What can I do as a QIA for revalidation?
GMC suggestions, which have dedicated templates on MARS:
- Review of your performance against local, regional or national benchmarking data
- Clinical audit
- Case review or discussion
- 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
There is also a generic ‘other’ QIA template on MARS, with headings to guide you to enter the necessary information for any alternative methods for QIA.
For revalidation purposes it is helpful to start from a position of identifying something that needs to be improved .
When the activity is complete you should be able to demonstrate that an improvement has taken place or that a high standard of practice has been attained or maintained.
Thinking about how you might measure or demonstrate improvement to complete the QIA will help you decide whether it has potential to be used as a ‘revalidation QIA’.
Often you will be able to reflect on the material you have submitted for your appraisal and identify areas for improvement. Your appraiser will be able to help with this during your appraisal discussion and build upon what you have already identified as an area of interest. The discussion should clarify what sort of activity might form a process of improvement. The activity should take into account the nature of your role. You should also think about how you will complete the activity to demonstrate that improvement has taken place and what standards you would set to aspire to. This will usually be included in your PDP for the next appraisal period and may even run into subsequent years.
It is usually more relevant and interesting to develop a QIA from something in your existing appraisal material, than to try to come up with an idea for a QIA out of thin air.
There is a very wide variety of learning methods e.g. reading (journals, articles, news items, patient safety alerts, prescribing information, research papers); on-line learning (e-modules, webinars, and podcasts); lectures: update courses; conferences, etc etc. The topics covered may be across the whole spectrum of your practice.
When you reflect on what you have learned using any of these methods you will usually highlight information that is new to you and will think about whether you need to change your practice to take this new information into account. Sometimes it will be obvious that you are not following current best practice because this has changed recently, and there is a clear need to bring your practice up to date, make a change and improve care. Sometimes you may learn about a topic and have a suspicion that you are not following best practice.
If you only ever learn that you are doing everything right already, then maybe you aren’t choosing appropriate educational activity
This learning can be a good source of ideas for audit topics. Often the educational resource will suggest possible audit topics that may be relevant to you.
You will usually decide to carry out an audit when the necessary change affects a significant area of your practice, and the numbers involved will give a meaningful result.
Sometimes the numbers are small, but the change is required for an important patient safety issue and you wish to be sure you have identified all those concerned, so a formal audit may still be appropriate.
In a typical completed audit cycle you will first collect data on what you are doing currently, and then you will evaluate this data and make a change if improvement is needed. Then you will re-audit after an appropriate time to confirm that there has been an improvement.
If there has been no improvement following the change, or only partial success, then you may wish to repeat the cycle with further evaluation, change and re-audit.
Changes should be made to improve the situation, not just for one audit cycle but for the foreseeable future, so that this is a worthwhile activity with meaningful improvement, and not just an exercise to tick a revalidation box.
Sharing QIA audits with the team also increases the value of the activity and makes it more likely that improvement will be maintained.
If performing well already then an audit may simply demonstrate that quality is being maintained. This activity can be useful evidence for appraisal that you are looking at the quality of your practice. Re-auditing may be required annually to confirm that you are maintaining your performance, but there is little scope for quality improvement, and it may not be appropriate to use this area to examine for your revalidation QIA.
Most doctors should be able to identify an area of their practice that could be improved, and it is likely that devising and completing a full audit looking at this will meet revalidation QIA requirements, as well as being a worthwhile personal activity.
Where an audit demonstrates a reduction in performance, the reflection would be expected to explore reasons for this and then identify and implement ways of improving the situation. The audit cycle could then be repeated to ensure that performance is improved.
Some doctors may have difficulty obtaining data to complete a formal audit that is relevant to their own practice e.g. locums. It is possible to review a series of cases prospectively to demonstrate that you have made an improvement to your previous practice.
You read about the National Review of Asthma Deaths and learn about the factors that increase the risk of death - over-use of reliever inhalers, under-use of preventer inhalers, frequent exacerbations, emergency admissions, and absence of an asthma care plan. It is clear from the review that asthma care nationally could be improved, and the number of deaths reduced.
If your role includes care of patients with asthma you might reflect that you could make improvements to your own practice.
If you are a Respiratory Physician or a GP lead for asthma then you could audit the processes in your hospital, department or practice to look at whether all patients have a follow-up appointment after an emergency admission, or whether there is a clear record of number of exacerbations or discussion of an asthma care plan at asthma reviews. It would make sense to focus on an area where you suspect you could be doing better. You may include sharing information on best practice with your colleagues as part of this activity. You might delegate data collection, but if you take the lead on this QIA you are justified in using it as evidence of QIA at your appraisal.
If you work as an occasional locum doctor, or in urgent care, then you probably have little influence on processes for chronic asthma care in your workplace. You might offer to carry out an audit as above, so that you have a QIA for your revalidation, but your appraiser may question how relevant the activity is to your own practice.
You need to think outside the box about how you could improve your own practice and demonstrate this.
If you frequently see patients with acute exacerbations of asthma in your role and have reflected that you could improve the quality of care you provide to these patients, then this could be developed into a valid QIA.
You might review a series of patients that you see with an acute exacerbation of asthma, say 10-20 consecutive patients, or all patients over a 3-6 month period, and reflect on how you have improved your care to address risk factors e.g. highlighting over-use of SABA or under-use of preventers; providing brief patient education interventions; ensuring a follow-up appointment is made to review ongoing treatment and asthma care plans; referring to respiratory OP etc
You might prefer to focus on complex cases, where risk factors have been addressed, but you feel more could be done to improve their care. Here it might be appropriate and effective to discuss these cases in detail with a peer, or peers. For these case discussions to count as a QIA, you would need to look at a number of cases and show how the discussions led to change and improvement. It would not be enough to just discuss and reflect on one or two cases, however interesting and detailed the discussion.
If you work as a doctor in the Sexual Health Service, and have a relative with asthma, you might still be interested in the NRAD, but asthma care is unlikely to be a significant part of your role. It would be useful to ‘file’ the learning, in case you have need of it in the future, and you may pass it on to your relative, thereby improving the quality of their asthma management, but this would not be enough for a revalidation QIA as it does not cover your areas of practice.
As part of your review of a serious significant event, or a learning event that does not meet the GMC threshold for SE, you will usually reflect on what could have been done better. This will often identify an area of practice where quality of care could be improved, and a QIA developed.
Keeping with the theme of asthma care, you might be involved in the care of a patient with a preventable death from asthma; you might be involved in the care of a patient who had repeatedly failed to attend asthma follow-up after emergency admissions, and is now being admitted as an emergency again; you might notice that over the last couple of months you have seen a number of asthmatic patients who do not have a care plan, or who are not on an ICS.
As above, the QIA that follows on from review of the events will depend on the nature of your role.
Reviewing significant and learning events as a team and responding as a team to the process of change and improvement, will lead to a greater impact on patient care. Think about how you will involve the team in any QI process to make the most of this QIA.
It is important to ‘close the loop’ if you are developing a QIA from analysis of a significant event. It is not enough to simply identify what went wrong / could have been done better, and to suggest an improvement – you need to review your practice to confirm that the change has taken place.
Complaints may also result from sub-optimal quality of care, and review of the complaint may identify an area for QIA.
Sticking with asthma: a patient is treated with repeated courses of oral steroids by their GP, OOHS and in A&E for exacerbations of asthma and develops diabetes. They complain that if they had been adequately followed up, treated with preventer inhalers, had an asthma care plan and been referred to a respiratory physician then this could have been avoided.
Again, any QIA that follows on from review of this complaint will depend on your role.
Sometimes complaints are about personal attributes or management of a case by a particular doctor, rather than processes, and highlight a need to update or modify behaviour. It is not so easy to demonstrate that change has resulted in improvement. This is an area where a series of case reviews with reflection and discussion on the issues identified may be a more suitable form of QIA to show that practice has changed.
Patient and colleague feedback
Negative feedback from patients or colleagues may highlight areas of practice that could be improved.
You may make changes to your practice in response to feedback.
Again, it is important to ‘close the loop’ and demonstrate that an improvement has taken place. This might require seeking further feedback on the area of practice concerned. Or, as above, a series of case reviews with reflection and discussion on the issues identified may be a way to demonstrate improvement.
Something that frustrates you
Improving something that frustrates you will usually involve change to existing processes or policies.
‘Audit and monitoring of the effectiveness of a teaching programme’ and ‘Evaluating the impact and effectiveness of a piece of health policy or management practice’ may be relevant here, and you could complete the appropriate MARS QIA revalidation template to ensure you include all the necessary information.
It is important to demonstrate that the change has actually resulted in improvement, and not just change for change sake. Sometimes collecting feedback from the team involved in the process will support this.
You also need to think about how substantial the activity is. It might frustrate you that patients do not realise you are a doctor, so you might change the way you introduce yourself. This would be an improvement in care but has limited impact. If you decided to discuss with your team, introduce a policy of ‘Hello, my name is‘, display a list of who’s who in the workplace to inform patients, and then gathered feedback from colleagues and/or patients that confirmed an improvement, then this would be a more substantial QIA.