Enhancing clinician confidence in ocular examinations via clinical audit

Hi, my name is Amy Wheeler and I’m a Regional Clinical Lead at CVS. I work closely with our group of practices to support clinical development and lead on quality improvement initiatives. One of our recent focus areas has been ophthalmology, an area that frequently comes up in practice and is critical to patient wellbeing, particularly where early diagnosis can prevent long-term vision loss.

In 2023, we launched a quality improvement project aimed at improving how we approach eye cases. Our goal was to introduce more structure around diagnostics when prescribing ocular medications and to reduce the risk of misdiagnosis, complications and unnecessary suffering. We initially focused on increasing the use of what we called a full eye examination, which included a Shermer tear test, intraocular pressure measurement and fluorescein staining every time eye medication was prescribed.

We audited cases across participating practices and found that only 4% of patients receiving eye medication also had a full eye examination documented. Interestingly, this was still four times higher than in non-enrolled practices where it was just 1%.

However, even in our enrolled practices, some of which had chosen ophthalmology as their own clinical excellence focus, engagement was still limited.

We gathered feedback and it was clear that a rigid requirement for a full exam every time was acting as a barrier. Clinicians told us they needed more flexibility and a more contextualised approach, so we changed our direction. For the 2024 to 2025 cycle, we shifted to a contextualised care approach, encouraging clinicians to choose the most appropriate test or combination of tests for each patient.

Alongside that, we provided updated guidance, in-practice training and practical resources. The result was a huge jump in engagement. 48.8% of treated patients received an appropriate ocular diagnostic compared to just 4% the year before. And this was on average 5% higher than those clinics that hadn’t enrolled on this project. And in some months was up to 20% higher.

This directly supported improvements in several domains of quality veterinary care, including effectiveness, safety, patient-centredness and team wellbeing. Importantly, early diagnosis of some of these conditions like glaucoma and ulcers and dry eye result in fewer complications down the line.

The success of the project came from teamwork. We involved clinicians, and nurses from the start and gathered honest feedback and adapted our project based on what they told us. Practice teams took ownership of the project and we worked closely with nurses, vets and support staff. By offering flexible tools and building on existing skills rather than dictating rules, we created a sense of shared purpose and practicality. So was there anything surprising?

Well yes, actually what surprised me most was that even teams who had selected ophthalmology as their own improvement area found that the full eye examination model was too restrictive. It reminded us that even well-intended standards can become blockers if they’re not achievable. Clinicians wanted support to make good decisions, not follow rigid checklists. And that insight was key to designing a better approach that worked in a real life setting.

So if you’re thinking about improving care in a specific clinical area, I’d say start by looking at your data and what you’re doing now and listen to your team. Keep it simple and make sure the changes are realistic in day-to-day practice. This project showed that when clinicians were supported and not micromanaged, you can get better engagement, better outcomes and happier teams. Contextualised care isn’t about lowering standards, it’s about raising them in a sustainable and patient-focused way.