How’s my driving? Using quality improvement to enhance patient outcomes

Using systematic audit is a good way to measure what you are doing well and what could be improved – which can be good for your professional development as well as for patient care

We all like to think we are doing a good job. As general practice nurses (GPNs) we see people with a huge range of health needs from cradle to grave and we aim to deliver good quality, evidence-based care. We should know what that looks like and we should, by and large, be able to implement it. But how do we know what is going well, and how do we recognise what might be termed a work in progress? Clinical audit is a process which helps us to know where we are and what should be happening versus what is actually happening in real life. NHS England describes clinical audit as a way of assessing whether healthcare is being provided in line with recognised standards, reviewing whether the service is doing well, and where there could be improvements.¹

The concept of audit might sound unexciting to some, but it can be hugely influential in identifying gaps in care and highlighting the need for additional time or money or new ways of working which might help to close them.

In this article we discuss how to use local and national data and systematic audit tools to measure what you are doing. There will be a focus on identifying key areas for attention and taking a more time-effective way to identify goals and improve outcomes. We will also describe how measuring and optimising care delivery can be good for your career as well as for patient care.

MEASURING CURRENT PRACTICE

For many of us working in general practice, the ‘proof’ that we are doing a good job will lie in the achievement of our Quality and Outcomes Framework (QOF) points. These points, awarded for reaching specified targets for a range of services, including the management of long-term conditions, can help provide reassurance that we are doing what is expected of us and offering patients a good standard of care. However, QOF points can still be achieved even if only a proportion of patients have been seen and QOF standards are considered by many to align with basic care rather than quality care. Based on the concept of the ’inverse care law’ where those most in need are those most likely to miss out, there is a real possibility that GPNs are seeing and treating people with the lowest level of need while those who do not attend, for whatever reason, are most at risk of harm. For example, in a practice where 65% of children are immunised, there is not only a risk of the loss of herd immunity, but statistically speaking, those left unvaccinated are more likely to be from families with additional health risks and needs, such as poor housing, low levels of income and inadequate nutrition.² Even if the same practice had 85% of its children vaccinated, those left without protection are more likely to be in the harder to reach populations who may accumulate risk. I realised this when I worked in a practice where we had two satellite surgeries in a city with a wide variation in deprivation scores. One clinic was in the least deprived area of the city while the other was in one of the most deprived areas with high levels of asylum seekers and people who were less able or inclined to understand or trust healthcare professionals. Knowing our numbers helped us to identify areas of risk and reconsider how we delivered services to take into account our population needs.

So how can you know how well (or otherwise) you are doing? I have a strong interest in long-term conditions and am heavily focused on reducing risk: minimising the risk of exacerbations in people with asthma and COPD, identifying risk factors for conditions such as cardiovascular disease (CVD), and chronic kidney disease (CKD), and ensuring that people with a diagnosis of type 2 diabetes (T2D) are able to implement lifestyle changes and access the medication that should reduce future complication risks. I thought I was doing well in informing patients of potential risks and supporting them to reduce those risks. However, I did not know for certain whether this was indeed the case. So, the practice agreed to invite a company which specialises in quality improvement to come and audit our T2D patient population and compare what we were doing with recognised standards of care. Once the initial audit was complete, I was surprised to see the number of patients who were not getting what I would consider to be basic care – structured education along with metformin, lipid lowering medication, SGLT2 inhibitors and renin angiotensin aldosterone system (RAAS) inhibitors. Admittedly we were doing better than many practices, as nationally only around 20% of the people who qualify for an SGLT2i are prescribed them, but at 40% we were still considerably short of where we wanted (and expected) to be. The owner of the audit company I had brought in, Kavita Oberoi, explained to me that this is the value of audit. It takes the blinkers off, moving the focus away from just the cohort of patients being seen and treated (which potentially gives a skewed impression of how well we were doing) and presents hard data about what is really happening in the practice for the entire T2D population.

GP practice systems such as EMIS and SystmOne have the capacity to audit practice and present a dashboard for a range of parameters. This can be used as the basis for measuring progress and identifying a possible quality improvement project. Some pharmaceutical companies can run these for practices too. In the past I had seen these dashboards presented but I had never found time to really examine or address the findings. The Oberoi review, which was fully compliant with NHS data protection rules, clearly identified the numbers of patients that required my attention, right from those who had not attended for a review since the pandemic (how had that happened?!) to those who had attended but who still had gaps in their management. For example, it was now easy to see the people with T2D and CKD who had not been prescribed an SGLT2i or a statin, or who had not had a urinary albumin creatinine ratio (uACR) measured. Once they were identified it was possible to triage those most in need of review.

USING AUDIT TOOLS

A basic introduction to quality improvement (QI) can be found here: https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2011/06/service_improvement_guide_2014.pdf. Although 10 years old, now, this useful article sets out a step by step approach to the audit cycle. Along with the previously mentioned practice system dashboards and the availability of audits carried out by commercial organisations such as Oberoi and pharmaceutical companies there are national tools which can be used to see how each practice, locality, integrated care board (ICB) or hospital is doing compared with others. Publications which can be useful for audit and QI purposes include the National Respiratory Audit Programme (NRAP, https://www.nrap.org.uk/) Public Health England’s ‘Fingertips’ tool (https://fingertips.phe.org.uk/), UCL Partners (https://uclpartners.com) and the CVD Prevent tool which includes a demonstration of how to use it, available at https://data.cvdprevent.nhs.uk/home.

The Primary Care Cardiovascular Society (PCCS) has examples of quality improvement projects that can be carried out in primary care to identify and address clinical areas that would benefit from audit, improvement initiatives and review. These include CKD, heart failure and lipid management. The tools are free of charge and available to members. Membership of the PCCS is free for registered healthcare professionals – go to https://pccsuk.org/ to find out more. The QI programmes are designed to support primary care teams to understand the impact of a disease (such as CKD or heart failure) or risk factors (such as dyslipidaemia) and recognise how improving identification and coding can lead to better management and outcomes.

IMPROVING KNOWLEDGE OF GOOD PRACTICE

QI programmes often begin with an understanding of what should be happening – i.e., what constitutes good practice. In T2D, for example, people should have had HbA1c, blood pressure, eGFR and uACR, height and weight, and a lipid profile measured at least annually, and a foot check and retinopathy screen carried out. Auditing allows practices to identify those who have missed out on any of these measures and to consider system changes which may be needed to avoid this happening in the future. It is not simply a case of recording these results, however. In those where abnormalities have been identified appropriate action needs to be taken. If uACRs are not being collected and tested, all of the team needs to know why the samples are important and what to say to patients who may not understand why they are being asked for a sample. The healthcare assistant who does the diabetes workup needs to be able to impress on the patient the importance of getting the sample and, if need be, requesting one to be supplied there and then. For GPNs who are not prescribers but who are running long term condition clinics, there needs to be a robust system in place to ensure appropriate prescribing of medication, so the patient does not miss out. Thus, audit can be seen as an ongoing activity where there is a cycle of planning, doing, studying and acting – the so-called PDSA cycle. Repeated audits are needed to show where improvements have been made and where action is still required. Where external support has been sought, as was the case in our practice, there needs to be a legacy effect, i.e., recognition from and empowerment of the practice team to ensure that the work that has been started is continued.

COMMUNICATING AND IMPLEMENTING BEST (OR BETTER) PRACTICE

An example of one of the areas addressed in our practice was the suboptimal number of patients with CKD on lipid-lowering therapy (LLT). The NICE guidelines for CKD recommend statins for anyone with a diagnosis of CKD, without the need for further assessment such as QRisk scoring.³ Working with our clinical pharmacist we contacted people with a diagnosis of CKD who were not on LLT to invite them to consider starting on a statin. They could choose to do so by replying immediately, or they could come in to discuss it further with a clinician. Similarly, the NICE guidelines for T2D recommend that anyone with T2D and a CVD risk score of 10% or more should be offered an SGLT2i for cardiorenal protection once they are tolerating metformin.⁴ Although I routinely take this approach for people newly diagnosed with T2D, I realised that there were others who had potentially missed out on this important intervention and who might therefore be at risk as a result of being unprotected. It can be quite a challenge to explain evidence-based recommendations to people living with long-term conditions, so we try to use all the media available to use – television in the waiting room, newsletters, posters and social media. We also use Accurx to share information and enable responses. Anything that helps to get the message out to the public can be considered. Those with CKD or T2D who want to have a more in-depth discussion about statins or SGLT2 inhibitors are then invited to a group clinic.

GROUP CLINICS

We have discussed the role of group clinics in a previous article in Practice Nurse.⁵ This approach, which has been endorsed by NHS England, allows clinicians and patients more time for education, debate and information-sharing than might be the case in a one-to-one appointment. In my experience, people feel more able to ask questions in a group than they might when alone with the clinician. Many people have expressed their surprise and relief when they realise that they are not alone with their condition and that there are others in the same boat. For the clinician, it is more time-effective to cover topics once rather than seeing 15 people to discuss the same issue one by one. The patients with CKD were invited to come in for an hour-long session where they were invited to ask questions about their diagnosis and the implications for the future. Many were concerned about the risk of end-stage kidney disease and the possibility of requiring dialysis or transplantation. When it was explained that this was far less likely than the risk of a cardiovascular event, they understood why we were offering lipid-lowering treatment. Needless to say, there were questions about statins and their potential side effects and key misconceptions were addressed by offering explanations, evidence, reassurance and options (e.g., rosuvastatin or ezetimibe with bempedoic acid). At the end of the hour, 14 patients had attended and 12 left with a prescription for medication which would reduce their future risk. The feedback was very positive, and people felt that the session had been more valuable than a standard one-to-one because of the presence of others.

ASSESSING IMPACT

As mentioned previously, it is important that the PDSA cycle is followed through to ensure that quality improvements are sustained and result in measurable outcomes. As a result, rather than seeing the 12 patients with CKD leaving with a prescription as an outcome, it is important to review the numbers that stay on treatment and the numbers that reach lipid targets (a reduction in non-HDL-cholesterol of at least 40% being the minimum standard of achievement as defined by NICE).⁶ Reviews can be done by telephone, or through another planned group clinic. A rolling rota of group clinics on different days and at different times will ensure that opportunities to attend are easily accessible.

SPREADING THE WORD

Success should be celebrated and shared. As well as spreading the word about health promotion, GPNs should recognise the importance of celebrating and sharing their own ‘wins’. Writing about audits and outcomes in lay terms for your patients in practice newsletters, or even through local newspapers, raises the profile of the practice, the condition and the GPN’s role. Another way to share key QI projects is to write them up – for example, in Practice Nurse journal. If you have followed a formal research model, you could aim to publish in academic journals or put together an abstract which could be presented at a conference. Organisations such as the Primary Care Cardiovascular Society, the Primary Care Respiratory Society, the Primary Care Diabetes Society and the Association of Respiratory Nurses (ARNS) are keen to receive abstracts for their conferences. There is support available to do so, too. Dr Kate Lippiett, a nurse who leads the Research and Education sub-committee for ARNS, is keen to support GPNs with their first steps into the world of sharing best practice and you can contact her at K.A.Lippiett@soton.ac.uk.

At a recent conference, attended by 250 nurses from primary and secondary care, a GPN colleague, Jo, explained how she had undertaken a piece of work for her primary care network aimed at moving people with COPD from using an inhaled corticosteroid/long-acting beta2 agonist and a long-acting muscarinic antagonist in two separate inhalers onto triple therapy in one inhaler. The move was better for patients (one inhaler, one technique, better adherence and reduced risk of exacerbations), better for the environment (reducing the number of inhaler devices being used) and better for the budget due to cost savings from using triple therapy inhalers. She described how she thought that what she did was an obvious move, nothing special and that ‘surely everyone is doing this?’ People in the audience, on the other hand, were impressed by how she had organised the project, how she had implemented the change with patients and clinicians alike and how she had accessed resources for the project. Jo became a resource for others through a project with far-reaching benefits, but which was relatively straightforward to put in place. So many projects worth sharing come from simple ideas implemented successfully. Dr Lippiett explained to Jo how she could turn her work into an abstract which could then be submitted to a conference so she could have a wider impact and also get further recognition for her project, potentially improving care for a much wider patient group.

THE NMC CODE OF PRACTICE AND REVALIDATION

As GPNs we are expected to follow the Nursing and Midwifery Council (NMC) code of practice and submit evidence of our continuing professional development in order to revalidate. Carrying out an audit is an excellent example of how to recognise current levels of care being implemented, contrast those with the recommended standards of care for a particular condition and identify and address any gaps in service provision. Once any gaps have been identified, the actions taken to address them and the implementation of ongoing reviews to determine the impact of changes in practice can all be submitted as evidence of reflective practice at its best.

SUMMARY

For me, having external support to carry out an audit of people with T2D and CKD has spurred me on to do more to understand what we as a practice are doing well and also what we need to work on. It has helped us to work more effectively through education and upskilling of all of the healthcare team and it has encouraged us to discuss our different approaches to managing these long-term conditions to ensure patients are getting the same message from us all. Everyone from the receptionists to the dispensary, from the GPs to the patients themselves knows why a uACR measurement is so important and why we recommend statins for so many people. Improving the team’s understanding of the tools that can be used to audit your clinical practice is key to getting started, whether it is through an independent company like Oberoi or by asking your practice IT support to interrogate your system dashboard or through the tools available via NRAP, UCL Partners or CVD Prevent. Once you have identified what is going well and less well, unmet needs can be addressed in a person-centred, timely way to improve patient outcomes. Although this in itself may be a positive result, sharing what has been achieved through effective clinical audit with a wider audience can extend the impact beyond an individual nurse and practice to the locality or even nationally. As someone famous once said, you can be the change you want to see in the world.

REFERENCES

1. Healthcare Quality Improvement Partnership. Clinical audit: A simple guide for NHS Boards & partners; 2017 https://www.good-governance.org.uk/wp-content/uploads/2017/04/clinical-audit-a-simple-guide-for-nhs-boards-and-partners.pdf

2. Haider EA, Willocks LJ, Anderson N. (2019). Identifying inequalities in childhood immunisation uptake and timeliness in southeast Scotland, 2008-2018: A retrospective cohort study. Vaccine 2019;37(37):5614–5624 https://doi.org/10.1016/j.vaccine.2019.07.080

3. NICE NG203. Chronic kidney disease: assessment and management; 2021 https://www.nice.org.uk/guidance/ng203

4. NICE NG28. Type 2 diabetes in adults: management; 2022 https://www.nice.org.uk/guidance/ng28

5. Brady L, Lynch M, Bostock B, Craig G. The case for general practice nurse-led group clinics. Practice Nurse 2024;54(5):21-25 https://www.practicenurse.co.uk/index.php?p1=articles&p2=2557

6. NICE Clinical Knowledge Summaries. Lipid modification – CVD prevention; 2024 https://cks.nice.org.uk/topics/lipid-modification-cvd-prevention/