6. Quality improvements activities (QIA) March 2019

• 6.1. Myth: Time spent on quality improvement activities is not CPD
• 6.2. Myth: I must do at least one clinical audit in the five-year cycle
• 6.3. Myth: I must do all my QIA myself
• 6.4. Myth: There are specific types of QIA that I must include

6.1. Myth: Time spent on quality improvement activities is not CPD

All learning activities can be included in CPD credits. They should be demonstrated by an appropriate reflective note about the time taken, lessons learned and any changes you made as a result.

Continuing professional development can include:

• traditional CPD
• QIA, including learning event analysis (LEA)
• significant events
• reflecting on feedback from patients and colleagues, including complaints and compliments.

You should avoid unnecessary duplication. Once you have demonstrated sufficient CPD to keep up-to-date across your whole scope of practice you do not need to write additional reflective notes. You should not stop learning, and reflecting on what you learn, but we recommend that you stop documenting in detail what you have learned and reflected on, unless it is important to you.

6.2. Myth: I must do at least one clinical audit in the five-year cycle

For the purposes of revalidation, the GMC requires that all doctors demonstrate that they regularly participate in activities that review and evaluate the quality of their work. Clinical audit is not a revalidation requirement, but it can form part of quality improvement activities or projects.

The RCGP recognises that there are many different types of quality improvement activity, in addition to clinical audit, that are equally acceptable as QIA. You should show that you have:

• thought about the quality of care you provide
• reviewed your care in the context of current guidance on good practice
• celebrated where there are no changes that you need to make
• made changes where necessary or appropriate to improve the quality of care you provide
• revisited the question to see if the changes made have made an improvement.

It is important that you routinely review the effectiveness and appropriateness of the care that you provide to keep patients safe. Demonstrating that this is a professional habit is a matter of choosing examples that show what you do and how you do it. You do not need to document every review of your work that you do.

Depending on your circumstances, different quality improvement tools are helpful including:

• reflective case review
• learning event analysis
• review of personal outcome data
• search and do
• plan, do, study, act cycles
• clinical audit.

You may wish to plan your quality improvement activities for the coming year with your appraiser and include them in your PDP. If you are aware that what you are planning as a quality improvement activity is unusual, you should discuss it with your appraiser and agree it with your responsible officer before including it.

6.3. Myth: I must do all my QIA myself

You do not need to do all the background work and data collection or analysis for your quality improvement activity yourself. For some doctors there are national clinical audits into which they contribute their personal outcome data. Where this exists for part of your scope of practice, it is important that you review the audit results to see how your performance relates to that of your peers. If the audit is not comparing like with like, this is your chance to reflect on how to improve the quality of the data being used.

Delegating someone else to run a search, or do some of the research, is a reasonable and proportionate use of your time. We recommend that you select QIA that allow you to review what you do. Your personal reflective notes should include an explanation about your role in the quality improvement activity and a description of the findings, including any lessons you have learned and the impact they have had on the quality of care that you provide.

GPs work in teams and much of the quality improvement activity that it is important for us to reflect on arises from teamwork. You can learn from the review of your own performance, and we recommend that you also try to learn from review of the performance of the team, including the mistakes and near misses of others. Learning event analysis in primary care is often a team activity.

The questions to ask yourself are about what you have learned about the quality of the care you provide and what, if any, changes you should make as a result.

6.4. Myth: There are specific types of QIA that I must include

You do not have to include any specific type of quality improvement activity but you must reflect on the quality of your practice and how you meet the requirements of Good Medical Practice (GMP).

The GMC requirements are sufficiently broad to recognise all activities that allow you to review what you do. We recommend that where you maintain a clinical skill, such as IUS insertion or minor surgery, you keep a log of your personal outcome data. You can then reflect on this at least once in the revalidation cycle to demonstrate the appropriateness of the quality of care you are able to provide in these areas. We recognise the value of reflective case review and learning event analysis as useful QIA but no longer specifically recommend that you include two every year in order to allow more personal choice and flexibility. Similarly, we recognise the value of clinical audit but no longer specifically recommend that you should include a two-cycle clinical audit every five years. There are many other types of QIA that may be equally, or more, appropriate for your circumstances, which will also meet GMC requirements.

Where your organisation provides you with clinical governance data about your practice, or there is a national clinical audit to which you contribute, which allows to you to benchmark your work, the RCGP recommends that it is important and appropriate to include this information in your portfolio of supporting information and reflect on what you have learned from the results and any changes you will make as a result.