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3 Supporting the delivery of high-quality careclinical leads, the National Institute for Health and CareExcellence (NICE), the Healthcare QualityImprovement Partnership (HQIP), the Care QualityCommission (CQC), Health Improvement Scotland,the National Leadership and Innovation Agency forHealthcare in Wales, specialist societies, other royalcolleges and patient groups.Clinical management guidelinesTo provide optimal patient care it is necessary to knowwhat constitutes optimal care. Determining this can bedifficult, increasingly so as medicine becomes morecomplex, more treatments become available and theassociated scientific literature increases. One way ofhelping clinicians to manage their patients effectively inthe face of information overload is the production ofclinical guidelines. The primary purpose of a guidelineis to set out recommendations for the most appropriatemanagement of patients with a specified condition.Therefore, guidelines should be as clear and direct aspossible. However, a patient with an uncomplicated,single pathology is something of a rarity. Concerns havebeen expressed that an over-reliance on guidelines willproduce doctors who cease to think through theirpractice and make decisions. This is no more anecessary consequence of relying on guidelines than ofusing textbooks or lectures for medical education.Recommendations must be applied to individualpatients with their particular preferences and theirdifferent comorbidities. But it is still important to havea clear, basic foundation from which to build, andguidelines provide this.Guidelines should inform routine patient care andwhile it is reasonable to be at variance from standardguidance, as determined by a patient’s circumstances, itis prudent to document why the alternative course wastaken. This leads to the secondary function ofguidelines – to provide a basis for the audit of thequality of patient care. Recommendations withinguidelines are an important source of audit criteria, andindeed many guidelines encourage this by suggestingappropriate topics.Producing guidelinesClinical guidelines are developed using a variety ofmethodologies. One of the most rigorous approaches isused by the National Clinical Guidelines Centre(www.ncgc.ac.uk).ThecentreishostedattheRCPtodeliver a large and diverse commissioned programmefor NICE. The guidelines have the advantage ofincorporating both clinical and cost-effectivenessevidence. Another common methodology is the ScottishIntercollegiate Guidelines Network (SIGN) approach,which is often adopted by the specialist societies as it isless resource intensive and is consistent with theAppraisal of Guidelines Research and Evaluation(AGREE) collaboration (www.agreecollaboration.org),an international collaboration quality assuringguideline methodology. This methodology is also usedfor the development of guidelines for occupationalhealth, stroke and in the Concise Guidelines to GoodPractice series.The topics that RCP guidelines cover grow on amonthly basis and can be found on the RCP website(www.rcplondon.ac.uk/resources/clinical-resources).Specialist societies produce excellent guidelines whichare particularly useful sources of information on rarertopics that are less likely to be covered by NICE. TheRCP is supporting specialist society guidelines bypublishing the Concise Guidelines series in ClinicalMedicine and in booklet form.National comparative clinical auditDonabedian defined quality of care as ‘the degree ofconformance to, or deviation from, normativebehavior’. 2 Brook and Kosecoff more succinctly definedit as ‘doing the right things . . . well’. 3 In 2010, followinga review of the literature and a consultation exercise, theRCP developed its own definition of quality. Itcomprises seven domains: safety, patients’ experience,effectiveness, equity, efficiency, timeliness andsustainability. All definitions imply the need forstandards – ‘normative behaviour’ and ‘doing the rightthings’ – and the need for measurement of practice, allkey elements of clinical audit.Clinical audit is conventionally considered as a cycle ofquality improvement that involves measurement of theeffectiveness of healthcare against agreed and provenstandards for high quality, and taking action to bringpractice in line with these standards so as toimprove the quality of care and health outcomes.Detailed advice for carrying out clinical audit can befound in New principles of best practice in clinical audit 4and Local clinical audit: handbook for physicians (HQIP,2010). 5Recommendations include the following:Determining standards for practice: increasinglystandards are based on evidence or derived from soundC○ Royal College of Physicians 2013 267
Consultant physicians working with patientsconsensus methods. Important sources of guidelinesand standards that form the basis of audit include NICEand SIGN, policy guidance such as national serviceframeworks (NSFs), commissioning frameworks orclinical strategies, and clinical guidelines from specialistsocieties, eg the British Thoracic Society (BTS)guideline Emergency oxygen use in adult patients. 6Measuring practice: clinical audit is a multiprofessionalactivity that should reflect the service provided by theclinical team. Measurement of practice is not simple.Careful consideration has to be given to the patientgroups to be audited, the audit criteria to be used, themethods for identifying patients, and for dataextraction, data collation and analysis. Cliniciansshould work closely with clinical audit departments toensure that the method is sound and thus time investedin clinical audit results in useful outputs. Clinical auditdepartments are invaluable in providing support andadvice, and ensuring that results and actions arereported through NHS governance processes to theNHS Boards. 7Changing practice: the purpose of audit is to improvepractice. Unless service improvement is included withinthe process, it is meaningless. The results from an auditshould be followed up with action plans forimprovement, and in order to achieve change it isimportant that there is close cooperation betweenclinicians and managers.Re-measuring practice over a time series enables trendsto be established and show whether progress has beenmade. Clinicians need to see clinical audit having animpact on service development if it is to establishsustainable change in practice.Clinical audit has many potential uses in clinicalpractice, in the following areas: Improving the quality of care: the audit topic must beimportant and of interest to the clinician. Theresults of audits must be reviewed within teams anddepartments, and used to inform servicedevelopment and improvement work. Repeat auditsmust be carried out to demonstrate whether or notprogress is being made. Audit as routine practice: the increasing developmentof information technology within the NHS providesthe opportunity for routine clinical data gathering tofeed into audit processes. Accessing the patient’s perspective: increasinglyclinical audit is developing to ensure that thepatient’s perspective is included in assessing thequality of service provided. Training: clinical audit provides an opportunity tolearn the principles of literature searching andcritical appraisal as well as scrutinising careprovision through data collection and subsequentchange-management processes. An understandingof these principles underpins informed analysis ofthe literature as well as the methods for improvingthe quality of care. Revalidation: clinicians participate in audit anddemonstrate that they have reflected on theoutcomes of audit.Clinical audit and specialist societiesSpecialist societies have the potential to make a greatcontribution to audit. Many societies already developguidelines for practice, the majority of which areamenable to audit.Through their existing contacts with all medicaldepartments throughout the UK, and for someinternationally, societies are in a strong position tocoordinate multicentre audit projects using agreedstandards and audit criteria. Such a role can enable therapid collection of powerful data for use both at a locallevel and for benchmarking between sites.Societies are very well placed to disseminate findings –through their publications and at regional andnational meetings. Such feedback can facilitate thesharing of best practice while providing a forum fordebating how the quality of clinical practice can beimproved.Dissemination and implementation(sharing best practice)The Clinical Standards Department’s approach todelivering quality improvement projects ensuresinteraction with key stakeholders throughout projectimplementation. This establishes routes for activecommunication and naturally facilitates disseminationof information and findings directly to our keystakeholders. The RCP works to embed a culture ofrecognising the importance of these activities andsharing ideas and mechanisms that are tried and tested;however, we recognise that we do not know eachorganisation’s or clinical team’s circumstances.Dissemination and implementation are thereforeinitiated both locally and nationally.268 C○ Royal College of Physicians 2013
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AcknowledgementsWe would like to th
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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