a teaching package was delivered to help bring about change, then the trainee could reflect on this in a separate entry or she could attach her teaching handout.
Describe what baseline data or information you gathered
Trainers should explain their choice of QI methodology to ‘crack’ the ‘problem’ they were trying to solve. Our trainee chose audit over other QI tools, for example, assessing baseline data, process mapping, conducting a survey or using fishbone analysis.
Our trainee used an appropropriate, well recognised QI tool (audit) to measure change, and she justified its selection.
Describe what subsequent data or information you gathered
Our trainee has not done her second cycle of data collection as yet, so she is unable to measure and evaluate the impact of her change. Until she presents this information, she will be marked as ‘below expectation’.
When she has completed the second cycle, she needs to demonstrate outcomes – there would be objective evidence from the medical record that more patients prescribed EC would be given PILs on LARC.
How did you plan and test out your changes?
Our trainee has not done her 2nd cycle of data collection as yet, so she is currently marked as ‘below expectation’ as she cannot tell us as yet whether the changes she proposed (completing the EC template, using econsult/Gov.uk Notify links) had the desired result, or whether she would need to rethink her strategy, using another Plan–Do–Study–Act (PDSA) cycle.
How have you engaged the team, patients and other stakeholders throughout the project?
Our trainee described engaging the clinicans in her presentation and IT walkthrough. Only her second data collection will tell whether she is successful at getting different team members engaged with her QIP.
At the second write-up, should she encounter difficulties, I would expect reflection on why challenges arose, her strategies to get all team members on board, her insights and proposed solutions.
Summarise the changes as a result of your work and how these will be maintained
On completion of the audit, after the 2nd cycle of data collection, I expect to see a clear summary of the changes that occurred and a discussion of whether the new systems have embedded into the practice’s ways of working.
If improvement is not achieved, I want an explanation of why this occcurred and what the trainee learnt from this.
What have you learnt and have you got any outstanding learning needs?
The trainee needs to articulate what she would maintain, improve and stop in QIA. For example, she could consider the size of project, the amount of evidence collected, how she worked with others, the effective use of IT, and the project’s value to long term care.
An excellent reflective log would also tell me what this trainee would do differently if she repeated the QIP; what small specific actions she would take to make the process easier or more effective. This would count towards personal learning on leading change, which links with both ‘Maintaining performance, learning and teaching’ and well as ‘Organisation, management and leadership’.
- Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP was published in January 2016.