In this blog we are going to look at the difference between audit and research in Quality Improvement (QI) and how these methodologies can work together in the quality space. We’re going to see which areas of research and audit can support your QI projects and exactly how they work.
Let’s start by taking a look at Quality Improvement or QI. There are many definitions of QI. The NHS describes it as 'the continual actions to improve outcomes for service users and to develop the workforce that supports them using systematic methods.’ QI has a focus on continual and systematic change to provide better outcomes for patients and team members.
QI is further described as ‘improvement in patient outcomes, system performance, and professional development that results from a combined, multidisciplinary approach in how change is delivered’ in the article 'Quality improvement into practice' by Adam Backhouse and Fatai Ogunlayi. This article looks at the roles of QI, audit and research, with the writers encouraging the reader to think of QI as a ‘principle-based approach to change’.
This can help to provide clarity about what QI offers to staff and patients, how QI can be differentiated from other approaches and how QI can be used with other change approaches and the benefits this brings.
This is what we are going to be looking at in this blog. We'll also see how QI can fit in with other methodologies and approaches, such as research and audit.
Let’s take a look at the definition of research. ‘The attempt to derive generalisable new knowledge by addressing clearly defined questions with systematic and rigorous methods.’
Research is also described as evaluating ‘practice or comparing alternative practices, with the purpose of contributing to a body of knowledge by asking what you should be doing,’ and ‘a systematic investigation, including research development, testing, and evaluation.'
Research has several areas in common with QI, including the fact that it requires a consistent methodology. However, in research this is used to ‘prove or disprove a fixed hypothesis rather than the adaptive hypotheses developed through the iterative testing of ideas typical of QI.’
While QI normally involves generating new knowledge and implementing it in a setting, ‘research aims to generate new generalisable knowledge.’
While both methodologies have a focus on the environment where the work takes place, QI’s aim is to understand what works best in a given setting or context, while research aims to ‘eliminate or at least reduce the impact of many variables.’ Also, while data collection and analysis are important in QI, these processes have a much higher importance in research.
Take a look at the Institute for Healthcare Improvement (IHI) video from James Moses, MD, MPH; Medical Director of Quality Improvement, Boston Medical Center. He argues that while research is important – ‘if we are trying to improve a healthcare system through research we would be here for eternity!’
This is where the two methodologies are hugely different!
What is Clinical Audit?
Let’s take a look now at clinical audit. The NHS describes clinical audit as: ‘A way to find out if healthcare is being provided in line with standards and lets care providers and patients know where their service is doing well, and where there could be improvements.’
Or ‘Clinical audit: is a way of finding out whether you are doing what you should be doing by asking if you are following guidelines and applying best practice.’
‘Audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes.'
When we look at QI and clinical audit together in the article ‘How to conduct a clinical audit and quality improvement project’, the authors contrast the two methods thus: ‘Quality improvement (QI) aims to improve the patient experience. Although audit is often more clinically orientated, QI can focus on more holistic issues, for example, the availability of hot drinks in the Emergency Department. QI can be done using the Plan, Do, Study, Act (PDSA) framework.’ PDSA cycles, as we know, are short cycles that enable improvement to be incorporated quickly.
The authors argue that while audit and QI projects are essentially similar – as they both drill down into standards in healthcare and improve them, audits measure against more formal standards and take place over longer periods of time, whereas QI uses PDSA cycles which are much swifter.
An example of clinical audit being used in the NHS is the National Clinical Audit and Patient Outcomes Programme (NCAPOP). This is made up of 30 national audits which are commissioned and managed on behalf of NHS England by the Healthcare Quality Improvement Partnership.
These audits collect and analyse data on the most commonly-occurring conditions, with data being supplied by local clinicians. This in turn provides a national picture of care standards for that specific condition in the UK.
Let’s go back to the IHI video with Dr. James Moses. He talks about how using improvement and research methodology together can contribute differently toward creating better health care systems. In his video, he advises people not to prioritise ‘proof of effectiveness’ over realising sustained improvement.
As improvement is a more organic process, with a focus on cycles of testing: ‘It’s not just one intervention but multiple – based on learning from prior cycles, so you actually get to the point of realising sustained improvements through a series of interventions which are informed by testing in the system you want to improve.’
He concludes that research and QI are similar and both very important, but concludes: ‘The sustained improvement realised in QI helps to be justified and validated through good research assessment of its effectiveness, but I don’t think that we should have improvement-prioritised proof of effectiveness over sustained improvement.’
So, although QI is not necessarily a ‘silver bullet’ in healthcare, it is a very effective methodology and if used in combination with other approaches and methodologies – such as audit or research - either consecutively or concurrently - it can deliver better care and outcomes for patients.