Evidence
Alert

Acting on feedback from national clinical audits: NHS staff describe their motivations and the barriers to engaging with the data

A national clinical audit (NCA) in a specific condition gives a picture of the standard of care provided by NHS Trusts across the country. Hospitals can use NCA data to determine where their service is doing well compared to other Trusts, and where there could be improvements. The aim is to improve the quality of care provided.

However, previous research has found that NCA reports are used differently by different hospitals; they do not always lead to clinical improvements. Researchers wanted to determine how this data could be used to its full potential and help hospitals improve their services for patients.

Through interviews with NHS staff, they identified several motivations for using NCA data, such as wanting to improve or maintain a hospital’s reputation or ensuring it compared favourably to other hospitals. They also discovered that staff were more likely to use local data, stored in local databases, before it was uploaded to the NCA, because it was more easily accessed, more trusted and could be customised by skillful audit staff to answer specific questions. Some staff said they lacked the support and IT resources to collect information from NCAs that was as accurate and timely as they needed.

The researchers are evaluating a dashboard to provide this information in a customisable, user-friendly way. It could help more hospitals make the most of NCA data.

What’s the issue?

NCAs were introduced in the 1990s to measure the quality of care in the NHS. They let healthcare staff know what is going well and what could be improved. There are over 50 NCAs in the UK and these cover many clinical areas. Reports of NCAs managed by the Healthcare Quality Improvement Partnership are publicly available on their website.

NCAs can take up a lot of time for NHS staff such as doctors, nurses and sometimes non-clinical support staff. They record data on admission, discharge, treatment and patient outcomes and submit the information to a central database.

NCAs have led to improved care in a number of areas. Older people with hip fractures are more likely to survive; people who have had a heart attack are treated more quickly when they arrive at hospital.

However, the extent to which staff engage with NCA feedback varies across the NHS. Researchers were concerned that the potential of NCAs to improve patient care is not being fully realised. This study explored why NHS staff wanted to use NCA data and what helped or hindered them from doing so. It is the first part of a research project on how the NCA process could be improved.

What’s new?

Researchers interviewed more than 50 NHS staff across five hospital trusts in England. The staff included doctors, nurses, audit clerks, and others working with NCAs such as quality and safety staff, and Board members of NHS Trusts.

The staff described their experience of two NCAs: one on heart attacks (the Myocardial Ischaemia National Audit Project, MINAP) and another on emergency care for children (the Paediatric Intensive Care Audit, PICANet).

The team analysed the interviews to determine how and why hospitals respond to NCA feedback.

They identified five motives which prompt different NHS staff to act on NCA data.

  • Their hospital’s reputation: Staff were keen to maintain public confidence in their hospitals for providing safe and effective care. They acted on NCA feedback where this was brought into question, or if services were identified as outliers. A consultant said: ‘We had a lot of deaths all together, which started to flag us up […]. It just flagged us up once and that was it, we were on it like a car bonnet, we were just looking at it all the time’.
  • Their own professionalism: Clinical service staff, including doctors, used the NCA data to ensure the care they give to patients is safe and effective. A paediatrician commented: ‘if there’s something I can change, I should be changing it […] as soon as I am aware’.
  • Competition with other healthcare providers: Hospitals can compare their performance to national benchmarks provided by NCAs. Doctors said positive NCA feedback was useful for attracting patient referrals; negative feedback would stimulate practice change. A cardiologist said: looking at our data and how well we’re performing and how quickly we’re able to offer this service is quite important. Because you want to be able to say to these centres, look, if you refer to us your average wait is a day. If you refer to centre Y, your average wait’s a week’.
  • Incentives: NCA data can affect the amount of funding a service receives and determine whether a trust receives accreditations. For example, certain standards of care are required to gain accreditation from the National Audit of Cardiac Rehabilitation. A cardiac nurse said this was a driver for engaging with NCA feedback: ‘It puts the service on the map which will then look good for patients looking online’.
  • Professional development: Trainee doctors and nurses complete internal audits as part of their professional development. One clinician said the findings could inform improvements: 'it can change what your perceptions are, because you’ve got accurate data [...] it can actually change your outcome and change where you’re spending money’.

NCA feedback is provided in a variety of ways. Most NCAs produce an annual public report and, for some audits, standardised data is provided online. Locally, staff may also produce performance reports based on their own or on NCA data.

The study identified common barriers to using NCA feedback.

  • Accessibility of data: Some services primarily used the public report because it was time-consuming to log on to supplier websites to review standardised data. One surgeon said: ‘the reality of our lives in the NHS, is that we don’t have time to do that’.
  • Concerns about the quality of data: Services trusted their own data collector and were more satisfied with the accuracy of their own, compared to other organisations’ data. One surgeon said: ‘I know that I’ve written every bit of that data myself’.
  • Timeliness: Public reports could be based on data collected two years or more previously. An information manager said: ‘We’ve already changed our practice by then’.
  • Local data was seen as more useful: Clinicians were most likely to use data in local databases, collected before it was uploaded to NCA suppliers, because it was easier to access and was trusted as accurate. The staff supporting audit participation and data use produced performance reports to answer clinicians’ and managers’ specific questions about local service performance. A paediatrician said that PICANet data, customised by the audit clerk: ‘to me is the gold standard of our activity’.
  • Lack of discussion at Board level: NCA reports were seen to receive little response outside the clinical service except in specific circumstances such as if the service appeared as an outlier. A paediatrician was not invited to the Board meeting following the PICANet annual report: ‘there’s never any discussion with me directly about it and what it means’. A cardiologist said: ‘absolutely nothing, nothing changes. Why collect the data?’.

Why is this important?

A better understanding of what motivates staff to take NCA feedback on board could help hospitals implement effective processes for making improvements that will ultimately benefit patients.

The research findings are similar to previous studies that have found healthcare staff are motivated to look at NCA data for reasons of reputation and professionalism. This research added context on what prevents staff from interacting with NCA reports.

What’s next?

Following this study, the researchers are working to improve the accessibility and timeliness of NCA data. They are exploring whether a web-based dashboard of NCA data would lead more staff to engage with the audits. This is being investigated as part of the wider project called QualDash. The aim is to:

  • provide clear, easy-to-understand and customisable presentations of NCA data
  • reduce the time staff need to spend constructing queries and reports
  • provide timely access to a clinical unit’s own data for monitoring and quality improvement.

QualDash has been evaluated by staff in the five NHS Trusts included in the original research and results will be published soon.

Further research could explore the best way to collect data and whether digital tools could make the process more efficient.

You may be interested to read

The full paper: Alvarado N, and others. Exploring variation in the use of feedback from national clinical audits: a realist investigation. BMC Health Serv Res. 2020;20:859

Research on an interactive dashboard that could improve the quality of care (Qualdash): QualDash - Designing and evaluating an interactive dashboard to improve quality of care

Information from the NHS on clinical audits

Information about the UK’s largest national clinic auditor, HQIP

A paper that explores the use of NCA feedback by Trust Boards and sub-committees in more detail: McVey L, and others. Institutional use of National Clinical Audits by healthcare providers. J Eval Clin Pract. 2021;27:143150

A blog on Understanding Patient Data that explains how NCAs can improve the quality of care  Guest blog: Using National Clinical Audit data to improve care quality

 

Funding: This research was funded by the NIHR Health Services and Delivery Research (HS&DR) Programme.

Conflicts of Interest: Some of the authors are members of national audit programme committees relating to cardiovascular disease.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

Understanding what motivates, and what supports and constrains NCA data use, is necessary to identify ways to support and improve how data are used by healthcare staff for quality improvement.

We understood that there was variation in data use across services. This study has enabled us to explore the extent of, and reasons underpinning, this variation. For example, the skills, experience and expertise of dedicated audit support staff (where they were available) supported clinical staff to use NCA data in routine monitoring processes. In comparison, in sites not resourced with audit support staff, use of NCA data was often limited to the annual report.

Natasha Alvarado, Senior Research Fellow, Faculty of Health, University of Bradford (previously University of Leeds)

Audit quality manager

I hope this paper will reinforce the need and importance of timely, robust and accurate data to enable changes to be made to services that are, in some cases, very well established. Completing the national audits takes time, commitment and resource at all levels within organisations, and the outputs should reflect this. Discussions between commissioners and providers about the findings of national audits should be encouraged, and the actions identified should be implemented to continuously improve patient care.

Bev Ryton, Quality Manager for Clinical Audit and Effectiveness, NHS Sheffield Clinical Commissioning Group

Audit assistant

This paper highlights constraints on the use of NCA feedback and identifies local and national opportunities to drive quality improvement.

Dissemination of audit rationale, along with discussions between clinicians and the staff supporting the audit could help increase belief in the accuracy of the data. Also, staff involved with audit could be invited to meetings about what the publicly available reports produced by NCA suppliers mean for practice if key changes are needed across multiple departments. And there could be incentives, such as accreditation, for services that meet specific standards of care.

Data needs to be easily accessed in real time; using shared local databases before data is submitted would help. The NCA supplier could create a file to be used as a local database, synched to the supplier website. The timeliness of data from the supplier website could also be improved.

As mentioned by the authors, the findings of this study came from well-established audits. It did not explore potential adverse impacts of NCAs; further research could cumulatively build knowledge on NCA feedback.

I have discussed feedback produced by NCA suppliers with our clinical teams and they were very interested and receptive. We are always making comparisons with national data and we see that a clear understanding of what and how indicators are measured make discussions more beneficial and productive. In one instance a simple change in the way practice was recorded led to a quick and sustained performance improvement.

Jefferson Lisboa Santos, Clinical Audit Assistant, Kingston Hospital NHS Foundation Trust