Multi-Cycle Audits and QI Leadership in Core Training (CT1-IMT3)

Governance Expectations for IMT: Linking to CQC Standards

As an IMT, your role extends beyond clinical care to actively participating in and leading clinical governance. The Care Quality Commission (CQC) assesses healthcare providers against a framework of Quality Statements, which replaced the previous Key Lines of Enquiry (KLOEs). Your audit and QI work provides direct evidence towards these standards.

IMT Curriculum Requirements for Audit and QI

The 2021 Internal Medicine Curriculum (Stage 1) specifies clear capabilities in practice (CiPs) and generic professional capabilities (GPCs) related to audit and QI.

• CiP 6: Managing medical complexity and uncertainty - Includes using audit to improve the quality of care for patients with complex needs.
• GPC 3: Quality Improvement - Requires you to "participate in and lead quality improvement activities, including audit." For higher levels, this involves supervising junior colleagues.
• GPC 4: Safety - Mandates the use of "systematic methodology (e.g., audit) to improve patient safety."

Successful completion of at least one full multi-cycle audit is a minimum requirement for ARCP. Progression through IMT1 to IMT3 should demonstrate increasing leadership and complexity.

Using NICE Guidance to Evidence Effective Care

National Institute for Health and Care Excellence (NICE) guidance provides the gold standard for evidence-based practice and is the most robust benchmark for clinical audit.

Types of NICE Guidance and Their Use in Audit

It is crucial to correctly identify and reference the specific type of NICE guidance you are using.

Practical Example: Building Audit Criteria from NICE

Scenario: Auditing the management of Community-Acquired Pneumonia (CAP).

1. Identify the relevant guideline: NICE Clinical Guideline NG138: Pneumonia (community-acquired): antimicrobial prescribing.
2. Extract a specific, measurable recommendation: Recommendation 1.1.3 states: "For patients with low-severity CAP, offer a 5-day course of oral amoxicillin."
3. Formulate your audit criterion: "Percentage of patients diagnosed with low-severity CAP (CURB-65 score 0-1) who are prescribed a 5-day course of oral amoxicillin."
4. Define standards: Set a realistic but aspirational standard, e.g., 95% compliance, based on local discussion and national averages.

Template: Audit Criterion from NICE Guideline

Handling NICE Guideline Changes Mid-Audit Cycle

NICE guidelines are periodically updated. A change during your audit cycle is not a setback but an opportunity to demonstrate robust governance understanding.

Action Plan for Guideline Updates

1. Immediate Notification: As soon as a new guideline is published (check the NICE website or subscribe to alerts), inform your audit supervisor and the clinical governance lead for your department.
2. Impact Assessment: Compare the new guideline (e.g., NG200) with the old one (e.g., NG138). Document the specific changes to your audit criteria.
   • Are the changes major (a new first-line treatment) or minor (clarification of wording)?
   • Do they invalidate your initial data collection?
3. Project Adaptation:
   • If the change is minor: Continue with your initial cycle but analyse and present your data against both the old and new standards in your report. This demonstrates critical appraisal.
   • If the change is major: It may be necessary to treat your initial data collection as a "baseline snapshot" against the old guideline. Pause, re-write your proforma for the new guideline, and commence a new first cycle. Document this change meticulously as it shows adaptability and a commitment to current best practice.
4. Documentation: In your final report, include a section titled "Response to Guideline Change" explaining the situation, your decision-making process, and its impact on the results.

Supervising Junior Colleagues in Audit

As an IMT2/3, you are expected to develop supervisory skills. Supervising a Foundation Year doctor or medical student in their first audit is excellent experience.

• Project Selection: Help them choose a focused, achievable topic with clear NICE criteria. Avoid overly complex pathways.
• Guideline Navigation: Teach them how to find and correctly interpret NICE guidance, differentiating between NG, QS, etc.
• Methodology Coaching: Guide them through the audit cycle: planning, data collection (emphasising confidentiality), analysis, and presentation.
• ARCP Evidence: For your own portfolio, document this supervision. A reflective entry on supervising a junior colleague's audit demonstrates leadership and meets GPC requirements for higher IMT levels.

Template: Reflective Note on Audit Supervision

IMT-Level Project Examples and ARCP Progression Tips

Your audit projects should increase in scope and leadership responsibility as you progress through training.

Stage-Appropriate Project Examples

ARCP Progression: Building Your Portfolio

The ARCP panel needs clear evidence of your developing QI capabilities.

• Be Specific: Don't just list "Completed audit." Title it precisely: "Multi-cycle audit: Improving prescription of DOACs in AF (NG136)."
• Show the Cycle: For a multi-cycle audit, provide evidence for all stages: baseline data, the intervention (e.g., teaching session, new guideline poster), and re-audit results.
• Include Impact: Quantify your results. "The intervention increased compliance from 65% to 88%." Even if the outcome wasn't perfect, reflect on what was learned.
• Link to Curriculum: Tag your evidence to the specific curriculum codes (e.g., GPC 3.2 - Leads quality improvement activities).
• Reflect: Write a brief reflection on each project. What went well? What would you do differently? How does this prepare you for consultant practice?