In 2016, the Royal Pharmaceutical Society (RPS) published a competency framework for all prescribers, detailing expected standards for the patient consultation and for documentation of the consultation to support safe and competent prescribing. Although documentation does not have its own criteria, they are mentioned throughout the framework.
It had been identified that the radiotherapy treatment review team at a UK hospital — comprising nine review radiographers, four of whom were also non-medical prescribers (NMPs) — did not have a consistent approach to documenting prescribing. In response, a quality improvement project was instigated to design a simple audit tool using criteria taken from the RPS competency framework.
The project also aimed to provide opportunities for peer-to-peer discussion, continuing professional development and to evidence on going prescribing competence.
The project incorporated four cycles of audit and feedback where changes could be suggested, implemented and tested by the participants across multiple iterations:
- Cycle 1: develop feasibility test, score and discussion;
- Cycle 2: refine criteria, score and group discussion;
- Cycle 3: refine process and criteria, score and discuss with multidisciplinary team (MDT);
- Cycle 4: implement audit tool among MDT prescribing members.
Studies show audit design and peer feedback is an important aspect of effecting change, along with the social pressure to not fall behind peers[2,3]. The audit and feedback design incorporated these aspects. By participating in the audit, review radiographers were able to learn from colleagues’ good practices dynamically as opposed to being passively given the results.
Participants audited ten of each other’s prescribing notes and ten of their own from round two. The scoring criteria used was:
- 1 — criteria met;
- 0 — not met;
- Blank if not applicable.
The template was developed for recording scores, which was amended between rounds one to three. The final tool template was used in rounds three and four. Peer discussion sessions were held after each round to consider results and evaluate practice. The sessions were designed to encourage discussion of good practice rather than individual results. Active reflection and discussion of the RPS competency framework was encouraged.
Participants reported a number of benefits from auditing their own, as well as colleagues’ documentation. Self-scoring led to effective reflection on good practice, provided valuable insights into their prescribing behaviour and generated motivation for sustained improvement.
Despite the value provided and importance of national guidelines, the project revealed that the RTTs were previously unaware that they were failing to meet certain competencies around prescribing documentation and were falling short of professional standards[3,5]. Participants reported that identifying this shortfall had been helpful.
The development of the evaluation tool resulted in a reduction in variance between prescribers’ documentation. The data show clear improvement in the maximum, minimum and median scores, with a reduction in range and standard deviation after each cycle of auditing. Adherence to the RPS competency framework improved rapidly owing to participation in the project. The project sample size was insufficient for reliable statistical tests so descriptive data analysis was used to measure changes in scores between rounds.
In summary, participants reported that the evaluation process was simple and sustainable. The audit cycles provided structure for constructive discussion, peer-to-peer learning and reflection; all of which can be useful for appraisals, CPD and revalidation. This aspect of the project was particularly useful for less experienced prescribers.
The evaluation tool encourages quality improvement and is designed to act as a comprehensive resource that any prescribing team can adopt. It includes an information page, reflection sheets and audit collection sheets, which provide an immediate score.
The tool measures only the documentation for the patient consultation and prescribing decision, it does not evaluate against the full range of prescribing competencies contained within the RPS competency framework. Intensive observational studies are required to make a full assessment of a prescriber’s level of competency.
Nevertheless, good standards of documentation are an essential component of effective communication with colleagues and an aspect of practice where there are clear legal and professional obligations that prescribers are required to meet[6,7]. This project demonstrated the benefits of developing a structured approach to documentation that supports prescribers to meet these obligations.
To contact us about this project and the evaluation tool, email: email@example.com
Tina McCloskey, head and neck advanced practitioner radiographer, supplementary and independent prescriber, at Guy’s and St Thomas’ NHS Foundation Trust
- 1A Competency Framework for all Prescribers. Royal Pharmaceutical Society. 2016.https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Professional%20standards/Prescribing%20competency%20framework/prescribing-competency-framework.pdf (accessed Aug 2023).
- 2Cooke LJ, Duncan D, Rivera L, et al. How do physicians behave when they participate in audit and feedback activities in a group with their peers? Implementation Sci. 2018;13. doi:10.1186/s13012-018-0796-8
- 3Ferguson J, Keyworth C, Tully MP. ‘If no-one stops me, I’ll make the mistake again’: Changing prescribing behaviours through feedback; A Perceptual Control Theory perspective’. Research in Social and Administrative Pharmacy. 2018;14:241–7. doi:10.1016/j.sapharm.2017.03.001
- 4Holmboe ES, Meehan TP, Lynn L, et al. Promoting physicians’ self-assessment and quality improvement: The ABIM diabetes practice improvement module. Journal of Continuing Education in the Health Professions. 2006;26:109–19. doi:10.1002/chp.59
- 5Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews. 2012. doi:10.1002/14651858.cd000259.pub3
- 6Griffith R. Putting the record straight: the importance of documentation. Br J Community Nurs. 2004;9:122–5. doi:10.12968/bjcn.2004.9.3.12436
- 7Black A, Gage H, Norton C, et al. A comparison between independent nurse prescribing and patient group directions in the safety and appropriateness of medication provision in United Kingdom sexual health services: A mixed methods study. International Journal of Nursing Studies. 2020;107:103590. doi:10.1016/j.ijnurstu.2020.103590