Quality assurance and quality control in veterinary practice

As a sector and a healthcare industry, the veterinary profession recognises the importance of quality improvement (QI). In fact, 96 percent of veterinary teams acknowledge that it improves veterinary care (RCVS Knowledge, 2020); however, barriers remain to its implementation in practice. Time constraints and a lack of confidence and support from practice leadership are just a few of the challenges facing our teams.

By breaking down the QI principles into more manageable chunks, we can effectively apply them to our everyday tasks and foster the foundations of a learning culture.

Why should we use quality improvement?

It is widely recognised that by implementing QI processes, we can generate the following results (RCVS Knowledge, 2023):

• Preventing avoidable harm to patients
• Determining better practice
• Embedding evidence-based veterinary medicine
• Fostering a learning culture and building a closer team
• Improving communication between our teams and with our clients

Despite the obvious benefits, the QI process can seem too large to start or too clinical for those without a clinical background. So, it is important to remember that QI is a principle not only applied in healthcare industries but in most industry sectors, and all team members, clinical and non-clinical, have an important role to play in its delivery.

It is important to remember that quality improvement is a principle not only applied in healthcare industries but in most industry sectors, and all team members, clinical and non-clinical, have an important role to play

Principles of quality improvement

There are many definitions of QI in the literature, but some common principles include (Backhouse and Ogunlayi, 2020):

1. An intent to create measurable improvement in a specific aspect of practice
2. A continuous process of planning, implementing and reviewing changes and using learning outcomes to adopt this process
3. The use of data to drive and measure improvement
4. The engagement of the whole team in the process
5. Fostering a culture that enables a safe space for improvement work

Many QI methodologies exist and can help you set up workable processes in practice, so it is important to find the way that works best for your team and the aspect you wish to improve.

Building the right culture

Eighty percent of improvement in healthcare industries is led by human behaviour (Sheffield MCA et al., 2016) – a fact that makes using a common language, fostering open and non-judgemental communication and recognising how stress can affect our teams essential to the effective implementation of QI.

Building a “no-blame”, “just” or “learning” culture is commonly discussed in the veterinary profession, and while the specifics of how you create the right culture in your practice will depend on your circumstances and teams, there are some simple steps you can follow to get started.

Getting started

1. Set clear expectations on how you expect your teams to communicate and work together: collaborate to develop a framework of expected behaviours (Box 1) and ask your teams to commit to it
2. Call out positive and negative influences on these behaviours in the appropriate manner: give positive feedback in private and public forums. This could be in regular catch-ups with your team members, in larger meetings or just during your normal working day. Remember, you should always give constructive criticism in private. Don’t “save up” examples of poor behaviour for formal meetings. Instead, take the team member aside to discuss the problem, why it occurred, whether there are underlying causes and how you would have preferred the situation to be handled
3. Lead by example: advocate for the culture you are aiming to create
4. Create space for constructive discussion: allocate time for collaborative conversations, such as case reviews, “positive and negatives” and debriefs, after significant outcomes and ask your team to bring their suggestions for discussion
5. Follow up on changes you intend to make. For instance, ensure you deliver what your teams expect you to in order to build a culture of trust. A shared action tracker can ensure accountability for the whole team’s actions by allowing progress to be monitored from both sides. This ensures that everyone knows the timescale for delivery and what is expected of them
6. Close the feedback loop: Tell your teams about the changes you have made, results achieved and whether further changes are required. You could do this via a team meeting, a practice communication or even by regular updates on a practice noticeboard. If further changes are required, bring your team together to discuss what further changes are needed

How do I “do” QI?

A simple and versatile approach to “doing” QI is the model for improvement with the Plan, Do, Study, Act cycle (Figure 1).

This model is based on three simple questions that help formulate an effective plan (RCVS Knowledge, 2023):

1. What is the aim of the plan?
2. How will we measure improvement?
3. What changes will we make to reach the aim?

Each change is then applied, and the outcome measured. The results are then used to inform the next change implemented, and so the cycle continues.

You can easily apply this approach to a variety of scenarios in veterinary practice. For example, perhaps you have identified that you have a high turnover of staff in their first month of joining. Here’s how you might proceed:

1. Define the aim of the plan: to improve the experience of new staff starting at the practice and therefore new staff retention
2. Consider how you will measure improvement: by gathering feedback from new starters about their experience via a quantifiable survey? By measuring the number of new staff who remain in post or leave in their first month? If possible, comparing your measurements to industry benchmarks will give insight into how your practice is performing
3. Consider what changes you will make to achieve the aim:
   • Review your current induction plan to see where improvements can be made. Ensure adequate time is spent in each area, and that your plan has the scope to be flexible so individuals can spend more time in the areas they find more challenging
   • Allocate each new starter with an experienced “buddy” so that they have an added point of contact for support
   • You will make further changes based on the feedback you receive from your quantifiable survey in step two

Where do I start?

Integrating QI principles into your practice can feel like a huge task, but don’t forget that it’s likely that you are already living some, if not all, of these principles.

While significant event reviews, clinical audits and benchmarking all form part of quality improvement, you can start with a small task to build confidence and get your team on board

While significant event reviews, clinical audits and benchmarking all form part of QI, you can start with a small task to build confidence and get your team on board. As an example, you could ask your colleagues to help identify some “quick wins” (changes that will quickly make their lives easier). These could be:

• Ensuring all patients admitted into the practice for procedures have name collars
• Auditing your estimate process – are they always given, are they recorded and are they accurate?
• Checking all patients are weighed, with their weight recorded, at annual booster appointments

By improving simple yet important tasks, your practice can work more efficiently while engaging your team by seeing the positive results of QI on their daily duties.

Conclusion

By adopting QI processes in your practice, not only will you see improvements in the work you do and in patient outcomes, but you will also start to foster a learning culture in your practice.

Break the processes down into small chunks with some initial high-potential gains to engage the team in the principles, and you will see how small changes can bear impressive results.