Paediatric trainees and the quality improvement agenda: don't just do another audit
Authors: Damian Roland, Sarah Haden, Kate Pryde, Peter Lachman
Journal: Journal of the Royal Society of Medicine (2011)

Over the past century, medicine and the delivery of healthcare have undergone constant change with a predilection for some common populist themes. Most of these have been driven by direct need – the Public Health agenda in Victorian times, development of triage and infection control in the Great Wars, and recently the explosion of the need to justify the way we do things with a strong evidence base. Over the past 10 years Quality Improvement has become the new challenge, a theme which is supported by both governments and health leaders. In some ways paediatricians have been at the forefront of quality improvement methodology. The need for clinical practice guidelines and standards of care, for example in neonatology, have been evident. However the implementation of new theories and practices in large health systems has always been a complex and frustrating process. Clinicians seldom embrace change easily and have not been trained in the theories and methodologies commonly used in other industries. Often intervention at an early stage of training is the key to enabling change to become ingrained in a clinician's day-to-day work.

Trainee doctors are integral to delivering patient care in many healthcare organizations. As a body, they have huge experience of system processes and how they differ from one organization to the other, moving, as they often do, from hospital to hospital. This group of doctors should be expected and supported to use these insights to identify areas where systems are under-performing, where risks might be reduced and safety enhanced, where processes are inefficient. Trainees are an untapped resource which could be directly involved in identifying solutions and effecting change. Trainees in paediatrics are no different, and one could argue its process driven nature make the specialty more receptive the quality improvement methodologies than others.

Batalden and Davidoff1 define quality improvement as ‘the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)’. Paediatric trainees in the UK have minimal or no meaningful involvement in the processes of improving the quality of the systems which deliver patient care. They simply are not taught the methodologies as part of their training, nor are invited to participate in quality improvement initiatives. Although it is a requirement that trainees demonstrate involvement in audit, the findings of these time and labour-intensive exercises are often never presented, and very rarely lead to meaningful and sustainable change (personal communication with Emma Stanton, 2010). Data gathering should not be the sole aim of the process (as is often the case in current trainee audit projects), but should rather have the aim of analysing systems, critically appraising process, proposing solutions, and being supported in implementing changes to improve clinical outcomes.

A quality improvement agenda, delivered within training programmes starting in medicals schools should not have to compete with the current curriculum and assessment burden that doctors in training in the UK currently face. It should be integral within it, as it will be vital for the future delivery of services. In the same way as evidence-based medicine now permeates throughout clinical practice (it is difficult to consider a clinical consultation in which the benefits of action or inaction are not considered) delivering high quality care should be regarded as an essential standard. In this context simply performing an audit would be considered an unacceptable training standard to promote. Although potentially a bitter pill to swallow for traditionalists, the benefits of this new approach are apparent for many stakeholders.