Shared learning database

Type and Title of Submission


North Bristol NICE Junior Doctor Electronic Toolbox


The initiative is about addressing perceived and real barriers to junior doctor engagement with Clinical audit and NICE related audit in particular. It is also about addressing the notions that clinical audit is a symbolic exercise with little meaningful prospect of effecting change and improvement in quality and safety. Following a small scale barrier analysis and utilising quality Improvement methodology. The Quality Improvement and Clinical Audit Service conducted a series of small scale tests of change to find solutions to these barriers and to tackle perceptions about the value and merit of clinical audit activity. It is manifested at a simple level in the development of an electronic tool box for audit tools but has required a strategic change in how clinical audit activity is supported, the tempo of that work and the innovative solutions that are needed to truly impact on quality and safety within North Bristol.



Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:


Category(s) that most closely reflects the nature of the submission:

Audit tool
New ways of working

Is the submission industry-sponsored in any way?


Description of submission


It is widely recognised that junior medical staff are a significant potential clinical audit resource which have been difficult to consistently engage in the clinical audit cycle. They are the future consultants and there is a need to influence their understanding and perceptions around clinical audit and its value as a tool to make sustained improvements in clinical practice. The initiative aim was to support clinicians and in particular junior medical staff to engage in the clinical audit and to remove real and perceived barriers to audit engagement around NICE related topics. There is an almost universal perception among junior medical staff that clinical audit requires a large amount of time and may have limited potential to make substantial change. It was considered more of symbolic exercise to demonstrate understanding of the principles of clinical audit cycle without a real meaningful prospect of improving practice and care. It was part of our aim to challenge these perceptions and demonstrate how clinical audit and in particular NICE related audit activity is a critical part of the wider continuous quality and patient safety programme within North Bristol. In looking at this issues it was our aim to use Improvement methodology and 'small cycle testing of change' as the mechanism to help develop a robust solution.


1. Barrier Analysis and Idea generation: In seeking to remove 'barriers' to junior doctor engagement we reviewed with them and their Clinical tutors what their perceived and real barriers were and what ideas they might have around tackling some of the issues raised. Unsurprisingly we found that the 'barriers' varied between Clinical tutors and the junior medical staff. For the Tutors the key barriers were around their own lack of developed processes around the selection, 'management' and monitoring of the clinical audits. The junior medical staff commented on the large amount of time needed for clinical audit and that they had experienced mixed messages about the need to complete a clinical audit and the value of clinical audit to effect change. 2. Small Cycle Testing of Change. In seeking to address the perceptions it was decided to use improvement methodology and undertake some rapid cycles of testing. It was decided to test some of the ideas within General Surgery with the Clinical Tutor and a group of junior medical staff. There were three strands of testing The first phase testing was around Audit Process design within Clinical Tutors. A new 'process' for the management of the junior medical staff clinical audit was tested that involved developing an agreed clinical audit programme in advance for their juniors. The Second phase testing was around 'Rapid Weekly Audit' and involved developing electronic tool which were sent as an electronic link to the juniors and with a defined weekly data collection programme.. The third phase was the development of an Electronic Toolbox for Junior Doctors which was hosted on our Trust intranet site and was the access route to a set of NICE related audit tools and support information. 3. Organisational wide implementation Following the successful testing of this approach it was decided to spread this approach and processes across the organisation and includes a full range of Clinical audit activity


North Bristol NHS Trust operates across two large sites some 4 miles apart. It has 1300 beds across more than 50 wards and it has around 300 junior medical grade staff. In 2007 it was one of 20 Trusts selected from across the UK to take part in the Safer Patients Initiative. This was a two year patient safety and quality improvement programme lead by the Institute for Health Improvement. In supporting the work around the Initiative the Clinical Audit Department reviewed its strategic role and objectives and sought to transform the nature and support it offered to frontline teams. Early on in this review the department recognised the value of Improvement methodology which was centred on small scale cycle testing of change and of the merits of continuous monitoring and measurement of clinical processes and outcomes to help drive improvement. The quality improvement methodology within the initiative called for a change in the tempo and timescales around a lot of our audit activity, it reinforced the value of prospective audit and the need to review and monitor results on a monthly basis if real change was to be effected on the frontline. In reviewing our records to identify some baseline measures we identified that Junior Doctor Audit activity had been reducing over the last five years. It was also recognised that a number of the re-audits were indicating limited improvement and that NICE related audit activity had been patchy and was also in decline. Prior to starting this initiative a small group barrier analysis was undertaken involving clinical tutors and junior medical staff and this highlighted some of the factors and issues that needed to be address. It was from this work that it was recognised that an initiative was needed if we were to challenge some of the perceptions around the value and impact of clinical audit and it was necessary to create processes and tangible systems to enable more direct engagement with clinical audit.


1. Barrier Analysis A barrier analysis was completed with a group of the clinical tutors and a cross section of the junior medical staff. Part of the analysis was the identification of the decline in the number of audits completed by junior staff over the last five years. It had declined by 17% overall and an important factor was a related reduction in NICE audit of more than 15%. We have reversed this trend and we have positive engagement form a range of medical staff around clinical audit and continuous quality improvement audit 2. Small Scale Testing From this work a series of ideas were 'tested' and multiple cycles of testing began. This began with testing with one tutor, one junior and one tool. Subsequent testing allowed the refinement of both the tools and the reporting methods. All of the testing phases have been completed and we have an agreed process and method for the management and coordination of junior doctor audits. An electronic tool box has been established on the Trust intranet which hosts a range of tools and information around clinical audit. 3. Organisational wide Implementation. This approach and new 'process' for the management, planning and integration of clinical audit activity by junior medical staff is being spread across all of the clinical tutors within the organisation. It provides a more efficient and relevant process and it has helped to reinforce the fundamental value of audit and measurement within the organisations quality improvement strategy. To reflect both the integration of quality improvement methodology and the department's role in underpinning the continuous monitoring of quality process and outcome indicators the Clinical audit department was renamed the Quality Improvement and Clinical Audit Department in September 2008. The former Clinical Audit Committee was also renamed and its terms of reference were amended to reflect the enhanced quality improvement leadership it was providing.

Results and evaluation

Within the underpinning principles of any quality improvement initiative is the need for continuous measurement and acting on results. As part of this initiative we review with the Quality Improvement and Clinical Audit Committee the registration and monthly activity against all of our audit activity and look at the junior doctor audit activity. A rolling programme of NICE audit activity has been devised and new electronic tools are posted against this programme. The audit cycle timeline has been reduced and there is a willingness to undertake audit and improvement work around key quality and patient safety issues. It is our aim to monitor progress over the coming 12 months and look to publish the outcome of our work when we can demonstrate a sustained and embedded process is in place and that hard tangible improvements have come from it.

Key learning points

The Model for Improvement and small scale testing of change is an important methodological shift in thinking and approaches to quality and safety within healthcare. Clinical audit shares a similar methodological foundation but lacks the tempo and rapid feedback loop that is needed to support frontline teams in their improvement journey. If clinical audit is going to remain relevant it must look to devising ways to harness the energy of frontline staff and directly support the rapid reporting and continuous monitoring of key process and / or outcome measures. This is an exciting challenge for clinical audit teams and allows the team to explore new ways of working and utilising existing technology to deliver low-cost solutions to local problems. What is needed is the commitment of leaders within an organisation to help deliver this transformation. This is the opportunity for Clinical Audit Departments to help lead this transformation work.

View the supporting material

Contact Details

Name:Frank Hamill, Tracey Lucas & James Calvert
Job Title:Clinical Audit and Assurance Manager. Senior Clinical Audit Facilitator.
Organisation:North Bristol NHS Trust
Address:Beaufort House
Postcode:BS10 5NB
Phone:0117 3232249


NICE handles personal information provided to the Institute in accordance with the Data Protection Act 1998. Find further details in our data protection policy.

This page was last updated: 30 September 2009

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Selected, reliable information for health and social care in one place

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.