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We work directly with a full range of key stakeholders in healthcare organizations to develop new or to review existing strategies and operational plans on subjects relating to the quality of health care. We use our international experience, our knowledge of best practice and our analytic skills to devise strategies that are tailored to the care settings, the organization, and the health system culture in the country. We work with key staff to translate our strategy into realistic long- and short-term performance objectives and work programmes.


As examples, working with a large number of diverse national stakeholders, we developed a national Clinical Excellence Strategy, which includes clinical audit and the implementation of evidence-based practice, for the Ministry of Health in Saudi Arabia. We also developed short-term and long-term operational plans for implementation of the strategy.


We developed the national Clinical Audit Policy and the national Quality Improvement Framework for the Ministry of Health in Botswana. In developing the Policy and the Framework, we worked with stakeholder groups representing clinical, managerial and research staff working in hospital and clinic settings across Botswana. The nationally approved strategies are now being implemented. 


We have developed clinical audit and quality improvement strategies for several healthcare organizations in the UK.

HQQ - Strategies


We have designed and carried out, or supported data collectors to carry out, several national or large-scale clinical audits including:


  • National clinical audits on hospital care of patients with major trauma, myocardial infarction, sepsis and stroke and a national clinical audit on the hospital management of patients with Covid-19 for a Ministry of Health. For the audits, we:

– derived the quality-of-care measures from international clinical guidelines and protocols or standards

   agreed by national consensus

– developed the data collection tools and tested the tools

– developed instruction books for data collectors and data analysts 

– developed and provided online learning programmes for data collectors

– developed and provided guidance and online learning programmes for hospital teams leading the audits.


  • A national clinical audit on the management of children with severe dehydration to be carried out in all hospital and clinic settings in Botswana. For this audit, we worked with a large expert panel to develop the quality-of-care measures based on WHO guidelines. We devised the data collection tool and instructions for data collectors and pilot tested the data collection process.


  • A regional clinical audit and a survey of views of nurses on a new patient assessment and care plan process in Health Service Executive (HSE) South facilities in Ireland. The audit led to substantial improvements, which were presented at an international conference.


  • A national clinical audit on the management of people with Parkinson’s Disease, which included redesigning aspects of the audit working with a large multiprofessional group of stakeholders, including doctors, nurses, physiotherapists, speech and language therapists and occupational therapists; analysis of data; and preparation of reports.


  • A national clinical audit for the former NHS Direct on call handling for which we designed and carried out all stages of the audit process for approximately 1100 calls.


  • Record-keeping across all specialties in large teaching hospitals.


We served as Clinical Audit Adviser to NICE from 2001–2006. We advised on the definition of clinical audit, developed the model for clinical audit design advice provided by NICE for technology appraisals, and developed the clinical audit designs and advice for all technology appraisals published by NICE from mid–2001 through June 2006 (72 technology appraisals and 2 clinical guidelines).

Large Scale Audits and Quality Improvement Projects


We have carried out a number of analyses of serious incidents involving, for example, unexpected deaths of patients or inappropriate serious situations involving patients and/or members of staff.


Our process for analysis follows these steps. We:

  • talk directly with the staff or others involved in or directly affected by the incident to gather the facts about the situation as completely and accurately as possible

  • gather more information about the incident, particularly when there is a cascade of unrecognized or unaddressed events that led to it

  • obtain any materials, equipment, devices and supplies relevant to the incident, staffing levels at the time/s involved, and documentation in patient records and other relevant sources

  • learn the key processes or systems related to the incident or situation in detail, including the intended process as described in approved policies and processes, the process staff usually follow in the workplace, and the process followed in the incident (Safety 1 versus Safety 2)

  • analyse information gathered to identify problems and the causes of the breakdown/s in work processes or systems that enabled the incident to happen or that didn’t act to prevent the incident

  • establish the changes in systems needed to prevent the recurrence of the incident and the actions to be implemented to achieve safer practice in the future

  • advise on how to measure the effectiveness of implementation of the actions to determine if recurrence of the same or similar event is being prevented or minimized.


We document the entire analysis and provide a report to those responsible. We have been required to give evidence in a Coroner’s Court.


When we work with staff, we explain that our purpose in face-to-face interviews is to learn from them their recollection of exactly what happened so that problems experienced can be prevented in the future. Our purpose in analysis of relevant documents is to create a complete and accurate timeline related to the incident. Our systems and process analysis is intended to learn about human factors related to the day-to-day implementation of key work processes and what impedes consistent use of safe and effective systems and processes by all staff.

Root Cause Analysis - woman writing down notes


We support clinical staff to:

  • design a QIP in detail, including the outcome to be achieved and the stakeholders to be engaged

  • work with team members to select quantitative or qualitative measurement tools and collect data for the tools selected

  • test reliability of data collection among data collectors and monitor data collectors’ adherence to the data collection protocol

  • collate and analyse quantitative or qualitative data

  • identify problems revealed and analyse them to find their causes

  • plan the implementation of action to overcome the causes of the problems to achieve improvements in practice

  • repeat data collection following the implementation of action

  • prepare a report on the improvement project.


We have provided expert support for Team-Based Quality Improvement Fellowships and Quality Improvement Fellowships for Staff and Associate Specialists sponsored by Health Education England, Wessex. The aim of the Fellowship programmes was to support existing teams or networks and doctors to work together to improve the services they provide. The programme was delivered over 12 months and included a mix of face-to-face learning and online resources. The support we provided involved teaching QI methods, working with teams to achieve major improvements in the quality of patient care and experience, and providing several QI and train-the-trainer workshops on QI, including several for primary care teams. This work resulted in the journal article, Effects of team-based quality improvement learning on two teams providing dementia careLINK

Team Facilitation for major QI projects


Our assessment of clinical audit and quality programmes includes consideration of how:

  • priorities were set for a project 

  • key stakeholders were identified and involved

  • the project was designed

  • quality-of-care measures were developed

  • the measures were defined to provide for valid and reliable data and how well data collectors were prepared to collect reliable data

  • findings were reviewed, particularly how clinical peers reviewed data and cases 

  • problems were explicitly named and their causes were identified

  • actions to achieve any needed improvements were decided on and implemented 

  • data collection was repeated to determine if improvements have been achieved and are being sustained.


Also, using assessment tools we developed from the evidence base, we screen proposals for QI and clinical audit projects to verify if the project design is consistent with good practice. We provide detailed comments on the proposal, including suggestions for how a project could be strengthened.


An example of our work was a qualitative assessment of The Diagnostics Collaborative Programme, which supported NHS Boards in Scotland in reducing waiting time for eight diagnostic procedures and sustaining the improvement. The assessment involved interviewing a range of staff in 10 NHS Boards in Scotland in addition to interpreting quantitative data. We identified key themes and provided a comprehensive report.


Also, we carried out an independent evaluation of a pilot care audit on the quality of dementia care in the care home sector in England. The purposes of the pilot were to determine if the care home sector would participate in a national care audit and use a nationally agreed audit tool; and if yes, the types of care home providers that are most likely to participate and why. We related to multiple stakeholders and provided a comprehensive report on the findings of our evaluation, including implications for a national care audit in the care home sector.


We carried out a detailed assessment of the quality programmes of bidders for the operation of Independent Sector Treatment Centres. 



We are very experienced in designing and carrying out literature reviews on clinical and healthcare subjects. All our publications and teaching materials are supported by extensive review and analysis of relevant literature. 


Examples are:


  • We carried out reviews and detailed analysis of clinical guidelines and quality standards published in several countries on major trauma, myocardial infarction, sepsis and stroke.


  • We completed a review on ethical issues related to clinical audit or quality improvement; circumstances for which a review of ethical issues is needed for a clinical audit or QIP, and structures, mechanisms or processes in healthcare organizations for overseeing ethical issues related to clinical audit or quality improvement. The findings were reported in the Review of Ethics Issues related to Clinical Audit and Quality Improvement ActivitiesLINK An update was published in the Guide to managing ethical issues in quality improvement or clinical audit projectsLINK


  • For NICE, we carried out 72 reviews of audit literature related to subjects of NICE technology appraisals. The reviews were intended to identify key issues related to clinical audit of implementation of the technology. 


  • For the former National Centre for Clinical Audit (NCCA), we carried out an original review of the clinical audit literature, Good Practice in Clinical Audit – A Summary of Selected Literature to Support Criteria for Clinical Audit. LINK The purpose of the review was to identify the evidence base for the criteria for clinical audit generated by national consensus by the NCCA. 


  • We carried out literature reviews for 11 large-scale clinical outcomes projects in 10 different NHS organizations in the former Wessex Regional Health Authority. Examples of subjects included surgical outcomes in the very elderly, stroke patients’ outcomes, myocardial infarction patients’ outcomes and major trauma outcomes. 


  • We carried out a literature search on best practice in relation to people with Parkinson’s disease. Based on the findings, we developed a model for delivering care to people with Parkinson’s disease: Model for Good Practice for the Care of People with Parkinson’s — An Overview of Evidence and Suggestions for the Way Forward.

Stacks of books


We analyse workloads related to clinical governance functions in healthcare organizations and the current level of performance of staff in roles intended to support this work. We review responsibilities and accountabilities of individuals, groups and teams related to patient safety, clinical audit, quality improvement, risk management and clinical governance functions and create or amend documents to clarify accountability for these activities as needed.


For example, we carried out an independent review of the current functioning and staffing levels of the patient safety department in a major London teaching hospital. Our review process included a demand-capacity analysis of the current workload, review of job descriptions for each role in the department, interviews with all staff, and review of routine and special reports produced by the department. We identified areas of good practice and where improvements could be made that would benefit the hospital and the department.


We developed job descriptions, person specifications and skills and knowledge needed for clinical audit staff for the Healthcare Quality Improvement Partnership (HQIP).  For the analysis, we reviewed existing job descriptions and person specifications in selected NHS organizations; findings of a survey we carried out with clinical audit staff; clinical audit responsibilities and competences we developed previously; and our experience in clinical audit.


We established a syllabus and curriculum for the training and certification of Clinical Audit Specialists for a Ministry of Health.

Clinical Audit for Improvement Conference, Clinical Audit Triumphs and Missed Opportunitie


We developed and published Standards for the Design and Conduct of a National Clinical AuditLINK The standards were referred to as a basis for assessing national clinical audits in England and were applied to national clinical audits carried out by NHS Scotland and to a stroke audit carried out in Australia. 


We have worked formally and continuously with designated clinical experts and other key stakeholders, including patients or their representatives, to develop clinical service standards on: elderly care services, management, patient records, major trauma care, myocardial infarction care, neonatal, nursing, ophthalmology and physiotherapy services, and sepsis and stroke care. Our standards were disseminated widely for review and we responded to all input on successive drafts until key stakeholders approved the documents.


Working with the clinical and management staff involved, and other stakeholders as relevant, we have developed policies for university hospitals on: clinical audit, clinical guidelines, clinical responsibilities for patients shared between specialties, complaints, communication, consent, dissemination of corporate policies, document control, handling patients who do not attend clinical appointments, handover, patient information, patient records, creation and approval of policies and procedures, publications, and notifications within the hospital of research studies being carried out involving hospital patients.

Standards and Policies Audits


When a healthcare organization or a clinical team wants to involve stakeholders actively in the organization’s or team’s improvement programme or other activity, we design and manage the stakeholders’ participation, including patients or their representatives, in projects.


Working with patient representatives and clinical staff, we have designed and produced patient information leaflets on a wide range of subjects for a university hospital including on: care of the elderly; coping with a traumatic event; coping with anxiety; depression; facial paresis; flexor tendon injuries; hospital-acquired infections; patient consent; varicose vein surgery; what a clinical psychologist does, and on physiotherapy exercises for a range of orthopaedic conditions.


We have carried out a number of patient focus groups for primary care centres to establish what the patients valued about the centre and what they would like to see improved. We analysed key themes from the sessions and provided a report on our findings.



We apply our years of experience to all aspects of quality improvement, clinical audit, patient safety, clinical governance and risk management as a basis for providing advice and guidance on these and related subjects as requested.


For example, for four years, as part of providing 5–day clinical governance and quality improvement courses for the Society of Hospital Medicine in The Netherlands for registrars in training to become ‘hospitalists’, we advised the hospitalist registrars as they completed ‘masterpiece’ projects on a subject related to quality improvement in order to receive their qualification as a hospitalist. We have supported the hospitalist doctors as needed as they work on their masterpiece projects in Dutch university hospitals.


We provide ongoing support to people we work with on projects they are working on, particularly in relation to promoting their work in journals and at conferences. 


We routinely respond to requests for advice on issues such as sample sizes to use for a clinical audit, how to display data collected for a QI project, recruiting audit or improvement staff, and clinical governance-related content for tender documents for organizations bidding to supply services to the NHS.

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Following are some unsolicited comments about our services.

‘Getting feedback on my project from you is like opening the best box of chocolates ever and browsing over all the delicious offerings’

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