If you have a question on any aspect of quality initiatives that you would like Nancy Dixon to consider in Q & A, please email it to her using the link on the left of this page.

I am thinking of applying for an audit post. Is this a good career move, or is it a dead end job? I have also heard that the posts are going to be phased out. What do you advise?

I have a Sagittarian's optimism, so adjust your interpretation of my answer accordingly. Your first consideration about applying for an audit post should be your personal interests and intentions. Think carefully about what specifically appeals to you about working in audit; jot down your ideas and ask yourself if there are other posts which would have the same appeal. This approach should help you decide if it is really audit that interests you, or if it is a career move in general you are looking for.

If your thinking still favours seeking an audit post, seek out job descriptions from a number of posts; the jobs appear to vary considerably, ranging from emphasis on note pulling or computer data entry to active participation in planning and executing audits with doctors and clinical teams.

Your third consideration should be whether or not you are ready to make a commitment to acquiring the knowledge and skills needed to do an audit job well. It's worth your time investigating exactly what aptitudes are involved by talking to several people who have worked in audit for at least a year. Try to speak to individuals in different parts of the country and in different types of organizations, to get as complete a view as possible of the job and of the personal investment you will have to make in learning the job.

If, after talking with people in audit posts, you are still interested, your fourth consideration may be about the future of audit with absolute confidence. In the long term, competent and appropriately trained individuals in audit posts should have excellent career prospects. Here are some of the reasons:

• The biggest challenge in healthcare today is achieving optimum health outcomes for the minimum resources and interventions – a challenge in which audit will play a major part.
• Now that audit is accepted and established, and its value to patients is being demonstrated, doctors, nurses and other healthcare professionals would find it unacceptable for the activity to come to a halt.
• Quality was the social movement of the 1990s and persists today. Activities which enhance the quality of healthcare services will continue to be supported.

If you decide to pursue a career in audit, there are two final thoughts for you to consider. First, be prepared for continuous learning and flexibility in your thinking about audit as new and more effective techniques are bound to emerge. Second, be prepared to work towards a qualification in the specialty of audit or quality monitoring.

Our NHS Trust has just employed a risk manager. We have been told that this new manager will be responsible for risk management and that this will eventually relate to our quality assurance programme. However, my co-workers and I are not sure we understand what this means. Can you explain in simple terms what risk management is and why we have it? Also, how will it relate to the work we have done on standards and audit?

Let's start with why NHS Trusts are establishing risk management programmes and hiring risk managers. Up until 1990, if anyone was injured or suffered harm as a result of failure to meet a standard of care in an NHS organization, a legal principle called Crown Immunity made it very difficult for patients and/or their families to obtain compensation from the NHS organization involved for the consequences of the injury or harm. Individual professionals could be sued, but as a public service, the NHS was legally 'immune' from financial liability. In 1990, the legal principle was changed from Crown Immunity to Crown Indemnity, meaning that the NHS, as a public service, now has legal responsibility for such situations.

In addition to this change in law, there has developed a public recognition that the lifelong care of a person who has suffered a serious medical injury can be very expensive. Most families do not have the financial resources to pay for the care needed for a young child who suffers serious brain damage from an accident during minor surgery, for example. Also, there is no formal mechanism for publicly funded compensation to be paid for people who suffer such accidents. So, when such cases occur, patients and families are turning to the courts to settle them. At the same time, NHS employees are now seeking financial compensation for injuries suffered at work, some of which may have been preventable had suitable health and safety provisions been followed by their employing organization. As a result, both the number of cases involving financial payment and the cost of each case are rising dramatically. NHS Trusts have to prepare themselves financially to handle such cases and that's where risk management comes in.

Now on to what risk management is. Simply put, risk management is a formal systematic programme of administrative and clinical activities which are undertaken to identify, evaluate and take action to reduce the risk of injury and loss to patients, staff, visitors and the organization. Usually, there are two approaches to risk management in a healthcare organization: one is concerned with preventing financial loss due to health and safety, physical plant maintenance, purchasing, financial or other administrative practices, the other with preventing financial loss due to injury or serious inconvenience to patients.

And that's how risk management relates to standards, audit and other quality activities. From a risk management perspective, it is critical that standards concerning aspects of care which have risk potential are implemented completely and continuously. Risk management may depend on audit to monitor these important aspects of care. Also, risk management activities may identify new topics for which standards need to be agreed and subject to audit.

Both quality improvement and risk management programmes are here to stay and, in time, the programmes should be integrated to provide the safest patient care possible consistent with agreed standards.

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