Foreword (taken from the 2012 RCoA publication Raising the Standard: a compendium of audit recipes)
We improve what we measure. We often do not believe that processes and outcomes require improving until we have the data we need to make us change. Data builds will for improvement, allows us to know if we are improving, and to understand the degree of improvement possible with a given change in practice. This book will help clinicians do all of this and more.
It is no surprise that this book is written by and for anaesthetists, and spear-heads a transistion from audit into quality improvement. Anaesthesia was the first medical specialty to champion patient safety as a specific focus. Anaesthetists have a long history of innovation and have lead the field in both measurement, and improvement, of clinical practice. From the 1950s through to the 1970s, though reports and data were imperfect, it was believed that anaesthesia care itself caused a high mortality in the region of one to two deaths per 10,000 anaesthetics. In order to improve the outcomes for patients, several actions had to be taken, the first of which was that anaesthetists had to decide that the cost of death and suffering was too high. The courage to look critically at practice and decide that the current outcomes were simply unacceptable was unprecedented. Secondly, anaesthetists had to look beyond the simply personal to the system of practice for answers. Thirdly, they used the data to build the will to embark on a systematic programme of improvement that resulted in a 10 to 20-fold reduction in mortality and catastrophic morbidity for healthy patients undergoing routine anaesthetics. Application of human factors and high reliability concepts to anaesthesia practice promises further gains. This is especially critical now, as technology extends our human capacity in ways that are not yet known or understood.
In the past, audit was used as a measure of the adequacy of a process or the reliability of a desired outcome. Many a medical student or doctor in training, required to do an audit, experienced the fact that audit was frequently used as a measure of the state of a process or outcome at a singular point in time. There was often no expectation of an improvement plan, and little discussion about what the data told them about their work. There are changes afoot that require clinicians to look at data over time to help understand variation – both wanted and unwanted- for the purpose of improvement not judgment. Doctors are increasingly being asked to lead or join improvement teams with the aim of learning, not only how to audit data, but how to improve the associated processes and outcomes.
We need data for research, improvement, and judgement of how we perform compared with the best – all are necessary but none alone are sufficient to ensure that our care is safe. Clinical research continues to create new knowledge at a rate that has thus far surpassed our ability to apply the findings to practice. Improvement science can help us bring those needed new advances to the bedside where they can help patients. This book will help anaesthetists continue their pursuit of ever safer, and ever more effective care for their patients, and ultimately, more rewarding work for themselves.
Dr Carol Haraden PhD