Knowledge Natter: Introduction and compliance of surgical safety checklists

RCVS Knowledge:
Welcome to this Knowledge Natter by RCVS Knowledge. Here we have friendly and informal discussions with our Knowledge Award Champions and those who are empowered by Quality
Improvement (QI) in their work. Whether you’re a veterinary surgeon, veterinary nurse, receptionist, or member of management, Quality Improvement will and can positively impact your everyday life. Listen and be inspired.

Julie Gibson:
Hello, I’m Julie Gibson. I’m Quality Improvement Clinical Lead for RCVS Knowledge and I’m
happy to be speaking with my celebrated predecessor, Pam Mosedale today and we’re going to
be discussing all things clinical audit in celebration of Clinical Audit Awareness Week 2025
which is running from the 2nd to the 6th of June.
The purpose of that week really is to promote the positive effects of clinical audit and Quality
Improvement in healthcare. It’s a week-long initiative organised by the Healthcare Quality
Improvement Partnership, the HQIP, in collaboration with the National Quality Improvement
Network.
Now, I don’t think Pam needs much more introduction from me because she’s really the kind
of queen of clinical audit and has done so much in this area and promoting the positive benefits
of clinical audit in the veterinary profession. So without further ado, I’m going to ask Pam if
she would talk to us about what this clinical audit thing actually is, because I know that there
are lots of people wanting to be involved with clinical audit and there are lots of people now in
the veterinary profession that different places really on their clinical audit journey and she’s
got so much experience, I’d just like to hand over to her to kind of ask her about what it is and
why we should be doing it.
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Pam Mosedale
Thanks Julie. Thank you very much for having me today to talk about this. I could talk about
clinical audit till the cows come home as they say. But yeah, clinical audit basically is just about
measuring what you do. That’s all it is. It’s just about people in practice measuring what they
do, seeing where they stand, seeing if they’re doing well or not so well, and then making
changes and measuring again. That’s the crux of the matter. It’s really not rocket science. It’s
really fairly simple. There are different things you can measure. You can measure outcomes.
You can measure the way care is delivered. So outcomes would be outcome audit. The way care
is delivered would be process audit. So that might be how you’re following a guideline or how
you’re complying with a protocol.
It doesn’t have to be great big projects, and it can be quite small projects. I think the way to
start is to talk to your team about it. Ask them what things they might think might need
changing in the practice and as practices get bigger and bigger it’s all well and good to think
you know what you’re doing with various things you might think you know how many bitch
spays have a post-op complication but you ask one person and they say “well I’ve seen a couple”
and you ask somebody else and they say “I’ve seen a couple”. Well, is that two or is that four?
You know, unless you’re measuring, they’re all just opinions, aren’t they? It’s everybody’s
opinion until you actually start measuring. And I think practices that are open to measuring
have to be open to making changes and listening to their team and finding out why things are
as they are. So I think that it really helps with the team spirit and the practice culture.
Julie Gibson
Yeah, and I’m really glad you touched on that because I think clinical audit, always think about,
well, we don’t always, but for a lot of people from my experience, they’re always thinking about
the outcomes for the patients. And of course, that is what we’re ultimately there to do and to
provide the best care that we can within the context that it’s meant. But I’m really glad you
kind of brought in that team spirit as well.
So that’s obviously one benefit that you’ve touched on. Are there any other kind of benefits of
doing clinical audit in veterinary practice that you’ve seen?
Pam Mosedale
Well, as you say, definitely, I think that one of the biggest benefits is team working really. I’ve
found when I’ve done audits in the past that the nursing team especially in my own practice
really embraced audit and ran with it. But there’s obviously massive benefits for the patients.
The benefit for the patients, of outcomes, of course there’s benefits in the care they’re given
but also benefits for owners because if you can tell them when owners say “I’m a bit worried
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about leaving my bitch to be spayed because you know I’m worried about the anaesthetic and
I’m worried about them might be any some complication” or indeed if somebody’s having their
colt cut and they want to know what sort of results you get from that in the equine world. To
be able to actually tell them figures rather than just kind of waffle a little bit about, “oh well
you know it’s a risk and things can go wrong but generally we’re fine”. Much better if you can
say “well, we measure it, we actually measure it and we know that only 0.1 % of animals die
under anaesthetic” or whatever your results are, it’s just an important thing so it can be a
benefit to owners as well.
So yeah, I don’t think there’s a lot of disadvantages as long as it’s implemented well which
means not just doing it without the team knowing it’s happening. If somebody starts to decide
to measure something without telling the team, then it feels like big brothers looking over your
shoulder. It’s got to be a really inclusive thing, as with all Quality Improvement. All Quality
Improvement is a whole team activity and clinical audit needs to be too.
Julie Gibson
So I’m hearing from you there that there’s a real benefit when you’re driving good outcomes
in practice or outcomes that are really beneficial for not just your patients, but for empowering
your team and that clinical audit really has a role. Is that what got you interested in clinical
audit in the first place? I’m really interested to know how you fell into this area or positively
moved towards this area? What stimulated you to do that?
Pam Mosedale
Well, it’s a long story, as they say, and it started quite a long time ago. I was a partner in a
veterinary hospital. When I became a partner in a veterinary hospital, I thought, I want to
know what the veterinary hospitals association are up to and how they’re going to alter the
standards, because it’s going to cost us money, to be perfectly honest with you. So I got
involved in British Veterinary Hospitals Association (BVHA) and went to various BVHA
meetings. One day when I was sitting in a meeting and somebody was talking at length about
the height of coving up the wall in the theatre. It was driving me up the wall, never mind the
coving, and I was thinking, “it’s all very well, we concentrate on buildings and kit, but what
about what goes on in practices? How can we assess that? How can we assess what goes on in
practices?” So foolishly, I actually vocalised this thought at the meeting and said, “why aren’t
we measuring what goes on in practice?” So, you know what happens, don’t you? If you ever
say anything like that, people say, “well, would you like to look into it then?” So, I kind of got
pushed into it that way.
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I started doing a few audits in my own practice, quite simple audits around anaesthetic deaths,
but that’s not a very good audit to do because hopefully they occur so rarely. It’s not a
particularly good subject. But around post-op affections in routine neutering and then our
reception team wanted to get involved and they started auditing client waiting times, there
was a few of those things. Then somebody asked me to present it at a BVHA meeting and then
In Practice asked me to write an article about it. And that was, as far as I know, that was the
first article about clinical audit in the veterinary world. Obviously, there’s a lot of clinical audits
in human health care, and I had borrowed a book from a friend of mine who was a human GP
to find out some stuff about what they were doing. So that’s what got me involved.
Then I was then a Practice Standards inspector for BSAVA and then that got taken over by
RCVS and ultimately, I was Lead Assessor for RCVS. But again, was always the trying to find
out more about the practices, more about what really happened rather than just, it’s important,
obviously buildings and kit are important. Joking aside, they are, but it’s also really important
the things that happen and whether teams know what happens in their practices. So that’s
what got me interested in it really. It was via thinking about standards in practices.
Julie Gibson
Yeah, and just I know most people listening will know who BVHA are, but I think it’s just
important just to clarify who that is for anyone who doesn’t know.
Pam Mosedale
Thank you. I should have done that, Julie. Yes, that was British Veterinary Hospitals
Association because the history of practice standards is that hospitals were all assessed by
British Veterinary Hospitals Association, and ordinary GP practices by BSAVA, I think
everybody knows what BSAVA stands for, and then the two got taken over by RCVS. Everybody
knows what that stands for. Then I got involved with RCVS practice assessment there.
Julie Gibson
Yeah, thanks Pam. I thought it was just something we should clear up for anyone who was
wondering. And just on that note, I think it’d be just nice to ask you about this link between
practice standards and governance and Quality Improvement just while we’re here.
Pam Mosedale
Yeah, well, I was looking because you’d asked me and it was 1998 when I wrote the article and
got thinking more about the bigger subject of clinical governance and then Bradley Viner got
involved in doing lots of work around clinical audit too. He did a professional doctorate with
Middlesex University and his was on clinical audit in veterinary practice. So, he was writing
lots of things about it too.
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And then via the Practice Standard Scheme and the Code of Conduct, clinical governance came
in and clinical governance is that kind of overarching framework of thinking about what you
do and how you can improve it if you need to. One of the tools that clinical governance uses is
clinical audit.
And when clinical governance got put into the Code of Conduct, there was lots of people who
thought, “well, what is this? It sounds a bit big brother”. So, there was lots of work around
explaining clinical governance and clinical audit via that. In Practice Standards Scheme, it says
that it’s in the Code of Conduct and therefore core standards to do some clinical governance.
But then clinical audit was put into the veterinary hospital level and then it was moved to the
GP level in about 2010 or 15. So then lots more practices had to actually do clinical audit.
So I think there’s two ways of looking at it. There’s kind of the carrot and the stick, if you like.
There’s the stick part is that it’s there in the code to do clinical governance and it’s there in
practice standards to do clinical audit. But the carrot bit, in my opinion, is the much more
important one, is that it will actually help your team and it will help your patients if you do
start to look at these things with a view to improving them where necessary. You might
measure something and find you’re absolutely marvellous at it. Again, I wouldn’t forget about
it. I’d audit it again maybe six months or a year later to check you’re still marvellous at it, but
you know it’s not always a negative thing.
Julie Gibson
No, and I love the comment that you made earlier and the suggestion really about rallying the
team together and looking at what people actually want to audit, and it’s more often than not,
people do think about this along the clinical lines, but your example of looking at consent
forms, for example, and perhaps something like prescribing behaviours and checks, that’s also
very important, isn’t it? And I think that’s, I don’t know, from my experience, that’s something
that’s sometimes missed or not always on people’s radar when they’re thinking about auditing,
but a really important thing and actually really important to people doing the work, isn’t it,
about how these processes work. So I’m glad you came to that.
Pam Mosedale
Yes, absolutely. If you think about it, something like estimates is going to be… Poor old
reception team, they’re going to have the people at the desk who are very unhappy, so they
know that that’s an important thing. But maybe also things like history being properly
transferred, all sorts of things which seem like fairly clerical type things are really important
to the running of the practice. It’s anything really that affects the running of the practice and
therefore the care of the patients.
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Julie Gibson
Yeah, absolutely. And as we’re in Clinical Audit Awareness Week, could you share with us a
couple of gems of clinical audit that you’ve seen? We obviously have the RCVS Knowledge
Awards for this, and there are some great examples of that on the RCVS Knowledge website.
But could you tell me a couple of top picks, some of your favourites that have come out of the
work that you’ve seen demonstrated.
Pam Mosedale
Well, there’s so many and that’s the beauty that there’s so many things that you can measure,
and it doesn’t have to be some huge project. It can be really quite small things. I mean, I do
like there’s quite been a few projects around antimicrobial use and reducing antimicrobial use,
which obviously is really important from a one health point of view, but some really simple
ones like there was a cat bite abscess audit, which I really liked. I liked the audit, which was
basically that they were measuring how many cat bite abscesses which didn’t have cellulitis
actually got better without antibiotics. But I really liked how they were reminding the team to
get involved by having a poster up in the consulting room saying, with a picture of a Tomcat
that had been fighting, saying, “I’m not a naughty boy” just to encourage people to actually
remind people. The thing is with audit; you can start off with the team being really enthusiastic
and then it can tail off if you’re not careful. So that’s why don’t think audit should take too long
because it’s hard to keep the enthusiasm going and keep people actually contributing the data.
So I really like that, how they’d involve the whole team in that.
Another really inspirational audit, a recent one, was a trainee nurse, a student nurse, along
with one of the qualified nurses, had instituted an audit around the use of anaesthetic gases
basically, to reduce the carbon footprint of the practice or try to, by using low flow anaesthesia
and changing the circuits they used, etc. and they were so enthusiastic, two who’d done it,
really enthusiastic, and they got the whole team on board. And they then did some very clever
calculations, which were a bit beyond me, but worked out that basically, from the amount of
carbon they saved was equivalent to driving from where they were in Yorkshire to Rome, I
think it was, and back again. So, you know, I mean, the effects can be amazing. So that was a
sustainability audit, really, so there’s so much that can be audited.
But right up to tiny little things like measuring… you can find out that something should have
been measured, like all microchips should have been read of all animals that come in could be
an audit that a charity did. And they looked at the results and one of the charity branches was
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so much lower than the others. But when they actually talked to the people, it was because
there microchip reader didn’t work anymore.
So it can be… doesn’t have to be big complicated things. I used to find that the collecting the
data was the interesting bit, but I really think that discussing it with the team and finding out
why the things are happening is by far the most interesting bit. But then not forgetting to
actually measure again, because if you don’t measure again, you haven’t actually completed
the audit cycle. If you don’t actually re-audit, just measuring once is not the answer. You’ve
got to re-audit.
Julie Gibson
Yeah, absolutely, and I think you’re so right there because you can’t learn from it, can you, if
you can’t see a change or if there is no change, then you can revisit it and think, “well, is there
something else that we need to implement”, can’t we? And I think using those powerful
messages and potentially imagery within the practice and working out what works for your
team is really powerful, isn’t it? I guess, again, you’ve hit the nail on the head in saying that
they don’t have to be big, for want of a better word, fancy or complex projects. Actually, simple
projects are perhaps the most impactful for the team because they can understand what’s being
measured, they can understand why it matters rather than having too many things going on at
the same time that just feels a little bit burdensome to people. I think it’s really important just
to be able to get started with it.
On that note, I think that in terms of people getting started and its Clinical Audit Awareness
Week, as we’ve said, we should think about if there’s someone out there thinking, how do I get
started or how do I maintain some sort of momentum around this? Should we talk about how
they may do that? We’ve certainly got lots of resources at RCVS Knowledge that people could
utilise, and you’ve been involved with a lot of those resources over time, Pam, so do you want
to talk to us about those?
Pam Mosedale
Yes, certainly. I’m quite proud of the resources we’ve got. They’re part of the QI Boxset, which
has got all sorts of Quality Improvement resources as well. But basically, the clinical audit
resources, we’ve got a course, a clinical audit course for anybody starting off. We’ve got a
clinical audit template, so if you’re doing an audit, you can slot things in. It makes you think
about what you need to have thought about, you know, what sort of subject, make sure it’s
measurable, make sure it’s achievable, make sure it’s relevant or all those things and timely.
We’ve got, I say templates, we’ve got walkthrough of a clinical audit, we’ve got very nice clinical
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audit diagram, which makes it all very clear. But also, we’ve got loads of our audit case
examples, including the two I mentioned earlier, which are a fantastic resource.
The only thing I would say is do not try and copy them exactly because those audits were what
worked in that practice at that time. They’re a good way to, for instance, if a practice is going
to start thinking about maybe auditing post-operative temperatures, you know, because postoperative hypothermia can be quite an issue, can’t it? So have a look what other people have
done. I think there’s four or five of those on there and they’re all slightly different. Or if you’re
to audit hand washing, there’s definitely three or four of those. They’re all slightly different.
You can look at them and get some ideas of how to do it in your practice, but then you need to
decide with your team what will work in your practice because clinical audit is not one size fits
all. And the results are only about your practice at the end of the day. They’re not something
that’s generalisable to the rest of the whole profession. You can’t say because this worked here,
this would work everywhere because that would be a research project.
However, there are some things you can participate in where practices can be benchmarked
against each other or … well, basically a benchmark for the whole profession or for a group of
practices and then you can look at how yours compares to that.
Julie Gibson
Yeah, absolutely. And those are available on the RCVS Knowledge website as well. Access to
them and all the information around them as well, which I don’t know if anyone listening, I’m
sure lots of people have used them already. But if you go onto the website, it’s just invaluable
the resources that they have around it, how to use them. And of course, the team at RCVS
Knowledge are available at any time if you just want get in touch if you’re unsure of how to use
it or want some extra support or help with it.
One of the ones that is particularly important for small animal practice and I think a really
good way for people to get started is the National Audit for Small Animal Neutering, a little bit
of a mouthful but we call it the NASAN. It’s free to use of course and it collects data on postoperative complications of neutering in dogs, cats and rabbits, but that is hopefully going to
be extended to other species too in the near future. And it’s anonymised so you can contribute
your data and look at how you’re doing within your own practice and like Pam said
benchmarking it against the data that’s already been collected from a huge number of
practices. And it collects data from across the UK and the Republic of Ireland.
What really struck me about this audit tool is that it doesn’t matter if you just contribute a
really small amount of data. I think working in practice, your so time bound in a lot of ways
and it can just feel really overwhelming. But small animal practices, the majority of small
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animal practices in this country will be doing neuters and they may be doing huge amounts of
them and they don’t know if they have to contribute all their data all at once and you know just
sitting down to get the time to do that can be quite a huge undertaking and it’s okay just to
start by uploading some data isn’t it Pam? I think that that’s the major message there.
Pam Mosedale
Yeah, just get started and then just have a look at the data and see when the benchmark report
comes out, have a look at how your data compares. And it is useful for Practice Standards that
we touched on earlier because you can get a certificate of having contributed data which with
other evidence of having made changes can be really useful when it comes to those kinds of
things.
Julie Gibson
Yeah, I guess, the other thing is that when you have that and you’ve contributed your data,
you’ve got your certificate, you’ve of got in the swing of it, it’s really helpful to just stimulate
people to do that, isn’t it? But we do have some resources that then show you how you can
actually look at that data to make the changes and close that loop, because that’s like a really
important part of it, isn’t it? Like you said, Pam, looking at changes that you may make off the
back of that understanding.
Pam Mosedale
Yeah, absolutely, and the fantastic thing with the NASA is it is whole profession data, a whole
companion animal, part of the profession data. It’s not just the data of one small group or even
a big group. It’s whole profession data. So it’s really interesting and really interesting to see
the trends over time. And over time, more things have been included and different things like
laparoscopy spays, et cetera.
Julie Gibson
Yeah, of course. I think the new benchmark report is out or out very, very soon, and that will
be looking at the data from 2024. So you’ll be to have a look at that. And then actually, the data
that’s been collected ever since 2005 is all there as well. So I think really important stuff and
really useful for practices just to start using it and out of interest to see, you know, what’s
happening profession wide like you said.
So, Pam, just to close, I think it’d be really nice just to talk about where we’re going to be with
this clinical audit in the future. What do you see going forward as you’re sort of not stepping
away from this area, because I know that you won’t be able to and you really, you know, will
maintain a really keen interest in this. But what do you see the future looking like in the
veterinary profession.
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Pam Mosedale
Well, I’d hope that clinical audit becomes more and more a normal part of veterinary practice,
and that people expect it to happen. You know, I’ve talked to students at vet schools and they’re
qualifying, knowing all about it, expecting practices to do it. I think being open to doing it and
being open to making changes as a result of it is so important. Also, as I think I alluded to
earlier, I think there’s going to be pressure from clients as well to know exactly what’s
happening. If you go to lots of hospitals, especially private hospitals, but all hospitals, often
have something in the waiting room that tells you what their infection rates are and what their
post-op or falls in the hospital, all that kind of thing. They measure these things, and they make
them public. I think I’m saying, if we want to have a joint replacement, I’m not quite up to that
stage yet. But then you can look up your surgeon and get their audit results on the NHS
website. So I think it’s an area that’s going to expand more and more. I like the idea of clients
being involved more and more in Quality Improvement generally, not just clinical audit.
And I think we’ve also got to acknowledge the RCVS Knowledge Canine Cruciate Registry
(CCR), which is a client reported outcome measures. It measures client reported outcomes
basically of cruciate surgery so they can follow a dog for the rest of their life. And colleagues
I’ve talked to who’ve been contributing data, have said that clients love it. They love to be
involved; they want to be involved. They want to contribute something so that other people’s
Labradors will actually benefit from what’s happened to their dog, etc. And I think it would
give us fantastic data when we’ve got these things.
So I’m hoping that those kinds of things will happen in other areas, in equine and in other
procedures. And yeah, I just think it’s… the way I think it will go is that it will all become just
much more a normal part of life. Because we want, I think it’s okay at being, it’s great that it’s
in Practice Standards and things, but we don’t want to go down the road that they’ve a little
bit gone down in human medicine where it’s sort of have to do it when you’re doing internships
and things and people collect data but then have to move on so it doesn’t necessarily get acted
on. So I think the most important thing is if you collect some data talk about it and act on it if
it needs acting on and make your changes and decide whether they’re changes you’re going to
keep or not. But you know don’t and think with auditors don’t wait to be perfect you’ll never
be perfect just try it the only way you learn to do it is by doing it
Julie Gibson
That’s great, Pam. I was going to ask you for some take homes, where I think you’ve kind of
rounded off really nicely there. So I think important take homes from our conversation, or me
learning from you as I go on in this role, are that we should be using the data to the best of our
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ability, not just collecting it. Having those conversations and making it about our teams and
our clients. Because it’s clinical audits not just about process, it’s about enabling those
relationships…
Pam Mosedale
…and contribute to the NASAN. That would be my other take home. It’s there, it’s an easy way
to do it, so why not?
Julie Gibson
Absolutely fantastic. It’s been so nice to talk to you Pam today. Thank you for sharing pearls
of wisdom which you have lots and lots of and I’m sure you will be sharing lots more in the
future too. I’m certainly looking forward to keeping in touch with you and learning lots from
you in terms of clinical audits and taking RCVS Knowledge’s supportive of the profession
forward.
Pam Mosedale
Thanks ever so much for talking to me, Julie. I’ve really enjoyed it.
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