The purpose of collecting and reflecting on quality improvement activity is to allow you to review and evaluate the quality of your work; to identify what works well in your practice and where you can make changes; to reflect on whether changes you have made have improved your practice or what further action you need to take.
You must discuss with your appraiser or responsible officer the extent and frequency of quality improvement activity that is appropriate for the work you do.
You must be able to show you have participated in quality improvement activity that is relevant to all aspects of your practice at least once in your revalidation cycle. However, the extent and frequency will depend on the nature of the activity.
You should participate in any national audit or outcome review if one is being conducted in your area of practice. You should also reflect on the outcomes of these audits or reviews, even if you are unable to participate directly.
You should evaluate and reflect on the results of the activity, including what action you have taken in response to the results and the impact over time of the changes you have made, and discuss these outcomes at your appraisal.
If you have been unable to evaluate the result of the changes you have made or plan to make to your practice, you must discuss with your appraiser how you will include this in your personal development plan for the following appraisal period”
When considering quality improvement activities the GMC does not define exactly what counts as QIA for revalidation purposes.
Quality improvement activity can take many forms depending on the roles you do and the nature of your practice.
You should think about the activities or work in which you have been involved that has focused on quality improvement.
Think about each part of the term “Quality Improvement Activity”.
You should be personally involved in some activity, doing something, but not necessarily carrying out all of the work, and it should be relevant to your practice.
The activity should focus on some aspect of quality of practice, preferably measuring your practice against a recognised standard
You should be involved in a process of change that leads either to improvement or show that good practice has been maintained and provide evidence to demonstrate this as appropriate.
The GMC suggests these examples of QIA:
- Review of your performance against local, regional or national benchmarking data where this is robust, attributable and validated. This could include morbidity and mortality statistics or complication rates.
- Clinical audit. This must be evidence of effective participation in clinical audit or an equivalent quality improvement exercise that measures the care with which you have been directly involved.
- Case review or discussion. A documented account of interesting or challenging cases that you have discussed with a peer, another specialist or within a multidisciplinary team.
- Learning event analysis.
- Audit and monitoring of the effectiveness of a teaching programme.
- Evaluating the impact and effectiveness of a piece of health policy or management practice.
Quality Improvement activity must take place at least once in the revalidation cycle.
Royal Colleges and speciality specific guidance may advise that it should take place more than once. Royal Colleges may specify what is required in relation to their own speciality. For the purposes of revalidation it is the GMC requirements that your RO will take into consideration when making a recommendation, not that of your Royal College.
Many organisations require participation in ‘audit’ activity that simply reviews the quality of your work. If this review identifies that quality of care could be improved, then further activity to make change, and to then demonstrate that improvement has taken place, is necessary to complete this as a ‘quality improvement activity’.
If you confirm that you are performing to a high standard then this activity may not identify any areas for change or potential for improvement.
Demonstrating whether an improvement has occurred, or if the activity showed evidence of good practice then this has been maintained, should be through the results of a repeat of the activity or a re-audit after a period of time where possible.
You should try to provide evidence of QI activity across all your roles.
The activity should be relevant to your work and based on your UK practice.
The reflection in the MARS entry for your appraisal should focus on how the proposed or actual changes would lead to an improvement in patient care.
There are a number of MARS QIA templates tailored to different types of activities, including a generic ‘other’ template. The headings are designed to draw out the required information.
It is your Responsible Officer’s decision whether there is ‘enough’ quality improvement activity over your revalidation cycle.
It can be quite difficult to work out whether you have done enough.
A substantial piece of work, often over 2 or 3 appraisal periods, may meet all the requirements. Simpler activities, such as a single case review or discussion, will probably not be enough on their own, but in combination with a number of other simple QI activities might be acceptable.
If your appraisals contain only minimal evidence of QIA then it may not be clear to your appraisers, or to the RO that you have done enough to meet the revalidation requirements.
The RSU has developed a tool for appraisers to help them assess QIA submitted for appraisal.
The tool considers each of the features of QIA described by the GMC:
- Relevance - relevant to your work and active participation
- Robust and Systematic – evidence of planning
- Considers Good Practice – evidence based
- Communication - discussion with a peer or the team
- Considers current practice – description, reflection, measurement of current process
- Outcome or Change - demonstrate an outcome or change
- Take Action - appropriate and in response to the results
- Improvement - improvement has occurred or good practice maintained
- Reflection - what you did with the information, reflection on that information, what it says about your practice, how you intend to develop or modify your practice
If your QIA covers all of the above bullet points then it is likely to be verified by your appraiser for revalidation purposes.
If there are significant gaps, then your appraiser is likely to mark the QIA on your revalidation page as ‘needs more work’, and will usually include completion of this work in your PDP for next year.
It is a good idea to start work on QIA for revalidation early in the cycle, so you have plenty of time to ensure you have enough evidence of the quality of your work by the time your revalidation is due.
The use of the quality improvement cycle of Plan, Do, Study, Act may help you clarify whether your activity meets the threshold. In general terms your appraiser is looking to see if your actions and reflection in relation to your activity, be it audit, case review or case series, would mean that any identified weakness in patient management would be less likely to occur following your reflection than before your reflection on the issue.
Demonstrating that you are maintaining good practice is mentioned by the GMC as an acceptable outcome, but it would be a much better use of your time and effort to choose an activity where you believe there is scope to improve the quality of your work, and to go on and make an improvement, rather than to simply confirm your expectations that there is no need to improve. Many so-called ‘audits’ are simply a review of performance to demonstrate that standards are being met, rather than a way of improving quality of care.
There are many ways to identify areas for improvement:
- CPD – you learn about a better way of practising, new evidence that requires action, new techniques that you decide to adopt
- Review against benchmark data or guidelines identify a need to improve your performance
- Significant events, learning events, complaints, patient feedback, or colleague feedback identify potential for improvement
- Something that ‘bugs’ you could be an area for improvement
Further information on QIA is available including ideas for different QIA activities to undertake:
- Ideas for QIA
- The RCGP has produced detailed guidance on QI for GPs that is relevant to other doctors
Other organisations, such as Royal Colleges and Health Boards may also have resources for QI.