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Revalidation in Wales

QIA Examples

QIA examples 

Primary Care 

1. Audit the effectiveness of monitoring patients on high risk medication e.g. DMARDs, DOACs, NSAIDs 

Learn about additional recommendations at update course. 

Should be relevant to your role, and numbers of patients should be enough to demonstrate an impact.  

Refer to recognised guidelines.  

Important to make improvements to the process that can be continued going ahead, not just ‘filling in the gaps’ for a second data collection, then going back to an ineffective process. 


2. Develop a practice protocol e.g. for investigation of low B12 and treating with oral or injectable B12 

Prompted by high numbers of patients on long term B12 injections, suspected many inappropriate. 

Refer to guidance.  

Involve the team. Consider team training.  

Consider patient information to support change. 

Keep it manageable – numbers may be high, requiring a staged process – new cases first, then working back through those on repeat prescriptions. Think about time scale. 

Audit to monitor change/improvement 

Not enough to just write a protocol then hope it results in improvement. 


3. Management of suspected UTI 

Common problem and often not managed consistently or effectively – has been a ‘hot topic’ with lots of guidance and educational meetings/articles/e-learning around improving use of resources and reducing antibiotic use and resistance 

Refer to guidance and identify area/s for improvement 

Lots of areas to consider – indication for antibiotic, choice of antibiotic, duration of antibiotic treatment, use of dip testing, use of lab for MSU analysis , clinical information on sample requests, handling of urine samples left with reception, telephone requests for antibiotics, care home dip tests, catheterised patients, etc 

Common condition – scope for locums or OOH GPs to carry out a QIA and look at a case series or for practice-based GPs to audit aspects of care. 


4. Review of referrals e.g. to urology/nephrology 

May be prompted by learning from study day 

Refer to guidance and local pathways e.g. local pathway for Non-Visible Haematuria, when to refer deteriorating renal function, what to include in referral letters 

Could be an audit, or a case series.  

Consider how many cases would be a reasonable number to demonstrate improvement – one or two not enough, 10 or more would be better. Pick an area which is a significant part of your caseload to ensure you can collect enough cases. 


5. Developing an educational module for colleagues e.g. management of suspected skin cancer 

Developed in response to inappropriate management bugging the doctor 

Not enough to assume that the existence of a learning module will lead to improved management. 

Would need to be supported by a before and after data collection to demonstrate change in response to education. 

Consider looking for feedback on the module. 

Think about numbers e.g. 2 people complete the module and one says it has improved their understanding of when to refer – this is not enough. 


6. Producing a Patient Information Leaflet e.g. how to take a self vaginal swab, travel advice for diabetic patients 

Prompted by reflection that it would save time and be more effective to give patients written information. 

Swab information brief and taken from manufacturer’s leaflet vs unique in-depth travel advice from a lot of personal research - not much personal activity involved in creating the former compared to the latter, even though given to more patients, so swab leaflet not really enough for a revalidation QIA. 

How do you measure the impact to complete the QIA? 

For the travel advice would need some patient feedback, or colleague feedback that this was a useful resource and improved patient safety. 

Demonstrating an impact for the swab leaflet e.g. improved numbers with timely self-test swab results attending for coil insertion could bring it up to revalidation standard, even though not much work involved in creating the leaflet. The QI activity would have been developing a process prior to coil insertion to obtain self-swabs and give out the leaflet to support this, and then to demonstrate that this process is effective. 

Simply writing a leaflet does not necessarily lead to quality improvement, so is not enough. 


7. Review of consultations 

Important to identify quality criteria to measure against e.g. quality of records, appropriateness of prescribing, advice given in line with clinical evidence etc. 

Simply reviewing a number of consultations and reflecting on them without any structure or meaning does not demonstrate quality improvement. 


8. Developing a practice template, assessment tool, or proforma to aid management e.g. bespoke computer template for recording information at chronic disease reviews, proforma for home visit requests, assessment tool for suspected sepsis or suicide risk in OOHS 

Often prompted by concerns about inconsistency and/or missing important information – may be in response to significant or learning event. 

Sharing with team in a way that promotes its use will increase the impact. 

Improved data collection will demonstrate achievement. 

Use of an assessment tool does not necessarily equate to improved quality of care- feedback from colleagues using the tool would be more useful, analysis of a series of cases where the tool was used would be even better but may not be easy to do in some workplaces. 


9. Improving prescribing e.g. hypnotics, controlled drugs 

Identified as a ‘hot topic’ or from practice prescribing information. 

Refer to guidance on good practice. 

Set a realistic timescale – may be something that takes several years to achieve goals, but you may be able to show improvement along the way in order to use as a revalidation QIA. Taking improvement a step at a time may be more achievable. 

Practice-based audits will demonstrate improvement and may be re-run at intervals. 

Think about involving the whole team, and how change will be communicated to patients. 

Locums could look at a series of cases and compare their practice to best practice. 


10. Audit of equipment e.g. doctor’s bag, resuscitation trolley, OOH drug cupboard etc 

This is often prompted by missing or out of date drugs or equipment when required. 

First step is to identify what is required to bring the equipment up to a recognised standard, and to compare the existing situation to this to see what needs to be improved – you already know there is a problem, but not the extent. 

It is not enough to simply bring the equipment up to standard and then re-audit. You know it is now OK as you’ve just updated it. It is essential to develop a process for ensuring that it is maintained, and that the standard is regularly reviewed. A re-audit further down the line when things have had time to slip again is required to demonstrate that quality has been improved and maintained. 



Secondary care 

1. Medical device comparison  

Prompted by use of different device designs favoured by different practitioners within the HB, and no consensus as to which, if any, gives the best results. 

Think about outcome measures e.g. clinically important early/late complications  

Numbers need to reach significance if your review is going to inform changes to device choice, and you may need to engage colleagues from further afield to gather meaningful data. 

The QIA is not complete until a change has been made and confirmation of improved practice is obtained. 


2. Audit of quality of practice against local and national quality indicators e.g. for operations/procedures 

Regular audit which shows results maintained that are comparable to peers, with an outcome of continuing to practice in the same way, is not really quality improvement.  

You may identify one or more key indicators where your performance could be improved, and could focus your attention on changes there, looking for improvement in future cycles. 

Without any change this is simply evidence that your performance is of satisfactory quality. It is still valid information to include in your appraisal material, but your appraiser would prefer to see evidence of improvement to verify this as a QIA for revalidation. 


3. Work on SOP & Governance structure for part of the service 

May be prompted by an external review which highlights areas for improvement. 

Think about your role. 

Identify the changes made e.g. new SOPs, new supporting documents; updated contracts. 

Collect data to confirm new structures have been adopted and that service now meets nationally agreed standards. 

Reflect on the impact of this work on the quality of the service. 


4. Review of referral pathway 

May be prompted when you notice that an existing pathway is not using resources effectively e.g. inappropriate prioritisation of certain groups over others, treatment step that delays progress without clear benefit etc 

First step would be to obtain evidence of the need for change. Discuss with team and agree change to be made.  

How are you going to communicate with stakeholders and ensure that they buy in to the new pathway? 

How are you going to demonstrate that improvement has taken place to complete the QIA? What could you measure? Where should you go for feedback?  Would a review comparing similar cases before and after the change support a gut feeling that the new pathway must be an improvement? 


5. Developing a web page to contain information relevant to your area of practice 

May be prompted by frustration at difficulty accessing key documents when required. 

Think about what you are trying to achieve, and who might help. 

What do the team members need – consult. 

How are you going to promote the webpage to colleagues, and how are you going to ensure it is kept up to date? 

How will you know that it has improved quality of care? 

Simply deciding to set up a web page and achieving this goal is not necessarily a quality improvement. 


6. Development of a new service 

May be prompted by seeing a gap in local services e.g. no access to a specialist service 

Why did you choose this activity, and how is it relevant to your role? 

Consulting with colleagues will be important when developing a new service. 

It might seem obvious that providing a new service is an improvement on no service. It would be useful to reflect on the uptake of the new service, and the benefits of providing this service more local, and possibly to obtain some feedback from colleagues and patients involved. 


7. Regular case-based discussions with a consultant colleague/s about challenging patients  

These discussions could be an opportunity to raise cases for a collaborative approach where management options are not clear 

Sharing expertise and ideas might improve individual patient care.  

Use examples to evidence improved quality of care, where the discussion has prompted a change in management plans, and a better outcome for the patient. 

How might you share the ideas more widely? 

You will need more than 1 or 2 cases for this to count as a QIA for revalidation. 


8. Review of complaints leading to change in operative technique 

This activity was in response to a number of informal complaints at follow-up from patients dissatisfied with the outcome of their procedure. 

The surgeon reviewed and reflected on each of the cases and discussed with a senior colleague. 

They have since changed their technique and are considering observing colleagues carrying out the operation to look for further improvements they might make. 

To close the loop on this as a revalidation QIA the surgeon needs to demonstrate that the changes to operative technique have been an improvement – a bespoke patient survey might be a good way of assessing patient satisfaction, rather than simply relying on a reduction in informal complaints or expressions of dissatisfaction at follow up. 


9. QI project supported by audit in response to critical incident and risk to patient safety 

Critical incident reporting identifies a patient safety issue. 

Consultant worked with trainees to address the issue, and had a key role communicating with management, as well as supporting and guiding the trainees in presenting and running the project. 

Initial audit identified extent of the problem. 

Changes made in several stages to eradicate the problem, including a pilot on one ward. 

Training and communication needs included and addressed as part of the process. 

Staff surveys part of the QI process. 

Re-audit confirmed significant reduction in use of unsafe equipment. 

Plan to further target remaining problem areas and re-audit to confirm complete removal of unsafe equipment. 

Overall intervention to be rolled out more widely and will provide a framework for achieving change. 

Project shared with peer groups and professional organisations as example of best practice and nominated for an award. 

This QI project ran over 2-3 years until it reached a stage of near completion. 

This clearly meet all the requirements for a revalidation QIA. 


10. Work to improve delivery of service  


(i) Delivery of emergency theatre work 

Consultant using the theatre regularly and frustrated by the way it was run 

Long-standing work focused on efficient running of theatre service 

Involved ongoing audit and monitoring of the service. 

Several changes made over time to booking process and introduced a daily team meeting. 

Gained experience in process mapping and analysis of data. 

Consultant ‘feels they have gone some way to improving things, and raised staff awareness of efficiency goals, but still some way to go’. Is a feeling things have improved enough to demonstrate quality improvement? You probably have evidence of improvement from the ongoing audits and monitoring. Make sure you include some of this data in your appraisal entry so that it is clear to your appraiser what has improved.  

Even though there is still more to do, and the work will continue, if you already have data to show that there is improvement in quality of service delivery, then this could be verified as a revalidation QIA. You can still continue this work after verification, and include it in your next PDP  


(ii) Introduction of electronic diagnostics results reporting 

Consultant leading the introduction and development of e-reporting for their speciality – ‘a long-term wish’ 

Working with HB IT services and suppliers of investigation systems 

Completed phase 1 with fully functioning system of e-results for some key procedures. 

Work planned in phase 2 to include more procedures in a phased manner, and to ensure process will be maintained by the HB. 
Longer term goal to include POC tests requires additional resources, and to address a number of technical constraints. 

Why is this improvement? It might seem obvious, but your appraiser will be interested in how this improves patient safety, improves efficiency and access to results, meets the needs of stakeholders etc. 

Phase 1 completed, and this QIA could be verified for revalidation. Phase 2 is essentially completion of this ongoing project, so would not be verified again if it continues into another revalidation cycle. 

The longer-term goal for POC tests seems like a separate, although linked, QIA, and could be submitted in the next revalidation cycle, depending on timing. 


(iii) Collaborative specialist regional event 

Attended as an opportunity to share experience and ideas with peers, then develop your own service accordingly. 

Needs more detail to count as a QIA for revalidation - examples of your contribution; relevance to your work; what changes have you made as a result of attending the events; how has this impacted on your practice and care of your patient. 

It is not enough to just attend the event and reflect on the learning – there needs to be evidence of change and improvement.  


(iv) Developing a guideline 

Prompted by unexpected death of a patient 

Worked with colleagues to update the existing protocol and adapt national guidelines to your own hospital. 

‘Much easier to follow now’. 

 Is this enough to verify as a QIA? 

Your appraiser will want to know how much you have personally been involved.  

How exactly will this improve patient care and safety? 

What is the impact of the new guideline on the colleagues who are using it? 

Do you have any evidence to back up your claim that this is an improvement in quality of care? 


(v)Investigating complaints about your service 

Recurring problem of complaints about access to your service for advice.  

Prompted to investigate following receipt of a written complaint. 

Investigation to find out where in the process things have gone wrong. 

Liaising with switchboard to clarify process. 

Discussion as a team to find a solution that is effective and considers resources. 

Does anyone care that we have fixed this? Did I get any thanks or praise? No.’ 

Think about how you could demonstrate that this is an improvement in quality of access. 

Some comparison of data on complaints before and after the change could be useful. 

Is this enough to count as a QIA? It depends on how much personal activity was involved, as well as on being able to demonstrate improvement. A complicated and time-consuming investigation, and discussion to find a solution would make this a more substantial QIA which could be suitable for revalidation purposes. 




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