C-9 Rehabilitation quality improvement

Doctors have been required to undertake an audit as part of their training since training programmes were introduced. The requirement has broadened to be a quality improvement project. I’d like to know how many trainees complete a project in their programme and how much the projects undertaken change practice. However, the knowledge and skills acquired should benefit their future work and career, which is the potential real but unresearched benefit. Trainees are also expected to gain research expertise. This can be achieved within any quality improvement project, giving them extra value.

Table of Contents

The competency.

To be competent at quality improvement, the trainee should be “Able to identify an area needing improvement, negotiate all bureaucratic and other required processes, gain cooperation, identify data needed and obtain it, analyse data, draw a conclusion and write up a report.” This depends upon many essential other skills. The trainee may not complete a project. Participation in ongoing projects and demonstrating the necessary knowledge and skills are sufficient. Detailed information on the behaviours expected, knowledge and skills needed, and some useful references are available here.


Healthcare is never perfect; every professional must know that improvement is always possible, both by the individual and, crucially, in the system. Any significant failure should be used to improve the service so that the same problem does not happen again. However, organisations and services investing in continuous improvement will always be better than those waiting to learn from significant failures. Such organisations value active learning from daily activities rather than intermittent learning from errors.

This, in turn, requires the person or service to be monitoring performance us data sensitive to the quality of the service. One way is to undertake a clinical audit against a standard based on evidence or a consensus recommendation. However, this can be a slow and intermittent process. Many processes are too complex to have evidence-based standards. For example, the quality of rehabilitation, from a patient’s perspective, depends upon smooth transitions between services and settings.

Most rehabilitation professionals will notice failure in the rehabilitation a patient receives daily. The problem is not a lack of opportunities. Instead, there are too many possible projects. However, most failures involve other professions, teams, agencies or organisations, and collaboration is vital for success.

Research or audit?

All quality improvement depends upon a systematic collection of data and suitable analysis to allow a conclusion to be drawn. The same is true of research; research and audit share much knowledge and skills. A third project category, service evaluation, further clouds the matter. An audit aims to discover whether healthcare achieves a given standard, whereas a service evaluation investigates the standard achieved by the service.

The differentiation is of practical importance. Research must be approved by an independent ethics committee, whereas audit and service evaluation do not. Although there is guidance on distinguishing these categories, the boundaries are ill-defined and ethical considerations apply to all three types. For example, allowing conclusions that can be generalised is supposed to identify research. Still, the national stroke audit has led to many publications with generalisable findings, and a single quality improvement project was published as having generalisable results.

When considering a quality improvement project, always seek advice from a responsible organisation, design and manage the project to research standards, and consider its ethical implications.

Expertise needed.

Competence in quality improvement depends upon general knowledge and skill used in many areas of professional practice. I will focus on three.

Collaborative teamwork.

Rehabilitation crosses many boundaries. The most extensive opportunities for quality improvement come from improving collaboration across borders. Even within a healthcare organisation, rehabilitation involves many other services such as intensive care, neurosciences, musculoskeletal, rheumatological and orthopaedic services. And, of course, the rehabilitation service itself encompasses different professions. The relevance and benefits of an audit within a single professional department or of an individual practitioner will be minimal.

Therefore, any significant quality improvement project will draw upon and enhance expertise in teamwork, leadership, being led, and similar attributes vital for any rehabilitation expert.

Method and design.

Before starting, the investigator must consider the project’s aim and the question being asked, which requires the active involvement of all interested parties because people will only help if they understand and accept the importance of the project. Quality improvement, both service evaluation and audit, depends on the methods and design. As in research, quality improvement requires a systematic approach when collecting data, avoiding bias, ensuring consistency, and minimising data loss.

The project team must also consider in detail who will collect data and how, whether patients will cooperate with the data collection, and how it will be stored and analysed. Therefore, as for research, it is wise to discuss a project with patients; they will usually improve a project considerably.

Writing and data presentation.

The success of any project depends upon good writing skills. Many people will be involved, and they will wish to know about the project – and contribute to its development. Face-to-face discussions can be very productive but time-consuming and limited in their reach. Well-written documents prepare people for any meeting and allow people who do not attend to contribute.

Once the data have been analysed, the conclusions need dissemination, and, again, well-written documents facilitate this and help achieve change. However, one must also recognise that achieving change takes much work, even with good evidence. One advantage of quality improvement projects can be that all parties are committed before starting, which should be associated with a greater willingness to change.

Achieving change.

Lisanne Hut-Mossel and her colleagues recently published a systematic review to discover what characterised successful audit and quality improvement projects. I summarise them here. Table three in their paper gives more information. None of the characteristics will surprise you; nevertheless, having evidence is reassuring.

  1. Externally initiated audits create quality improvement awareness, although their impact on improvement diminishes over time.
    These are usually national audits imposed with no opportunity for discussion or influence. They are associated with change for one or two years, but the benefits decline and disappear.
  2. A sense of urgency felt by healthcare professionals triggers engagement with an audit.
    These projects are stimulated by someone in the service identifying a significant problem recognised by professionals who become more committed to participating and changing practice. Organisational issues may reduce enthusiasm.
  3. Champions are vital for an audit to be perceived by healthcare professionals as worth the effort.
    Having one team member recognised by the organisation as a champion (leader) leads to high-quality data and a more significant commitment to change by the team.
  4. Bottom-up initiated audits are more likely to bring about sustained change.
    These are associated with teams whose members already trust and respect each other. It reduces some of the organisational barriers to change within the group.
  5. Knowledge-sharing within externally mandated audits triggers participation by healthcare professionals.
    If data from an imposed external audit are shared collaboratively with the service’s team members, new ideas and insights may arise, leading to active engagement in change.
  6. Audit data support healthcare professionals in raising issues in their dialogues with those in leadership positions.
    Where the managerial structure allows and encourages discussion by healthcare professionals, audit data may provide them with evidence to substantiate suggested changes. Success may lead to further quality improvement projects and change.
  7. Audits legitimise providing feedback to colleagues, which flattens the perceived hierarchy and encourages constructive collaboration.
    Audit data may precipitate opportunities for non-confrontational discussion within the team about the behaviours of some team members and may improve team functioning. This is useful if there is a hierarchical team structure.


Competency in quality improvement draws on knowledge and skills also needed in other areas of rehabilitation, both clinical and non-clinical. Quality improvement while a trainee is likely to involve participating in existing projects; it may include planning and starting a project but training posts rarely last long enough to complete an entire improvement cycle.

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