risk management and quality carequalityin healthcare 1995;4:102-107 riskmanagementandqualityofcare...

Quality in Health Care 1995;4:102-107

Risk management and quality of care

Fiona Moss

An honest concern about quality, howevergenuine, is not the same as methodicalassessment based on reliable evidence.'

Risk management is about reducing thelikelihood of errors. Its particular aims are toreduce errors that are costly in terms ofdamage, discomfort, disability, or distress to anindividual and to limit financial loss to anorganisation. Risk management achieves thisthrough detecting, reporting, and correctingactual or potential deficiencies in the processof care that, however small, could lead to asignificant and costly mistake. Risk manage-ment programmes therefore involve all aspectsofwork, production, and interactions within anorganisation - and in health care this includeslooking beyond clinical care. An establishedand well run risk management programmecontributes towards providing hospital carethat is free of mistakes and it makes a clearcontribution to healthcare quality. Thebenefits to patients of care in a hospital whosetreatment can be guaranteed to be as safe aspossible are obvious. But risk management isonly one of a clutch of programmes whose aimis to improve quality of care, and reducingharm is only one aspect of healthcare quality.Linking risk management programmes withother quality initiatives will help to develop a

coherent approach to quality improvementwithin a hospital or practice.

This paper will explore some of the ideasand definitions of quality of care and examinethe particular contribution of risk manage-ment with some other quality initiatives toimproving different aspects of healthcarequality.

Central MiddlesexHospitalFiona Moss, consultantphysician

Correspondence to:QHC Editorial Office,BMA House,Tavistock Square,London WC IH 9JR

Quality of care: what does it include?Healthcare quality is much more than a matterof technical or professional performance, butit is difficult to sum up the individualcomponents of good quality care. Much careis to some extent a series ofcompromises, tradeoffs, and choices, made, in the bestcircumstances, by properly informed patientsguided by knowledgeable healthcare pro-fessionals in safe and comfortable surround-ings. Good quality care incorporatesappropriate and competent technical care withopportunities for patients to make choices andto discuss concerns and fears, and it shouldresult in an outcome appropriate to theproblem. Even this long and cumbersomedescription excludes some important aspects ofgood quality care, such as fairness and access,and assumes much in the phrase "competenttechnical care" and says little about theorganisation of care.

CLASSIFYING QUALITY OF CAREThree classifications provide a useful frame-work for discussing quality of health care. Thefirst, the basis of much work on quality im-provement, is Donabedian's classification ofhealth care into its structure, process, andoutcome components as targets for qualityassessment.2 The second is the six dimensionsof quality described by Maxwell as part of adiscussion on the need for an integrated qualityimprovement programme based on methodicalassessment (box).' The third, also from the

work of Donabedian, considers health care inthree parts: the technical aspects of care, theinterpersonal aspects of care, and the amenitiesor the environment in which health care isprovided.3 Of course, these classificationsoverlap, but each approaches the definition ofquality of care differently and together theyprovide a more complete picture than eachalone. By combining structure, process, andoutcome with the six dimensions of quality astructure emerges that can be used to compilea series of questions about the quality of, say,an intensive care unit (box).'

Structure, process, and outcomeThe structure of care describes the resourcesthat combine to deliver care and includes allaspects of the environment of the hospital,clinic, or practice premises where patients areseen and treated. Structure includes thenumber and grades of staff as well as thenumber of beds, the number and configurationof clinics, and the availability and standard ofequipment and other items necessary fordelivering health care. Clearly, some aspects ofstructure, although desirable, are not crucial forgood quality care and, conversely, bad care isquite possible within a well equipped hospital.The process of care refers to all the events,

procedures, and actions included in the healthcare received. This includes assessments such asclinical examinations and investigations, clinicalinterventions such as prescription of a drug oran operation as well as outpatient appoint-ments, and the processes of nursing care andtherapy. The interpersonal aspects of care mayalso be considered part of the process of care.

Dimensions of quality* Effectiveness* Efficiency* Appropriateness* Acceptability* Access* Equity

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Assessing quality in an intensive care unitStructure

Effectiveness Staffing level and skillsEquipmentAccess to theatres, etc

Acceptability Is setting frightening orreassuring?What provision is there forrelatives (privacy forcounselling, overnightaccommodation)?

Efficiency Avoidance of extravagancein structure, equipment,and staffing

Access

Equity

Relevance Bearing in mind otherneeds, is this service anappropriate use ofrecources at the currentactivity and expenditurelevel?

From Maxwell4

ProcessWorkload (volume ofpatients treated)Compliance with protocols,where relevantData based peer reviewInfection andcomplications ratesIs explanation to relativesrequired and recorded innotes?

Throughput, staffing, etcAdmission and dischargearrangementsHow many patientssuitable for admission haveto be refused because theunit is full?Is there any evidence ofbias in who is admitted orhow they are treated?

OutcomeSurvival rates comparedwith similar units formatched cases

Is there follow up ofpatients and of relatives toobtain their opinions andsuggestions forimprovement?

Costs for comparable cases

What actually happens topatients refused or delayedadmission because the unit isfull?Is there any evidence of biasin outcomes?

How much difference doesthe unit make to survivaland health status, and forwhom?

health status. Some measures of health statusare condition specific - for example, changesin blood glucose concentration in diabetes.Generic measures express changes in healthstatus that apply to any condition and describethree domains of wellbeing: physical func-tioning, mental health, and social function.The development and validation ofhealth statusquestionnaires such as the SF 36 questionnaire6offer a means of comparing outcomes across

specialties. The use of health status measures

permits an understanding of the impact ofclinical interventions on patients' wellbeingand, when used alongside conventional clinicaland physiological measures, adds to theinformation on effectiveness of interventions.

DIMENSIONS OF QUALITY

Effectiveness is the extent to which a healthcareintervention, when used in routine practice,achieves the desired outcome.7 From allperspectives - those of patients, providers, andpurchasers - promoting the use of effectiveinterventions and limiting the use of ineffectiveones is an important focus for qualityimprovement programmes. However, evidenceexists that some patients are treated withineffective interventions and others who wouldbenefit from specific effective treatments donot receive them. One example of the use

of ineffective care is the continued use ofdilatation and curettage for women under 40with menstrual problems, for whom this pro-cedure is unlikely to have any benefit. Amongpatients not always receiving effective inter-ventions are those admitted with acute

The outcome of health care is any changein a patient's health status attributable toa healthcare intervention and includes res-toration of function, relief of symptoms, andimprovement in life expectancy. Improvinghealth - either current or future - is a centralaim of health care. Knowing what works orwhat is effective is important to individualpatients and to healthcare providers, pur-chasers, and policy makers. Measurement ofoutcomes is of crucial importance to assessinghealth care and attempts to improve effective-ness and efficiency. Outcomes might seem tobe a measure of the sum of all that goes intohealth care - an outcome less than expectedmight indicate poor quality care. However,measuring outcome is not always straight-forward; a change in health status of anindividual must be directly attributable to ahealthcare intervention to be classed as anoutcome of health care - that is, a direct causallink must exist between the result and theintervention.'

Assessing outcomes of clinical interventionshas mostly been described by healthcareprofessionals and expressed largely in terms ofphysiological or other technical measures.Thus the outcome of the use ofinhaled steroidsin patients with troublesome nocturnal asthmais understood technically in terms of change inthe morning peak expiratory flow rate. Butwhat matters for the patient may not be somuch this criterion but a reduction insymptoms and undisturbed sleep.Measuring the outcome of a clinical inter-

vention implies assessment of a change in

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myocardial infarction, some of whom do notreceive blockers and aspirin, which preventfurther infarction.8

Appropriate care has been defined as .... theselection, from the body of interventions thathave been shown to be efficacious for adisorder, of the intervention that is most likelyto produce the outcomes desired by theindividual patient."' Again, there is evidencethat interventions are at times used in-appropriately. One example is the use ofcoronary artery surgery in coronary arterydisease; in one health region in the UnitedKingdom 16% of coronary artery bypasssurgery, assessed retrospectively by a panel ofexperts, was found to be inappropriateGood quality care must be acceptable. The

working group who defined the appropriate-ness of care quoted above emphasised theimportance of the individuality of the patient,the social and cultural context, and the avail-ability of healthcare resources when consider-ing appropriateness of health care. Appropriatecare goes further than just medico-technicalconcerns and must include a measure ofacceptability to the patient and to society(box). Thus the assessment of the appropriate-ness of coronary artery surgery referred toabove may have underestimated its level ofinappropriate use as the study examinedappropriateness from only a medicotechnicalperspective and did not investigate patientchoice or other criteria.

Assessing the acceptability of care is difficult.No mechanism exists for routine collectionof information about the acceptability ofinterventions to individual patients. Theweight an individual places on risks oftreatment and likelihood of a treatmentworking is not always predictable. And societalattitudes to acceptability of care are not alwaysexplicit. A recent case reported widely in theBritish press of a 10 year old girl who hadexperienced a relapse of leukaemia after a bonemarrow transplant illustrates the tensions thatmay emerge when differences exist between theacceptability of an intervention as perceived byan individual (represented by the girl's fatherand his legal advisers) and by society(represented by the purchasers of care). The

purchasing authority, having taken medicaladvice, refused payment for further trans-plantation, estimated at £75 000, as there was

judged to be only a minimal chance thattreatment would be successful. Its view wasthat the girl should be made as comfortableas possible and not given active treatment.But the girl wanted to pursue active treat-ment. The case went to the Appeal Court,which ruled in the purchasing authority'sfavour. "l 2

Acceptability of care to an individual may beas much about the interpersonal aspects of careas the technical task of delivering care.Healthcare professionals need to be good atcommunicating if patients are to be able tomake choices and to decide what is to themacceptable. Allowing people to make choicesrequires respect and sensitivity.

Access to care, in terms of waiting lists, is

perhaps the most easily measured of all thedimensions of quality and in the UnitedKingdom has become a matter of politicalconcern. Debated in the media, access to care

as defined by waiting lists for operations andfor first outpatient appointments has a greaterprofile than other aspects of quality of care.

The patients' charter has set out standards thatmay help improve the way that hospitalsmanage waiting for appointments withinhospital clinics.'3 The easy availability of dataon waiting lists may give undue weight to oneaspect of quality at the expense of others. Thisis illustrated by a case of a child who had beenwaiting for 12 months to have an ear operationand that became public in the run up to thegeneral election in 1992 in the UnitedKingdom. The political furore and mediadiscussion that followed focused on access tocare and paid little attention to considerationof more pertinent issues, such as theappropriateness of the procedure. 14

Equity, is about fairness and assuring thathealthcare delivery is related to need and is a

specific aspect of access to care. In the UnitedKingdom the health care provided by theNational Health Service is based on equitableprinciples and is free at the point of delivery.Access to care is related to need and not, forexample, to ability to pay. This contrasts withmuch health care in the United States. Butequity has a wider application than just thesystem of health care and within the healthservice in the United Kingdom examples ofinequity can be found. People whose firstlanguage is not English may have a restrictedaccess to advice and care, unrelated to need,if they are unable to explain their problemsfluently to the doctor because of lack ofinterpreting services. The introduction offundholding for some general practices has ledto concern that the patients of fundholdinggeneral practitioners may get preferentialaccess to some aspects of hospital care as theirdoctors control budgets for elective care. Andstudies in both the United Kingdom andUnited States have shown that women withcoronary artery disease are less likely thanmen with similar disease to have coronary

angiography or surgery.

Additional criteria for appropriatenessofan intervention*Availability of technical skills and resources toallow intervention to be performed to a highstandardIntervention performed in a manner acceptableto the patientPatient to have adequate information about therange of effective interventionsPatient to be fully informed of and to beinvolved in discussions about likelihood ofadverse outcomesPatient's preferences to guide choice ofinterventionPatient's preferences should reflect both primaryoutcome and perceptions of potential adverseoutcomes*From working group report')

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INTERPERSONAL AND TECHNICAL ASPECTS OF

CARE

The third classification of the quality of care

includes a distinction between interpersonaland technical aspects of care. Practitionersrequire skills in both in order to deliver goodquality care. Being able to discuss the risks andbenefits of interventions and describe possibleoutcomes is a prerequisite if patients are tomake informed choices. Technical competence

is crucial but alone will not guarantee goodquality care.

Systematic approaches to qualityThe range of questions encompassed in thenotion of the quality of care - from details ofthe effectiveness of technical interventions toequity and respect - indicate the enormity ofthe task of its assessment. Risk managementdeals with only some of the dimensions ofquality and targets adverse events and aims atreducing errors. A quality improvementprogramme that relied only on riskmanagement might reduce risk and result in a

safer hospital but would not, for example,tackle issues such as effectiveness or appro-

priateness of care. Each quality programme hasa particular perspective and a contribution todifferent aspects of the quality of care.

A jungle of terminology and the differingfunctions and origins ofprogrammes that focuson the quality of care have made this seem

a perplexing area to many healthcareprofessionals. I shall describe quality pro-

grammes briefly in three broad categories:quality assurance, quality improvement, andclinical audit. Although each may have a

different emphasis they all entail a systematicapproach to assessing quality of care.

QUALITY ASSURANCE

Quality assurance, which has had greaterprominence in the United States than theUnited Kingdom, tends to rely on

measurement of indicators of performance.Broadly, quality assurance systems rely on

external inspection. One aim is to guaranteethat an organisation meets predefinedstandards and may be described as a checkingmechanism. In the United States since the1950s external monitoring agencies haveaccredited hospitals and monitored the qualityof care. The system is complex and is a mix ofprivate and public organizations whoseobjectives include cost containment as well as

quality improvement.'5 16External quality assessment and accredita-

tion have not been a major feature of healthcare in the United Kingdom. But examples ofmechanisms for external checks on quality doexist and include the quality assurance systemfor chemical pathology; the Health AdvisoryService, set up to inspect services for longstay elderly and mentally ill patients; theconfidential enquiry into maternal mortality;and the confidential enquiry into perioperativedeaths conducted by the Royal Colleges ofAnaesthetists and Surgeons."7The confidential enquiry into perioperative

deaths (CEPOD) has had an important im-

pact on the organisation of emergencysurgery particularly on procedures performedout of hours. By focusing on possiblyavoidable serious events this enquiry is similarto the process of risk management. Further-more, it is based on a reporting system -another important element of risk manage-ment. Local risk management programmesshould work closely with those involved inCEPOD.

CLINICAL AUDITThe introduction of medical and then clinicalaudit into the United Kingdom health servicein 199018 19 represented a fundamental changein approach to the quality of clinical care. Untilthen the approach in hospitals was rarelysystematic. Discussion about methodicalapproaches to quality assessment was limitedto groups of enthusiasts. But backed up withspecific central funding of £48m annuallymedical audit very quickly became part of thecontractual commitment for hospital doctorsand a near mandatory activity for generalpractitioners. In the definition of auditincluded in the Department of Health'sdocuments medical audit was described as aprofessional activity. At first, audit wasapparently only for doctors. But this inwardapproach changed and medical audit wassuperseded by clinical audit, which has a widerremit by including the work of all healthcareprofessionals.The principles of clinical audit are described

in the notion of the audit cycle.20 Using thebest evidence available - from scientificpublications or nationally agreed standards orlocally agreed codes of practice - local practiceis measured and compared with the agreedstandards. Appropriate sampling methods andsample size are necessary to ensure that thedata give an accurate view of the aspect of carebeing examined. After discussion of the resultswith the relevant healthcare professionals anydifference between the agreed observedstandards is analysed and attempts are made tofind the reason for any difference so thatchanges can be made with a view to improvepractice.2' Thus a quantitative approach isused to gain a picture of the standard of care.But the action needed to change practice isoften less clear, which may explain why auditsoften fail to change practice and improvequality.The success of this service wide imple-

mentation of clinical audit in improving patientcare has not been formally evaluated, and thebenefit of this investment is not known.22Nevertheless, clinical audit is now establishedin the United Kingdom as the focus of qualityassessment in hospital practice. Most hospitalshave audit meetings, designated audit officersor facilitators, and a programme of topics foraudit. Direct central funding for audit has nowbeen passed to the purchasing authorities.Audit continues as a provider function, butpurchasers can now add some externalpressure by including quality statements incontracts and asking for audits of specifictopics.

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QUALITY IMPROVEMENTThe essential features of quality improvementare that it is largely an internal mechanism; thatit is reflective and not punitive or defensive;that it relies on learning and improving; andthat it is based on an understanding of theneeds of the customer and on good evidence.Compared with quality assurance, qualityimprovement does not primarily set out todetermine whether care is substandard or notor whether it meets a set standard, but it is amore dynamic approach to quality that relieson systematic analyses of the processes ofwork- quantitative or qualitative - that areconsidered and used by those doing the workto improve what they do. All healthcareprofessionals and all who work in health care

should be involved; quality improvement is nota specialty or discipline in its own right. Tobring about change those involved in qualityimprovement must not only undertakemethodical study but also understand howtheir organisation works and what motivateschange.Some readers will identify in this a de-

scription of continuous quality improvementand others might recognise it as total qualitymanagement. Much has been written aboutthe development of total quality managementin industry and its relevance to health care. Inhealth care, quality is almost exclusivelyfocused on clinical quality; there is a tendencyto disassociate managerial and clinical activitywithin quality improvement. In total qualitymanagement the idea of quality improvementis linked to the notion that quality is acharacteristic of the whole organisation. Thisapproach to quality improvement was

developed by American experts asked byJapanese industrialists to advise aboutimproving Japanese industrial productionprocesses. These advisors, among themW Edwards Deming and Joseph M Duran,understood that documenting the technicalquality or specifications of components on a

production line would not alone producelasting improvement in production quality.They approached quality improvement from amuch wider perspective. Drawing from a widerange of disciplines, they advocated thedevelopment of an approach to qualityimprovement that involves everyone in theorganisation as part of a continual drive to dobetter. The box shows some of thecharacteristics of total quality management.Although total quality management may soundlike jargon to people working in health care andits industrial origins may provoke resistance, itis an approach which could be applied to theNational Health Service.2425Some of the characteristics of total quality

management are similar to those of riskmanagement - for example, examining theprocesses of care rather than individual

performance for explanations offlaws or errors.Others, in particular the emphasis onmeasurement, are in line with the principlesthat underpin audit. The need to develop anintegrated approach to quality and itsimprovement and to avoid separating those

programmes that within one organisation aimat improving the quality of care would be inkeeping with total quality management.

COMPARING THE CONTRIBUTIONS OF RISK

MANAGEMENT AND CLINICAL AUDIT

Risk management and clinical audit focus ondifferent aspects of the quality of care and arecomplementary, not alternative, programmes.Structure is more often a topic for riskmanagement than clinical audit. Safetydepends on good, well maintained equipment,and hospitals should have a mechanism todetect faulty equipment. Staffing also affectsthe quality of care. The national confidentialenquiry in perioperative deaths highlighted therisks of operations being done by surgeons ofinappropriate seniority for the tasks they areasked to do. Buildings also need to be safe, wellmaintained, and to provide the appropriateenvironment for patients and for staff.Much audit activity is about the process of

care, which is relatively easy to measure. Theimportance of the process of care is its relationto outcome and the presupposition of a relationbetween the appropriate use of an effectiveintervention and a favourable outcome. Both(in)effective and (in)appropriate care inter-ventions may be a focus for audit. By settingstandards and measuring care against them thedegree to which care meets those standardscan be assessed. An example is the useof thrombolytic therapy for people withmyocardial infarction - an intervention ofproven benefit. Reasonable targets for audit, asprocess markers of good quality care, are

the rate and timing of administration ofthrombolytic therapy. Many hospitals, throughthe audit process, know the proportion ofpatients admitted with myocardial infarctionwho receive thrombolytic therapy and the delaybetween arrival in hospital and receiving thistreatment. This information, used properly,can help a hospital to improve this aspect ofcare.26

In contrast, effectiveness and appropriate-ness are not prime targets for risk managementprogrammes, although questions about theseaspects of quality may be asked when anuntoward event has occurred. Sometimes the

Some characteristics oftotal qualitymanagement*Making customers' needs a priority for everyoneDefining quality in terms of customer needsRecognising the existence of internal customersand suppliersExamining the process of production rather thanindividual performance for explanations of flawsor poor qualityUsing sound measurement to understand how toimprove qualityRemoving barriers between staff and promotingeffective teamworkPromoting training for everyoneInvolving the whole workforce in the task ofimproving qualityUnderstanding that quality improvement is acontinuous process*From Moss and Garside"3

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process of care is a trigger for risk management,but the targets are unexpected activity andindicators of problems with care. For example,a need for a patient to return to theatre afteran operation or a greater than predicted bloodtransfusion after a caesarean delivery is anintervention that might indicate that somethinghad not gone according to plan.The government white paper Working for

Patients included outcomes within the workingdefinition of medical audit.27 In reality usingoutcome for audit is difficult. Problems of casemix, different perspectives on outcome, theneed for large numbers to make sense of smallchanges, and the importance of medium andlong term outcomes which may be difficult tocollect at discharge have thwarted attempts toaudit outcome. For to act as a lever for changea link with process is needed. Some outcomesare most usefully measured some time after theintervention so that both collecting the dataand communicating them to the healthcareprofessionals who initiated the interventionmay not be straightforward.Unwanted outcomes or adverse outcomes

are important triggers in risk management.Unexpected death or a complication from anintervention warrants investigation. Eachspecialty will have its own series of suchoutcomes - for example, a poor apgar score ofa newborn baby, neonatal death, or any deathafter an elective operation.Most instances of care that patients find

unacceptable are probably unreported and areunlikely to be disclosed by any of the qualityimprovement initiatives. Acceptability of careis not a usual focus for audit but may bedetected through risk management pro-grammes, in some cases passing through theclinical complaints process. One study ofclinical complaints found that most complaintswere seldom about a clinical problem alone;most also included some dissatisfaction withpersonal treatment.28

CONTINUOUS QUALITY IMPROVEMENTFirm links between clinical and managerialactivity are necessary if risk management orclinical audit is to be effective. All theseinitiatives depend on organisational supportand the cooperation and the involvement of allstaff. An organisation that works through theprinciples of continuous quality improvementwill be responsive to the demands of bothaudit and risk management and enable linksbetween these and other similar programmes.A workforce receptive to the notion ofcontinuous quality improvement is likely toadopt a positive attitude to the reportingsystems that are part of risk management. Andsome features of good quality care - allowingpatient choice, assuring equity, and providinginformation - are difficult to measure andrarely assessed. But these aspects of quality willbe integral to organizations whose functionsare based on the principles of continuousquality improvement because of the emphasison the needs of their customers and theimportance given to training of all staff. Thesuccess of risk management may depend on the

adoption of the principles of continuousquality improvement.

ConclusionsGood quality care is more than either averagecare or simply care free of mistakes. No singletechnology that purports to improve the qualityof care can encompass the many dimensions ofquality. Some aspects of quality are more easilytargeted by audit and others by risk manage-ment; and some are unlikely to be the focus ofeither programme. In the United Kingdom thedevelopment of clinical risk management isbeing introduced after the implementation ofclinical audit. With their separate funding andperhaps their aim at primarily different groupswithin the health service, there is a risk thatclinical audit and risk management willdevelop separately. They should be linked bygood organizational support.

1 Maxwell, R. Quality assessment in health. BMJ 1984;288:1470-2.

2 Donabedian A. Evaluating the quality of medical care.Millbank Memorial Fund Quarterly 1966;44:166-206.

3 Donabedian A. The definition of quality and approaches to itsassessment. Ann Arbor, Michigan: Health AdministrationPress, 1980.

4 Maxwell R. Dimensions of quality revisited: from thoughtto action. Quality in Health Care 1992;1:171-7.

5 Shanks J, Frater A. Health status, outcome, andattributality: is a red rose red in the dark? Quality in HealthCare 1993;2:259-62.

6 Brazier JE, Harper R, Jones NMB, O'Cathain A,Thomas KJ, Usherwood T, et al. Validating the SF-36health survey questionnaire: new outcome measure forprimary care. BMJ 1992;305:160-4.

7 Hopkins A. Measuring the quality of medical care. London:Royal College of Physicians of London, 1990.

8 Eccles M, Bradshaw C. Use of secondary prophylaxisagainst myocardial infarction in the north of England.BMJ 199 1;302:91-2.

9 What do we mean by appropriate health care? Report of aworking group prepared for the Director of Research andDevelopment of the NHS Management Executive.Quality in Health Care 1993;2:117-23.

10 Gray D, Hampton JR, Bernstein SJ, Kosekoff J, Brook R.Audit of coronary angiography and bypass surgery. Lancet1990;335: 1317-20.

11 Mullin J. Leukaemia girl loses court fight. Guardian 11March 1995:1.

12 Mihill C. Guideline plea for rationing treatment. Guardian11 March 1995.

13 Collins C. Implementing the patient's charter in outpatientservices. BMJ 1993;302:1396.

14 Black N. Jennifer's ear: airing the issues. Quality in HealthCare 1992;1:213-4.

15 Wareham NJ. External monitoring of quality of health carein the United States. Quality in Health Care 1994;3:97-101.

16 Wareham NJ. Changing systems of external monitoring ofquality of health care in the United States. Quality inHealth Care 1994;3:102-6.

17 Buck N, Devlin HB, Lunn JN. Report ofa confidential enquiryinto perioperative deaths. London: Nuffield ProvincialHospitals Trusts, 1988.

18 Department of Health. Medical audit in thefamily practitionerservices. London: HMSO, 1990. (HC(FP) 90(8).)

19 Department of Health. Medical audit in the hospital andcommunity services. London: HMSO, 1991. (HC 91(2).)

20 Russell IT, Wilson BJ. Audit: the third clinical science?Quality in Health Care 1992;1:51-5.

21 Crombie IK, Davies HTO. Missing link in the audit cycle.Quality in Health Care 1993;2:47-8.

22 Buxton M. Achievements of audit in the NHS. Quality inHealth Care 1994;3(suppl):S31-4.

23 Moss F, Garside P. The importance of quality: sharingresponsibilities for improving patient care. BMJ1995;310:996-1000.

24 Berwick DM, Enthoven A, Bunker JP. Quality managementin the NHS: the doctor's role. I. BMJ 1992;394:235-9.

25 BerwickDM,EnthovenA, BunkerJP. Qualitymanagementin the NHS: the doctor's role. II. BMJ7 1992;304:304-8.

26 Nee PA, Gray AJ, Martin MA. Audit of thrombolysisinitiated in an accident and emergency department.Quality in Health Care 1994;2:29-33.

27 Secretaries of State for Health, Wales, Northern Ireland,and Scotland. Medical audit. Working paper 6. London:HMSO, 1989.

28 Bark P, Vincent C, Jones A, Savory J. Clinical complaints:a means of improving quality of care. Quality in HealthCare 1994;3:123-32.

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