Improving the quality as well as the safety of patients requires a structured, data-driven approach. In this post, we will explore the difference between quality improvement programs and audits as well as provide a step-by-step guide to practically develop and implement these.

Quality Improvement Programs:

Quality improvement programs (QIPs) give healthcare a structured approach to identifying problems, trialling solutions and implementing successful interventions into everyday practice. QIPs are valuable at every stage of training and prepare clinicians for careers that are driven by evidence-based practice. Firstly, it is important to understand the principles of quality improvement, which are fundamentally derived from the deliberate and systematic effort to make services, outcomes, and processes better in a given context. QIPs focus on real-time learning within a particular setting as opposed to the aim of proving universal truths, as in traditional research. Frameworks such as Plan-Do-Study-Act (PDSA) encourage quality improvement teams to experiment, measure outcomes, and refine practices based on findings. Should one want to publish the QIP findings, the SQUIRE guidelines provide a structure for writing up QIPs.

The next step is to clearly define the problem. Data, audit reports, and incident reviews are some resources that can be used to identify an area where performance or patient safety practices can be improved. In order to clearly focus efforts, the problem should be clearly defined as to what, where, who, and how big the issue is. Once the problem has been clearly defined, stakeholders should be engaged early. QIPs require a team, which may involve clinicians, nurses, pharmacists, allied health staff, and even patient involvement if relevant. Building a multidisciplinary team not only builds ownership but also surfaces any practical barriers that could be missed.

Next is developing a well-defined aim statement, which will make success measurable. The aim statement should be specific, measurable, achievable, relevant, and indicate a time period. It should define what exactly you are trying to improve, how you will know there is improvement, what the target is, who this improvement matters to — patients or staff — and by when you will achieve it.

Before changing anything, you will need to understand how work currently happens. This will involve studying the current process and performing a gap analysis. This will entail understanding the workflow, shadowing staff, and gathering baseline data. This analysis highlights the gaps between what is deemed best practice and what the current practice is, thus also highlighting where a need for improvement might be.

Equipped with knowledge of current practice, you then proceed to the process of designing and testing interventions. Within the team, brainstorm potential solutions to the identified gap and prioritise one or two that are simple and most feasible. The PDSA cycles can be used as a framework to trial the suggested interventions. It is important to track process and outcome measures in order to obtain reliable data. The data can be converted into visual formats such as control charts or graphs and shared with stakeholders to aid in maintaining momentum and transparency. If an intervention works, it can be adopted into routine practice by adding it to standard operating procedures, monitoring compliance through regular audits, presenting findings at governance meetings or grand rounds, and celebrating the team's success.

QIPs are not solely about fixing problems but are also a skill-building exercise. Trainees should be encouraged to participate in institutional QIPs, as these activities create a culture where improvement is part of everyday practice.

Audits:

While QIPs emphasise ongoing improvement and experimentation, audits are a complementary process that centre on checking whether current practices align with predefined standards or guidelines. They are often less flexible in design than QIPs, but just as essential for ensuring safety, consistency and accountability in healthcare.

What is an Audit?

An audit is a systematic review of existing care or processes against explicit, evidence-based criteria or standards, whether national, international, or local protocols. The goal is to identify gaps between current practice and those standards, and then implement changes to close those gaps. It tends to be more fixed in scope than a QIP. Audits often follow a cycle: define standard → measure practice → compare practice to standard → implement change → re-audit to see if improvement occurred. This “closed-loop” or “full-cycle” audit is where the audit's power lies.

Step-by-Step: Doing an Audit

Here are the practical steps to design, conduct, and use an audit effectively:

1. Choose a topic and standard

Pick a clinical practice, process, or outcome that has a clear guideline or benchmark. Use recognized standards (national/local/international) or locally agreed protocols.

2. Define your criteria and standards

Explicitly state what standard you're auditing against. This may look like defining what that ideal looks like, what percentage compliance is acceptable and over what time period.

3. Measure baseline practice

Gather data from charts, electronic records, direct observation, or other sources. Be systematic and ensure your data collection is reliable, reproducible, and approved by governance and ethics if needed.

4. Compare with standards

Analyse how current practice measures up. Identify where performance is below, or even above, standard. This is where you quantify the gaps.

5. Feedback and action planning

Share results with stakeholders: staff, management and the multidisciplinary team. Decide on feasible actions to correct deficiencies. This may include education, changing workflow, reminders or resource changes.

6. Implement changes

Put the action plan into practice. This can be as small as adjusting how forms are filled or larger such changing protocols or introducing a new system entirely.

7. Re-audit

After giving enough time for interventions to take effect, re-measure using the same criteria to see if things have improved. This is crucial as audits that don’t close the cycle are much weaker in impact.

8. Sustain improvements

Embed successful changes into practice via policies, checklists, regular monitoring, staff training, etc. Also plan for how to monitor longer term, to ensure improvements in performance are not lost over time.

Tips for Making Audits Effective

● Choose standards that matter (patient safety, outcomes, resource use) and that are feasible to measure

● Get buy-in early as the audit only works if those involved believe in it and are motivated to change

● Make sure data collection tools are easy, consistent, and reliable. Using existing data systems helps

● Feedback should be clear, actionable, timely, non-punitive, and ideally include comparisons

● Plan for re-audit right from the start including the timing thereof, resources required as well as who will collect follow-up data

● Document everything from the methods to data collection to who did what. This helps with credibility, reproducibility, and when publishing or presenting findings

When to Use an Audit vs QIP

Use an audit when: There is a well-established standard or guideline you want to check compliance with. You need to demonstrate accountability or compliance (e.g. for regulatory/governance reasons). You want to measure a gap in care that is relatively stable over time.

Use a QIP when: You want to experiment with changes or improvements, especially where the standard is less clear. Iterative testing or innovation is required. There is a need for stakeholder engagement and behaviour change. Ultimately, audits and QIPs aren’t competing tools but they are complementary. Audits tell us where we stand, QIPs help us move forward. When used together, they create safer systems and better care for our patients.

Additional Resources

1. ATS Scholar – “What Makes a Good Quality Improvement (QI) Project” — guidance from the American Thoracic Society on designing and evaluating QIPs. (Full text article) https://www.atsjournals.org/doi/full/10.34197/ats-scholar.2019-0012PS

2. QI Roadmap – “Develop a QI Plan” — a framework to help organizations formalize their quality improvement vision, governance, methods, and project selection. QI Roadmap https://qiroadmap.org/develop-plan

3. BMJ Open Quality – Case studies & research articles on QIP methods — good for seeing practical examples and learning from what others have done. https://bmjopenquality.bmj.com/content/4/1/u208829.w3999

4. Springer – Theory in Quality Improvement and Patient Safety Education: A scoping review — explores how educational theory has been used in QI & patient safety training. SpringerLink https://link.springer.com/article/10.1007/s40037-021-00686-5

5. South African Family Practice – Rationalising blood tests in a resource-limited emergency unit: A quality improvement project — a local example showing how QIPs can be applied in resource-constrained settings. South African Family Practice https://safpj.co.za/index.php/safpj/article/view/6067/9351?utm_source=chatgpt.com

6. PMC / NCBI – Recent research & reviews relevant to QIP design and outcomes — helpful for deeper dives into evidence and methodologies. https://pmc.ncbi.nlm.nih.gov/articles/PMC8182456/

7. Audit and Feedback as a Quality Strategy. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK549284/

8. BMJ Guide: Quality Improvement Project, differences to clinical audit. https://www.bmj.com/careers/article/the-bmj-guide-quality-improvement-project-qip

9. FutureLearn: Research, Quality Improvement, and Audit; similarities & differences. https://www.futurelearn.com/info/courses/conducting-health-research-in-conflict-settings/ 0/steps/379020