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Use of Clinical Audit to improve MSK pathway

20 November 2017

It's Clinical Audit Awareness Week and as part of the event, we are sharing stories of clinical audits at Connect and showing how these have helped shape quality improvements. 

First up we're looking at our Advanced Practice Physiotherapist Aimee Robson's poster from Physiotherapy UK 2017 on 'Use of Clinical Audit to improve MSK pathway: NICE Metastatic Spinal Cord Compression (MSCC) Guidelines'

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Within the North East of England, 7 Clinical Assessment and Treatment Services (CATS) were commissioned to Connect in the community. We worked alongside 4 Acute Trusts in the region who had separate MSCC pathways based on NICE guidelines. These pathways were poorly understood by primary and community care providers in the region, and only accessible by medical staff and not by Allied Health Professionals (AHPs). Our clinical audit was initially designed as a quality assurance method to measure compliance against NICE MSCC guidelines in their standards of care. However, from this clinical audit, we were able to identify variation from the quality standards by NICE and present this information to Acute Trusts MSCC Coordinators and Clinical Leads. We also discussed, in collaboration with Clinical Commissioning Groups, that AHP lead services should have access to this information for patient referrals.

The clinical pathway is outlined here:

Audit Objectives

  1. Right choice of clinical care – to evaluate appropriateness of the referrals into the service based on presence or absence of features from NICE guidelines for ‘early detection’ MSCC (of those with confirmed spinal malignancy).
  2. Right choice of clinical care – to evaluate the effectiveness of the service pathway of those with confirmed spinal malignancy in the overall duration of their care (number of days).
  3. Quality over time – to monitor the impact of service quality improvement initiatives on the appropriateness and effectiveness of the service pathway of patients over time.



  • Identified patients diagnosed with spinal metastases collated from 2012-2016 in continuous annual audits.
  • Evaluation of clinical referral into the service and signs/symptoms at that time to determine appropriateness of acceptance into the service (quality measure against NICE guidelines for ‘early detection’ of MSCC).
  • Evaluation of duration of time from referral to onward referral for hospital oncology.
  • Development of annual service quality assurance or quality improvement strategy was planned with service managers and clinical leads.



Initially this audit formed a quality assurance function, to identify variance with NICE quality standards (quality features: appropriateness and effectiveness). We identified areas for quality improvement from these findings in 2012-13. Several service quality improvement initiatives and training were planned, discussed, implemented and monitored collaboratively with Acute Trust MSCC teams and CCGs.

Summary of annual action plans included:

  • Late 2012 – Training for staff, service improvements including development of urgent care guidelines for clinicians with local hospital clinical leadership
  • Late 2013 – Service improvement developments- gaining access to MSCC coordinator direct without referral via GP (efficient process)
  • Late 2014 – Measure of impact of service improvement noted and follow up training delivered
  • 2015-2016 – Quality assurance measures assessed the ongoing benefit through clinical audit with feedback to Acute Trust MSCC teams and CCGs

MSCC Clinical Audit: Serious Diagnosis Audit Trend 2012-2016


Clinical audit is an effective method for measuring and monitoring clinical quality against standard quality benchmarks (NICE guidelines). We have seen improvements in our clinicians, leaders and patient feedback from this clinical audit that exceeded our original aims. In addition, we have;

  • Used quality assurance tools to identify areas for service improvement
  • Gathered and analysed information to inform change in the patient pathway (analysis)
  • Measured impact of change and maintained quality of care
  • Developed our clinicians’ skills (evident in clinical competences)
  • Adopted a more integrated working with primary care and hospital (acute trust) specialist teams

To download the full version of the poster, click here.


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