PDSA – Injecting a little improvement into Audit

For decades the medical profession has worshipped at the alter of audit: embracing the method in everything from large national confidential enquiries, increasingly complex extensions to NICE guidance and a key competency for all doctors in training. In the last decade even our NHS Masters have got in on the act – mandating nurses to complete weekly and monthly audits (think Safety Cross) to ‘maintain’ standards in everything from infection control to waiting times.

So, national confidential enquiries aside, what is it about this industrious investment of staff time that makes me feel the urge to challenge such wisdom?

I have to tell you it’s the insanity of ALL the effort expended in the face of such little evidence of impact, so many FY1 audits handed in on week 16 with recommendations to implementation ‘some thing’!  So many repeated with no change in outcome. So many before and after measures showing something has changed over two data points. So here’s another way to make a difference that is, well… less insane!

Contained within the Model for Improvement, the Plan-Do-Study-Act (PDSA) test cycle is a well established way of learning and improving through small, rapid incremental steps. Each series of PDSAs are designed to test the hypothesis that a particular idea or intervention will improve a process or outcome. Each test cycle contains a prediction which, using simple measures (quantitative or qualitative), indicate whether the idea tested should be abandoned, adapted or adopted and spread further.

What if… all clinicians, managers and support staff learnt to use this approach and used it to implement changes designed to improve the services they deliver? Might we just break through this insanity and increase the chances that their efforts really will make a lasting difference?

So whilst audit has its place, in a resource strapped health service, from where I stand, the majority look and feel like a sorry waste of physical and emotional capital worthy of Einstien’s description of insanity. If you feel the same, get curious about the Model of Improvement and PDSA – and inject a little know how into your improvement efforts!