How auditing with AMaT leads to quality improvement

Clinical and nursing staff at Lancashire Teaching Hospitals NHS Foundation Trust are embracing digitally-enabled quality and service improvement through a new clinical audit platform from Meantime IT.

One of the greatest opportunities for increasing efficiency and effectiveness in the NHS is the reduction of unwarranted variation in care. Clinical audit can be an essential tool to help realise those opportunities.

As NHS England notes, clinical audit is a way to find out if healthcare is being provided in line with standards and lets care providers and patients know where their service is doing well, and where there could be improvements.

Quality is at its heart, and it is no surprise the Care Quality Commission takes a keen interest in the status of clinical audit as part of its hospital inspection regime.

However, clinical audit can be seen as a laborious process for hospitals, with multiple forms to complete for clinicians, junior doctors, nurses and ward staff. Facilitators need to be aware of hundreds of audits, past and present, if they are to use clinical audit effectively. The quality and service improvements recommended in audit action reports can slip down the priority list, in the face of competing demands on time and energy.

Lancashire Teaching Hospitals NHS Foundation Trust is delivering a step change in how it is embedding the use of clinical audit as part of its service and quality improvement commitments through the use of AMaT. The Audit Management and Tracking tool from Meantime IT is designed to streamline auditing requirements in one simple, easy-to-use system.

"AMaT has reduced the time taken to carry out an audit, and increased visibility of the process," said Alison Leather, clinical audit & effectiveness manager. This is helping to make sure that quality improvement actions are more embedded in the culture and activity of the trust.

By providing an interactive and intuitive online tool for trust staff to register, manage and report on clinical audit, AMaT is giving doctors, nurses and healthcare professionals at the trust more time to care, and creating action plans that deliver meaningful improvements on the NHS frontline.

Duplication and paper-based processes cut as audit becomes more effective

AMaT allows clinical teams to register audits, associate guidance such as NICE quality standards, complete audits online, and manage action plans and scheduling. This timely and efficient solution means that healthcare professionals have more time to spend at patient bedsides.

Junior doctors, for example, are expected to carry out clinical audit and quality improvement projects as part of their training. Previously, they might not have known what audits have already been undertaken, leading to duplicate projects that did not address the needs of the trust.

"We could have junior doctors doing duplicate audits," said Alison. "Now with increased visibility of AMaT, junior doctors can see what audits have been done." This means that those embarking on an audit project can focus on areas with real impact, for example by carrying out re-audits of previous quality recommendations, or work with colleagues to focus on areas that have the most benefit.

"We now know what we are doing, so if we wanted to focus on a pathway such as COPD, you can use an audit to get real insight into what is happening in that area."

AMaT is also providing greater visibility of the progress of quality improvements. "We can say instantly, because they are updating their audits, how many have led to an improvement or achieved their criteria. We just wouldn't have known this before," said Suzanne Henderson, project manager & AMaT system manager.

Clinical audit staff also save time through a more efficient process. Previously, they would have to undertake a paper-based process and transfer information into multiple systems, leaving little time to progress actions that had come out of previous audits.

The department has saved over £40k by not replacing retiring staff, after taking on AMaT. The department has also increased the number of projects that they facilitate and support, due to the time released by using AMaT.

"Now we don't have any pieces of paper coming into the office," said Alison. After about 12 months of use, the process now is entirely online.

With AMaT, a series of online forms make the creation and validation of clinical audits simple and quick. More time can be spent examining the actions that have been recommended, supported by automated reminders to those responsible for implementing improvement actions. This is helping to increase the number of audits being carried out at the trust.

"We had around 250 audits every year using our old system," said Alison. "There were 467 audit and quality improvement projects registered last year."  

Impact of clinical audit and quality improvement felt across the trust

Governance teams are also seeing the benefits of AMaT. They have increased visibility of audit progress, resulting in a greater focus on implementing change in NHS priority areas such as hand hygiene compliance. They can now actively consider where an audit is required, such as in support of seven-day services, rather than reacting to the audits suggested across the trust.  

Clinical teams can see everything, governance teams can see everything. It is much more open," said Suzanne.

AMaT also features Ward and Area Audit support, which enables wards to actively complete and action their audits. By increasing the visibility of ward-based audits from other teams such as Pharmacy and Outreach, AMaT has extended the number of people who can give feedback on activity. This has provided a holistic view of safe care being delivered to the patients, and enabled more immediate and responsive service improvement. Previously, such feedback and results would have taken some time to filter back to the wards and their Matrons.  

The visibility of the regular clinical audits taking place on each ward or area also enables the clinical teams to work closely together, and has encouraged nursing staff to embark on their own audit-related projects.

AMaT is also helping staff with the many national clinical audits they have to carry out. Such audits can be seen as time-consuming and struggle to effect positive change, especially if such changes are not clinical in nature. Now, with more visible action plans, and clear status indicators, everyone can see what needs to happen to act on the recommendations.

For example, the national stroke audit (SSNAP) sets out clear areas for development at the trust. The Stroke business manager can access the audit to drive forward both clinical and operational improvements that came out of the audit, allowing healthcare staff to focus on making the changes they can deliver. The manager can then look at wider operational issues to enhance performance.

As a result, specialities such as cardiology can see instantly the progress on their national audits but also the regular, traditionally nursing-related assurance audits at ward level.

The system is also helping with Care Quality Commission (CQC) inspection process. This data-hungry exercise looks to ensure that high standards of care are being maintained. The ready availability of clinical audit progress saves staff the many hours it can take to provide an accurate picture of audit activity and equipment. The trust is even using AMaT to run its own CQC-style exercises to ensure that it meets national quality standards.

Developed to meet the needs of clinical audit teams

AMaT went live in the autumn of 2016, following a trust review of the clinical audit tools available on the market. Trust quality leads wanted to work with an IT supplier to develop a solution that supported its desire to use clinical audit to drive organisation-wide quality improvement.

The result was AMaT, which has been developed to meet the trust's clinical audit needs, and which can be used by others who recognise that proper use of this process through an easy-to-use tool can drive a culture of quality improvement.

We looked at different systems on the market," said Alison. There was nothing that did everything that we wanted it to do, for example ward audits and NICE compliance statements. We thought, there must be something better out there. We worked with Meantime and they have developed a solution that best meets our needs."

Now, over 2,700 staff at the trust have access to AMaT, out of the 7,000 employed. Alongside increasing the transparency and visibility of activity, it is making audit simple by guiding staff through the audit process.

"You don't have to be an expert to use AMaT," said Suzanne. "It can be checked by everyone with access."

User-driven technology that can support integrated care

Such global access is leading to many fresh ideas for development. These include the use of AMaT to review the trust's mortality and morbidity performance, and further work around developing it around specific clinical specialities. AMaT is also being explored to support cross-trust audits, so that standards of care can be monitored across the multiple care settings central to the NHS's drive for more integrated care. 

For others considering how they might use technology to support clinical audit and quality improvement, Alison - drawing on 25 years in the field - suggests that clinical audit teams look at what will best meet their needs. "Have a look round, and see what you need. Speak to people using the system on a daily basis," she said. "I would wholly recommend AMaT, if they wanted to come and speak to me. Come and see how it works in real life."

With quality at the heart of the future NHS, and with frontline staff keen to drive forward that agenda, AMaT shows that it is an essential improvement tool that can be embraced by all.  

Download the Lancashire Teaching Hospitals case study

Organisation-wide quality improvement, service evaluation and audit activities are being supported by Meantime's flexible and intuitive Audit Management and Tracking tool, says Deborah Kershaw, the trust's head of outcomes and assurance.

At Stockport NHS Foundation Trust, AMAT is becoming a single reference point for quality improvement, enabling nursing and clinical staff to more easily engage in such activity across multiple areas of care.

"With AMaT, we have a system to capture what activity is taking place, one that gives people ownership and puts names against actions, and one that provides visibility of how projects are progressing and who has completed what, "says Deborah.

This visibility and action-led approach means that AMaT is supporting clinical audit, quality improvement, service evaluation, NICE compliance and even CQUIN recording at the trust. Meantime IT’s simple and flexible technology is becoming the cornerstone of quality improvement; so much so that it will be the agreed repository for capturing quality improvement projects agreed as part of the new quality faculty being developed at Stockport.

The system to underpin trust-wide quality improvement

AMaT's breadth of use was not as first planned. In development at the trust since late 2017, the system was originally intended to replace a legacy audit tool that was not keeping pace with trust needs. The clinical audit team, who saw that it could coordinate clinical audit across the trust and reduce reliance on manual processes and email, had planned a staged implementation.

That changed with the arrival of new chief nurse Alison Lynch in 2017. Her immediate ambition was to engage staff in the delivery of high-quality patient care. One early initiative was to get the Accreditation for Continuous Excellence (ACE) ward accreditation scheme up and running.

The matron-led ACE programme sees wards undergo rigorous evaluation covering 20 different topics. Wards are then awarded a performance rating and are then invited to identify the actions they need to take to improve the quality of care.

Technology to support ACE was already under consideration. Deborah could see how AMaT could help fulfil the ambitions of the chief nurse and save the trust a five-figure sum. The decision was made to use the technology for the ACE programme, and AMaT had arrived.

"Everyone got to know about the system quite quickly," says Deborah "Even if people weren’t using it, most people had heard of it. Now it is in use across the trust."

ACE is now an ongoing programme of quality improvement at the trust, which is already having a positive impact.

"It helps raise pride in the ward, and in its achievements," says Deborah. Staff are sharing their ACE success stories on Twitter, showing how they are visibly and measurably improving the quality of care they provide.

Ward audit transformed with the support of AMaT

AMAT is also being used to support a more rigorous approach to the monthly ward-based quality assessments that were in place.

"Before we got involved in the ward audit, they had quality checks, but they were not registered as audits. There was not a lot of robustness in the system they were using. They were all scoring 100%. It was not an independent review, and the questions were not worded correctly to measure the quality, i.e. is the form in place, rather than is the form completed fully and correctly."

With AMaT, ward audits can be better managed, monitored and scheduled. Teams are guided through the process of checking across 12 key areas such as hand hygiene, medication, falls assessment, and pain management.

Nursing teams can see in real-time how compliant they are with quality standards as soon as they enter the data. They can then use the intuitive AMaT interface to record the actions they intend to take and assign ownership and due dates against those tasks. Dashboards can be printed out and displayed outside each ward, indicating positive achievements and areas for improvement.

By making the audit process easier to perform for nursing teams, AMaT has helped to increase the quantity and quality of ward audits.

AMaT helping with NICE and CQC compliance

Compliance with national clinical standards is also being made more straightforward with AMaT, as the system makes the latest NICE guidance available for its customers.

"We use AMaT to send NICE guidance out to the relevant owner for review and to check compliance. They then send a report to the quality governance group, saying where we are at, and what actions need to be done."

The trust is also using AMaT to address issues raised by the Care Quality Commission (CQC). In addition to supporting regular spot checks, AMaT is to be the central repository for the trust's safe high-quality care improvement plan, Stockport's response to a recent CQC report.

"Working with the deputy director of quality governance, who is monitoring the plan, our staff will find it easier to update the work they have been doing directly into the action plan," says Deborah. "We can see on the dashboard the percentage of actions completed. Then we can produce a report for the senior managers demonstrating the activity that has taken place to address the CQC recommendations."

Having all such activity in one place, and making it visible to all staff, means that Stockport has a much better idea of what quality improvement activities are taking place. "Just by knowing what’s out there has really improved things," says Deborah.

"It is a lot easier to monitor activity, you don’t have to go in and out of Word documents. It would take a lot of time to follow up an action plan. You were reliant on people sending updates and information through. Now, as it is on the system, we can see where people have not updated actions, and you can see who to chase."

Multiple benefits for audit and quality improvement

As well as saving money and supporting key organisational priorities, AMaT is saving time for staff.

"One of the nurses, for example, was having to type up CQC spot checks on paper, at night and over the weekend. Now this is done in AMaT, the data and reports are all there. It has saved her a huge amount of time. She is now a firm believer in AMaT as well."

Further benefits include the ability for trust staff to register direct on to the system; now, there are over 1,000 registered users. The system is cloud-based, so that access to documents does not depend on individual permissions - a real bugbear of previous approaches.

Auditors can register audits on the system, and update as actions progress knowing that their activities are being recognised. Action plans no longer sit in people’s email accounts; overdue actions can be highlighted and are reported to business group quality boards.

The system is providing a central focus for the trust’s quality ambitions. Audit and improvement activities are much more visible across the trust. The audit team can capture improvements over time and use filters to identify activities using terms, such as sepsis - a feature that can help deal with FOI and CQC requests.

"AMaT is a great place to know where to go to find out about quality activity across the trust. It is almost a programme management tool, it brings everything together to support multiple functions."

Throughout this, tech support from Meantime has been responsive and helpful, and the trust can feed its own development suggestions to the supplier.

Challenges and opportunities for the future

Unsurprisingly, AMaT’s role in supporting quality at the trust is expanding. It is to act as the central repository for a new quality faculty being set up to drive quality improvement projects, so that teams across the trust can work together to improve care, deliver efficiencies and potential savings. Also, to provide visibility and transparency of activity taking place.

The technology has enabled a small team to support an impressive amount of quality improvement work at the trust, although this has not been without its challenges.

"We are victims of our own success. I championed the use of AMaT for multiple areas, and then everything came our way. If anyone else was to come on board, I would suggest don’t try to do it all at once, do it one bit at a time. It is not a fault of the system, it was down to the scale of what we were trying to do."

Deborah sees that AMaT has made a huge impact, and its future potential is impressive. Already in use for infection prevention, the system is already loaded with CQC Key Lines of Enquiry (KLOEs). Shortly it will be used to capture evidence and compliance levels, support information governance audits and act as a quick reference point for evidence required for some FOI requests.

Ultimately, AMaT could even support a consistent approach to audit and quality improvement across the whole health economy.

The potential for AMaT is clear - but only because it provides quality-driven staff with the right tools to finish the job. It provides the technology and support that nursing and clinical staff need to measure current practice and to capture and monitor actions to support them to transform how they deliver care.

Download the Stockport NHS Foundation Trust case study

Tracey Brailsford, the Trust's Lead for Improvement, Innovation and Effectiveness, talks about how the cloud-based system 'AMaT' is helping senior leadership and frontline staff learn from performance and continually improve services for patients.Tracey joined Derbyshire Community Health Services NHS Foundation Trust in 2015, at the time the organisation's clinical audit activity was largely managed via paper forms and spreadsheets.

"Audits were quite administrative," says Tracey. "They were sometimes not completed and didn't always lead to improvement."

"We did a lot of work to develop from being an audit team to become the Improvement, Innovation and Effectiveness Team," says Tracey. "We successfully began to change the culture of the organisation to help people to see clinical audit as a quality improvement methodology."

"The system we were using was still administrative in that it could only be accessed by clinical audit staff," says Tracey.

An organisational view for geographically distanced services

The Trust provides services within Derby city and across Derbyshire's 400-square miles in a wide range of locations including community hospitals, clinics, GP practices and in people's own homes. The range of services provided is equally diverse and includes district nursing, school nursing, 0-19 children's services, health visiting, GP/primary care services, integrated sexual health services, specialist wound care, therapy services (physiotherapy, occupational therapy, speech and language), rehabilitation wards, older people's mental health services, urgent treatment centres and a variety of other services. With such a challenging range, the Trust wanted to gain a better picture of its effectiveness.

"We needed a view, organisationally, of what was happening around quality improvement, clinical effectiveness and clinical audit," says Tracey. "We needed to be able to shine a light on where brilliant activity is happening locally, and where it is not."

In her role as the Improvement, Innovation and Effectiveness Lead, Tracey discovered AMaT, a system developed with NHS clinical audit teams to give more control over audit activity and to provide real-time insight and reporting for clinicians, wards, audit departments and healthcare trusts. With support from the organisation's chief nurse, the medical director, and her managers, Tracey oversaw the deployment of AMaT in 2020.

"I built a business case for AMaT with the argument that it would give visibility to where teams are doing really well and where we might need to have some concern," says Tracey. "It would reduce repetitiveness, improve access and visibility, and save clinicians' time when using the system, who would have easy visibility about audits they needed to complete."

The Trust's internal assurance framework, Quality Always, which Tracey describes as like "CQC on a local level", has easy access to the AMaT reporting dashboards and the ability to drill down and examine any service.

Immediately helping with Covid challenges

AMaT has been rolled out across the Trust and is being used both by services on the ground and senior leaders. It is providing visibility to external organisations including commissioners and organisations such as the CQC.

"The feedback we get is incredible," says Tracey. "I have not had a single person use it and say they don't like it."

Clinicians proactively contact the Clinical Effectiveness Team, wanting to use AMaT to better understand and improve frontline services. This helped the Trust face challenges which were specific to the pandemic.

"Shortly after go live, the chief nurse rang me with a requirement to do an organisation-wide hand hygiene audit," says Tracey. Even with her team largely redeployed, and working from home, the Trust was able to rapidly launch the audit in AMaT for the entire county and its 4,500 staff.

"This led to immediate improvement. AMaT highlighted a ‘red area' with compliance on people not using hand gel from their wrist to their elbow," says Tracey. "People knew they should wash from hand to elbow with soap and water, but not everyone knew to do that with hand gel. We did some comms to make sure everyone was aware of best practice. Without AMaT we wouldn't have known we needed to address that at an organisational level."

Covid also led to new ways of delivering services for which the Trust used AMaT to assess effectiveness. Tracey explains: "All of a sudden our community physiotherapists, for example, were doing consultations via video – they were keen to evaluate that. Using AMaT we were able to send surveys to patients and to staff." There might be "anecdotal fear and myth" about "doing a video conference with an 80-year-old with a broken hip", she adds. "Sending a survey to a patient and finding they loved it is really powerful evidence that it can work."

An organisation engaged with clinical audit

Within a year, AMaT had "raised the profile of using audit in the Trust to improve quality".

"We want people to be engaged and excited to improve care for patients, rather than seeing audit as a chore," says Tracey.

"I have noticed an increase in people coming to us who want to do different things. People who notice that their results in an area are not 100% or 95% have come to us, asking what they can do to improve."

One example of this involves the Trust's four urgent treatment centres.

"They approached us to use AMaT to place audits in the system. All their audits are now on the system and visible across the trust. If there were any points of concern, they would become visible very quickly. The tick-box bit is that they are providing the evidence needed for commissioners – but the quality piece is that the senior leadership team and the staff themselves have really engaged in it. It is really easy for them to fill in and see results."

AMaT can help with standardising how services are measured, and because each area is using a shared pro-forma, this enables organisations to provide meaningful feedback to commissioners when variation in commissioning requirements impacts on service provision.

Widespread interest

Tracey sees many possibilities for improving care. "If you have an interest in falls prevention, for example, you can now look at performance across the organisation – whether you are the falls prevention lead, the chief nurse, or the CQC."

Importantly the ‘helicopter view' across the county offers significant potential to reduce variation in care. She gives another example: "If we decided to do an audit around lower limb wound management, we would have a county-wide picture of compliance with the evidence base. If there was variance, we would be able to pick that up quickly."

Saving time for clinicians

Tracey emphasises that AMaT is helping clinicians to avoid wasting time. She describes how doctors are required to carry out audit as part of their professional development, which she says has led to a culture in the NHS of doctors often doing this in isolation. "Sometimes, no one knows they have done the audit, other than the person reviewing their professional development."

Through AMaT, all audits and projects are now visible and, along with their action plans for improvement, can be picked up by the next clinician for re-audit. This creates a "real legacy", and ensures a "robust, scientific methodology is used".

Tracey says this is helping to avoid "ticking boxes… enabling clinicians to be collaborative workers on a project".

"We are not in the business of doing audit for the sake of audit," she adds.

A national picture

With staff across Derbyshire now using the system to learn from each other's performance, Tracey sees the potential for AMaT to be used nationally. "It's not just about benchmarking results. It's about driving a culture of improvement. There is a lot of power in sharing and collaborative working across systems."

"There is something to be said for it being a nationwide, cross-trust system. We can all learn from each other's best practice."

Download the Derbyshire Community NHS Trust case study