PEPs - Clinical Quality and Evidence

Module 4 - Quality Improvement

Other forms of service improvement/audit

There are a wide variety of other pieces of information that reflect on clinical services. Some of these come under the guise of clinical audit and others would be considered as addition service  improvement tools. However they are generally rich in information and analysis of this information can lead to important improvement.

Critical incidents

A critical incident is any unintended or unexpected incident that could have, or did, lead to harm for one or more patients receiving NHS-funded healthcare. Such events are reported to the National Patient Safety Association through the National Reporting and Learning Service. These events are collated by the NPSA (National Patient Safety Agency) and a national picture of such events collated. Locally such events are investigated and usually a root cause analysis performed so that learning occurs to prevent recurrence. This exercise of reporting and analyses is a rich source of information, and if handled correctly should lead to improvement of services.


Invariable we will not be able to please all of our patients and their families. This can lead to complaints. These also are a rich source of information. All such complaints should be handled by the host institution, be it a hospital or Clinical Commissioning Groups.  If such complaints cannot be resolved at local level there is recourse to the ombudsman’s office (Tier two complaints). As with critical incidents, such complaints are investigated and these reviews and action plans are important to improve services.

Confidential Enquires

There are other types of review that can complement audit. The two that are used commonly are peer review and confidential inquiry.  

The former is performed locally, regionally and nationally. A local peer review would be when a multidisciplinary group of clinicians, together with managers and patients review a service or a certain aspect of a service ¹.  This would commonly be looking at a disease pathway or part of a pathway. Regionally, the best example of this would be the Cancer Peer review ² process which is a Department of Health group of experts who constantly review the quality of cancer services, of various types, thereby driving improvement. Nationally the laboratory accreditation service ³ carries out the same process for all of our laboratory services, thereby assuring that they all perform to a certain standard.

National Confidential Enquires into Patient Outcome and Death (NCEPOD) ⁴. These are well-established reviews into a variety of events. NCEPOD's purpose is to assist in maintaining and improving standards of medical and surgical care for the benefit of the public by reviewing the management of patients, by undertaking confidential surveys and research, and by maintaining and improving the quality of patient care and by publishing and generally making available the results of such activities.

  1. Setting up interdepartmental peer review. The British Thoracic Society's scheme
  2. National Cancer Review Programme
  3. United Kingdom Accreditation Service (UKAS)
  4. National Confidential Enquiry into Patient Outcome and Death