Quality improvement and revalidation: two goals, same strategy?

‘Quality improvement’ and ‘revalidation’ are processes which will be key considerations for the health service in the UK over the coming years and are likely to have considerable implications for both professional and public resources. They also have many common elements that are relevant to the delivery of quality in health-care worldwide. Clinical audit is a quality improvement initiative which is currently undertaken by many doctors, either individually or within their departmental teams, and when conducted appropriately such activity has clear value and importance. However, we are entering an era where our professional performance will be assessed not just by process measures (such as evidence of audit participation) but also by qualitative and quantitative outcome metrics. At an institutional level, the publication of both patientreported and clinical outcomes for the purposes of benchmarking, improving standards, and determining payment to health-care providers is a UK Government goal, as set out in its recent White Paper. At individual physician level, the inclusion of outcome measures has been recommended as part of the annual medical appraisal process that will be central to revalidation in the UK. For anaesthetists, there is equipoise over which outcomes should be measured and reported to fulfil both the revalidation and quality improvement agendas. When evaluating outcome measures, the profession should consider; whether they are useful and valid, the methodology used for measuring and reporting these outcomes, what benchmark they will be assessed against, and whether the collection and reporting of such data will actually lead to improvement in standards of care. Professional behaviour in doctors is central to quality of care and there are a variety of measures which may be used to assess it. These include subjective feedback from patients and colleagues [multisource feedback (MSF)] and these metrics have been recommended by the General Medical Council (GMC) as a central tenet of appraisal for revalidation. Peer feedback is now being used by many healthcare providers as a way of obtaining information about individual doctors’ professional performance, attitudes, and behaviours, which can then be used in a formative way to assist their professional development. There are examples of such tools developed specifically for anaesthetists which are reliable and valid. However, no speciality-specific tool for anaesthesia, which maps to the GMC’s Good Medical Practice domains, has yet been validated in the UK. A recent systematic review evaluating the effectiveness of workplace-based assessments found that the impact of patient and peer feedback on practice varied with both the grade of doctor being assessed and their speciality. For example, a study of consultant surgeons found them to be unlikely to make changes in their practice based on such feedback, even if the results indicated that change might be required. However, a randomized-controlled trial found paediatric trainees to be more responsive. Importantly, there are currently no published studies examining the effectiveness of MSF feedback for driving performance improvement in anaesthetists. Volume 106, Number 4, April 2011