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Governance controls

Quality improvement

Turn guideline use into measurable improvement: define a standard, measure performance, act on gaps, and keep evidence that stands up to governance and inspection.

What "good" looks like (QI in one page)

Quality improvement is repeatable measurement against a defined standard, followed by action and verification. For guideline-led care, the standard is usually "appropriate application of current guidance" with clear documentation of rationale when deviating.

  • Standard: what should happen (and where the guidance says so).
  • Measure: how often it happens (and how reliably).
  • Improve: interventions that address root cause.
  • Verify: re-measure and show sustained improvement.

Pick measures that prove control (not just activity)

Avoid measures that only show throughput (e.g., "number of searches"). Prefer measures that show clinical governance control and documentation quality.

Examples of audit-friendly measures

  • Currency compliance: % of cases referencing the current guideline version/date.
  • Documentation quality: % of cases where deviation rationale is recorded clearly.
  • Time-to-answer: median time to locate the relevant guidance at point of need.
  • Safety escalation: % of high-risk scenarios where escalation criteria were met.
  • Closed-loop learning: % of issues that reach verified closure within agreed timescales.

Run an audit cycle that produces evidence

  1. Define the standard (link it to a named guideline and a date/version).
  2. Define inclusion criteria (which cohort, which services, which time window).
  3. Collect a sample (small but defensible; prioritise higher-risk scenarios).
  4. Analyse gaps (categorise: currency / coverage / interpretation / workflow / system).
  5. Implement interventions (training, workflow change, governance control, content update).
  6. Re-measure and keep a one-page summary plus supporting evidence.

Note: If you need standard phrasing auditors accept, start with Audit-safe standards.

Evidence pack (what to keep)

  • QI/Audit plan (standard, measures, sample logic)
  • Data extract / audit worksheet (de-identified where applicable)
  • Findings summary (top issues and root cause categories)
  • Action plan (owner, due date, expected effect)
  • Re-audit / verification result
  • Governance sign-off (minutes or approval record)

How QI connects to governance risks

QI is also your early warning system. If your audit shows recurring issues, route them into your risks process and track closure.

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