Significant Event Analysis Research Articles

The Primary Care Respiratory Society-UK Quality Award: development and piloting of quality standards for primary care respiratory medicine.

In an attempt to improve the standards of primary respiratory care in the UK, the Primary Care Respiratory Society-UK (PCRS-UK), in conjunction with other leading respiratory-interested health professional and patient groups, has devised a General Practice Quality Award for Respiratory Medicine. The Award is divided into three modules separated into a total of seven clinical standards (in parentheses): ‘Clinical’ (prevention, early and accurate diagnosis, acute care, chronic care); ‘Organisational’ (equipment); and ‘The Practice Team’ (practice learning needs, educational strategy). Assessment is by submission of a written portfolio of 37 pieces of evidence including audit, reflective learning, patient feedback, and significant event analyses. The Award was piloted in five respiratory-interested practices across the UK. The practices reported improvements in practice organisation, practice teamwork, improved process measures such as improvement in quality of spirometry, and improved patient access to patient services. All practices in the UK are being invited to apply for the Award in 2013. It is hoped that it will provide a framework and stimulus for provision of high-quality primary respiratory care, not only in the UK, but also some aspects of the Award may be applicable on a wider international scale.

震災支援者のストレスマネージメントおけるSignificant Event Analysisの有用性について－非盲検化ランダム化比較試験－

【目的】震災派遣医師のストレスマネジメントにおけるSignificant Event Analysis（SEA）の有効性を検討する。【対象と方法】自治医科大学同窓会東日本大震災支援プロジェクトにより被災地（東北地方）に派遣された医師67名である。SEA施行群（SEA群）と非施行群（対照群）に無作為に割り付け，SEA群には震災派遣から帰還4週間後に質問紙にてSEA調査を行った。【主要なアウトカム評価】改訂出来事インパクト尺度（IES-R），K6質問票を用いて，帰還4週間後（SEA調査前）と8週間後の改善度を調査した。【結果】IES-Rの改善度は，SEA群: 1.27±5.08［平均±標準偏差］，対照群: 2.43±4.05であり，p=0.30と有意な差を認めなかった。K6質問票の改善度は，SEA群: 1.83±2.68，対照群: 0.76±3.01であり，p=0.13と有意な差を認めなかった。【結語】ボランティアで被災地支援に行った医師にSEAを行うことは，ストレスの軽減につながらない。

From cottage industry to post-industrial care? The RCGP response to the King's Fund report on the quality of care in general practice

> ‘Most of the care provided by general practice is good … however, there are variations in performance and some quality gaps which need to be addressed …’ With these words, the King's Fund report sets out the challenge for general practice in the 21st century.1 This report is a product of an independent inquiry and represents the most extensive examination of quality in general practice for many years. In his foreword, Sir Ian Kennedy describes general practice as ‘not given to self-reflection and self-challenge’. Little evidence is provided for this contention. General practice has been at the forefront of the profession in promoting reflective practice as part of its specialist training programmes. General practice was an early adopter of clinical audit and significant event analysis to improve clinical care.2 Not for the first time, preconceived ideas about general practice have run ahead of the evidence, and such assertions should not go unchallenged! The recommendations of the report have been categorised into five key themes as the basis for the Royal College of General Practitioners’ (RCGPs’) response. General practice must ‘own’ the quality agenda and provide effective clinical leadership. College members are encouraged to consider professional leadership roles over the course of their careers and the RCGP is committed to providing opportunities to support them.3 The RCGP Leadership Programme helps GPs develop skills in thinking strategically, leading, persuading, and challenging colleagues, and working collaboratively. Awareness must be developed among GPs and their colleagues of the extent of the variation in clinical practice and the ‘gaps’ in quality. Quality improvement needs to be understood as a key component of the ‘core business’ of general practice. All professionals must be more open to scrutiny by their peers and by their patients, and quality data from practices should be widely available. …

Patient Feedback Via a National Registry Could Improve Physicians’ CME

To the Editor: We welcome your review by Reinders1 highlighting the limited data supporting the effectiveness of patient feedback on improving physicians’ consultation skills. To address this, we seek to highlight the potential role of registry data from medical licensing authorities using patient feedback as a mandatory requirement for physician training and revalidation.2 This process has the potential to further research the reliability, validity, and delivery of patient feedback tools. We acknowledge the author’s recognition that feedback is an essential part of medical education as supported by the wider literature.3 We propose the research agenda should focus on not if, but how to implement patient feedback. In the United Kingdom, doctors’ performance data are collected in a national registry for the purposes of continued medical licensing and revalidation. This registry includes standardized patient feedback questionnaires in addition to other sources of physician performance such as workplace-based assessments and significant event analysis. Analysis of a large cohort of patient feedback data in this setting may identify previously unidentified predictors of future observed or actual performance. For example, problems communicating risk identified from patient feedback may correlate with a particular adverse clinical event. These data could then support early intervention by supervising physicians to address problems in a format that is likely to have improved face validity for trainees. This process can then form the basis for the iterative development and quality improvement of patient feedback mechanisms. To conclude, feedback is an essential component of improving continuing medical education, and patient perceptions should be no exception. We propose that further research should use national licensing registries with the ability to triangulate other measurements of physicians’ performance. Christian H. Hariman, MBChB, MRCP Clinical teaching fellow, University Hospital Coventry & Warwickshire, Coventry, United Kingdom; [email protected] James Bateman, MBChB, MRCP, PGA MedEd Arthritis Research UK education research fellow, Warwick University, Warwick, United Kingdom. Jack Bond, BMBS, MRCP Clinical teaching fellow, University Hospital Coventry & Warwickshire, Coventry, United Kingdom.

The gold standards framework: an audit of local practice from a hospice perspective

The Gold Standards Framework (GSF), developed in 2000, has been an important resource designed to strengthen the organisation and quality of primary palliative care. The aim of this audit was...

Room for improvement? Leadership, innovation culture and uptake of quality improvement methods in general practice

Leadership and innovation are currently seen as essential elements for the development and maintenance of high-quality care. Little is known about the relationship between leadership and culture of innovation and the extent to which quality improvement methods are used in general practice. This study aimed to assess the relationship between leadership behaviour, culture of innovation and adoption of quality improvement methods in general practice. Self-administered postal questionnaires were sent to general practitioner quality improvement leads in one county in the UK between June and December 2007. The questionnaire consisted of background information, a 12-item scale to assess leadership behaviour, a seven-dimension self-rating scale for culture of innovation and questions on current use of quality improvement tools and techniques. Sixty-three completed questionnaires (62%) were returned. Leadership behaviours were not commonly reported. Most practices reported a positive culture of innovation, featuring relationship most strongly, followed by targets and information but rated lower on other dimensions of rewards, risk and resources. There was a significant positive correlation between leadership behaviour and the culture of innovation (r = 0.57; P < 0.001). Apart from clinical audit and significant event analysis, quality improvement methods were not adopted by most participating practices. Leadership behaviours were infrequently reported and this was associated with a limited culture of innovation in participating general practices. There was little use of quality improvement methods beyond clinical and significant event audit. Practices need support to enhance leadership skills, encourage innovation and develop quality improvement skills if improvements in health care are to accelerate.

Encouraging students to develop lifelong learning.

Lifelong learning is a skill that is required of medical school graduates. In the foreword of the GMC's Tomorrows Doctors 2009, Professor Peter Rubin states that: > ‘Today's undergraduates — tomorrow's doctors — will see huge changes in medical practice … Basic knowledge and skills, while fundamentally important, will not be enough on their own. Medical students must be inspired to learn about medicine in all its aspects so as to serve patients and become the doctors of the future.’1 The outcomes for the graduates set out by the GMC include the ability to acquire, assess, and apply and integrate new knowledge and the establishment of the foundations for lifelong learning and continuing professional development. In my experience as an undergraduate primary care course organiser, students are driven to acquire new knowledge and skills, but seem less motivated to develop their skills for lifelong learning. In line with GMC requirements, one of the aims of the undergraduate medical course should be to help students develop the skills of lifelong learning. It's over 30 years since Knowles first described the concept of adult learning and since then many other theories of adult learning have been developed. Knowles first defined andragogy in 1975 as ‘the art and science of helping adults learn’.2 He set out seven principles of adult learning. These are establishing an effective learning environment, involving learners in curriculum planning, diagnosing their own learning needs and formulating their own learning objectives, encouraging learners to identify resources, supporting learners in carrying out their learning plan, and involving learners in evaluating their own learning. In 1975 Kolb and Fry3 described the cycle of experiential learning. This is commonly used in practice as the basis for significant event analysis. In 1976 Marton and Saljo4–5 defined deep and surface …

地域医療必修実習における"Significant Event Analysis (SEA) を用いた振り返り"の検討

地域医療必修実習における"Significant Event Analysis (SEA) を用いた振り返り"の検討

Significant event analysis: a comparative study of knowledge, process and attitudes in primary care

Significant event analysis (SEA) is now well established in UK primary care. Previously, considerable variation has been reported in the knowledge, skills and attitudes of general practitioners undertaking SEA. Little is known about the wider team's understanding, participation or perceptions. We therefore aimed to determine the awareness, degree of analysis and perceived risk of recurrence of a recent significant event, types of discussion forums, staff groups' participation and perceived barriers. Comparisons were made with a 2003 survey and significant changes described. A postal questionnaire survey was undertaken of a random selection of general practice team members in National Health Service Greater Glasgow in 2008/9. In total, 375/711 respondents (53%) from 111 practices participated. The vast majority was aware of a recent significant event, 29% reported not implementing a change and 23% perceived the risk of recurrence as moderate to high. Administrative and community-based staff were infrequently involved in meetings. Dedicated significant event meetings remain uncommon (P = 0.06). Perceptions improved since 2003, but lack of time remained a concern. This survey was the first known attempt to include all members of the primary care team while studying SEA. Awareness and analysis levels were high, but only lead to sustainable improvement of care quality and clinical safety if teams implement change. Greater use should be made of dedicated SEA meetings and participation of all staff groups increased to gain full benefits. Lack of time can be managed pragmatically by prioritizing events based on their perceived severity, potential for change and potential team involvement.

Safer pharmacy practice: a preliminary study of significant event analysis and peer feedback

The aim was to investigate the effectiveness of significant event analyses (SEAs) undertaken by pharmacists as judged by a new system of independent peer feedback. The setting was a convenience sample of 37 pharmacists working in community pharmacy, secondary care and academic settings in NHS Scotland. Preliminary study involved the content analysis of pharmacists' SEAs and written feedback reports, which were generated by pharmacists trained in using a validated instrument to facilitate peer feedback. The content of reports and feedback letters were systematically coded and categorised by identifying and quantifying key words and phrases. Data collected included the range and severity of significant events identified; the reported reasons for the events occurring; types of learning needs identified; action(s) taken; and learning issues raised by peer feedback. A total of 37 pharmacists submitted 43 SEA reports during the study period. All events submitted were classified as having a negative impact on the quality and safety of patient care. Most events related to prescribing, dispensing, administration, communication and patient-/relative-centred issues. Patients reportedly came to harm in 13% of cases. Sixty-three per cent of reported learning needs related to personal awareness/responsibilities when undertaking work tasks, and 58% of implemented change involved amending existing protocols or introducing new procedures. Seventy per cent of SEAs were judged to be 'satisfactory' by the peer reviewers. The effectiveness of change implementation and providing a clear description of an event were highlighted as key issues which required improvement in those event analyses judged to be 'unsatisfactory'. The findings demonstrate that most pharmacists in this study were able to apply SEA in a satisfactory manner by demonstrating reflective learning, undertaking insightful analyses and implementing necessary change. SEA and peer feedback may have a potential role to play in enhancing the quality and safety of pharmacy practices.

Developing self-assessment skills amongst doctors in Nepal

Background: Accurate self-assessment is essential to direct life-long learning. Most research on self-assessment is from the West. This study takes place in Kathmandu, Nepal.Aim: To develop tools to aid the development of self-assessment skills in Nepali doctors.Methods: Fifteen doctors were asked to complete three self-assessment tasks per month over a 6-month period; one mini-clinical evaluation exercise, one clinical case review and one significant event analysis. Self-assessment was compared with mentor assessment for each task. Changes over time for each individual were noted. Results were analyzed using SPSS 10.0. Self and tutor scores were compared using Pearson’s correlation coefficient. Reliability of the tools was assessed using Cronbach’s Alpha. Participants completed a qualitative questionnaire regarding each tool.Results: All three tools had high content and face validity, as well as reliability. The use of the “intra individual” approach, with multiple assessments over time demonstrated that most doctors were able to accurately self-assess in some areas. Feedback from a senior tutor was vital. Doctors appreciated feedback that was immediate, specific and delivered in a safe environment. Even where self-assessment was less accurate, the process itself helped to develop awareness of key learning issues.Conclusions: These self-assessment tools are feasible, reliable and valid for the hospital setting in Nepal.

Training the trainer in general practice: the perceived value of independent peer feedback for learning activities

To complete the compulsory training course for prospective GP trainers in Scotland, participants must submit criterion audit and significant event analysis reports and a video of six consultations for independent review by trained peers. This study aimed to determine if feedback provided on these learning activities, using the NHS Education for Scotland peer review model, was perceived to be feasible and acceptable and to have an educational impact. A mixed methods approach used data from interviews to inform the development of a questionnaire which was sent to all course participants between 2005 and 2007. The number of questionnaires returned was 55/65 (85%). Peer feedback for learning activities was reported to be feasible and acceptable to participating GPs. The number of participants who scored greater or equal to four out of seven in a statement relating to perceived improvements in practice as a result of peer feedback was 37/55 for criterion audit, 42/55 for significant event analysis and 46/55 for videoed consultations. Mean perceived knowledge and skills ratings improved by 1.2 (P < 0.001) for criterion audit, 1.0 (P < 0.001) for significant event analysis and 0.6 (P < 0.001) for video of consulting. The peer feedback model utilised was perceived to be feasible, acceptable and educationally valuable in the learning and development of potential GP trainers in this survey.

Safer pharmacy practice: a preliminary study of significant event analysis and peer feedback

The aim was to investigate the effectiveness of significant event analyses (SEAs) undertaken by pharmacists as judged by a new system of independent peer feedback. The setting was a convenience sample of 37 pharmacists working in community pharmacy, secondary care and academic settings in NHS Scotland. Preliminary study involved the content analysis of pharmacists' SEAs and written feedback reports, which were generated by pharmacists trained in using a validated instrument to facilitate peer feedback. The content of reports and feedback letters were systematically coded and categorised by identifying and quantifying key words and phrases. Data collected included the range and severity of significant events identified; the reported reasons for the events occurring; types of learning needs identified; action(s) taken; and learning issues raised by peer feedback. A total of 37 pharmacists submitted 43 SEA reports during the study period. All events submitted were classified as having a negative impact on the quality and safety of patient care. Most events related to prescribing, dispensing, administration, communication and patient-/relative-centred issues. Patients reportedly came to harm in 13% of cases. Sixty-three per cent of reported learning needs related to personal awareness/ responsibilities when undertaking work tasks, and 58% of implemented change involved amending existing protocols or introducing new procedures. Seventy per cent of SEAs were judged to be ‘satisfactory’ by the peer reviewers. The effectiveness of change implementation and providing a clear description of an event were highlighted as key issues which required improvement in those event analyses judged to be ‘unsatisfactory’. The findings demonstrate that most pharmacists in this study were able to apply SEA in a satisfactory manner by demonstrating reflective learning, undertaking insightful analyses and implementing necessary change. SEA and peer feedback may have a potential role to play in enhancing the quality and safety of pharmacy practices.

Portfolios and Personal Development Plans

The ePortfolio—love it or loathe it—is an integral part of the workplace-based assessment, it is now a fact of life for general practice trainees. It is also preparation for the appraisal system for qualified GPs, which is heavily reliant upon portfolios of evidence and the creation of personal development plans (or PDPs). Such reliance is only likely to increase with the proposed new revalidation system, which is currently expected to be introduced in 2010–11. Given this context, it is wise for GP trainees to learn how to use these tools to best effect, not only to provide robust evidence of good practice but also to aid personal development. This article aims to describe the way in which PDPs and portfolios can be best employed during your years as a trainee, equipping you with useful skills for a career in general practice. Although the use of tools such as significant event analysis, audit and the consultation observation tool (COT) and case-based discussion, assessments are all important reflective components of the ePortfolio, they will not be discussed in depth in this article.

Independent feedback on clinical audit performance: a multi‐professional pilot study

PurposeThe purpose of this paper is to investigate the acceptability and educational impact of independent feedback on the clinical audit performance of different groups of healthcare professionals by trained colleagues.Design/methodology/approachThis is a pilot study involving review of the criterion audit and significant event analysis (SEA) attempts of west of Scotland dentists, pharmacists, physiotherapists, practice managers and nurse practitioners by trained colleagues using validated instruments. Audit, SEA and feedback reports were content‐analysed. Data on pre‐ and post‐study attitudes, experiences and knowledge levels were collected by questionnaire. T‐tests for differences in mean group scores were calculated, along with 95 per cent confidence intervals for mean differences. A difference in mean scores of 1.0 or greater would be indicative of educational gain.FindingsA total of 34 participants submitted 54 audit and SEA reports, with 20 submitting both (58.9 per cent). In total, 14/20 audits (75.0 per cent) and 26/34 SEAs (76.5 per cent) contained evidence of appropriate learning needs and action(s) implemented for healthcare improvement. Feedback focused on knowledge and skills in applying audit methods; demonstrating insight into deficiencies; highlighting appropriate learning needs; and implementing change. Audit knowledge and skill scores increased by a mean difference of ≥1.0 for most stages of audit and SEA method (p&lt;0.001). Strong agreement on the value of independent feedback on clinical audit was reported.Research limitations/implicationsThe study highlights some of the difficulties in applying audit methods across professions and highlights the added value of feedback by trained colleagues, but is limited in size.Practical implicationsIntegrating clinical audit and peer feedback with continuing professional development obligations may facilitate greater engagement and more effective quality improvement, but will require a policy change and additional resource.Originality/valueThis small study provides further evidence of the acceptability and educational impact of independent feedback on clinical audit performance for healthcare professionals.

Verifying appraisal evidence using feedback from trained peers: views and experiences of Scottish GP appraisers

GP appraisal is currently considered inadequate because it lacks robustness. Objective assessment of appraisal evidence is needed to enable judgements on professional performance to be made. To determine GP appraisers' views of the acceptability, feasibility, and educational impact of external peer feedback received on three core appraisal activities undertaken as part of this study. Independent peer review and cross-sectional postal questionnaire study. NHS Scotland. One of three core appraisal activities (criterion audit, significant event analysis, or video of consultations) was undertaken by GP appraisers and subjected to peer review by trained colleagues. A follow-up postal questionnaire elicited participants' views on the potential acceptability, feasibility, and educational impact of this approach. Of 164 appraisers, 80 agreed to participate; 67/80 (84%) submitted one of three appraisal materials for peer review and returned completed questionnaires. For significant event analyses (n = 44), most responders believed the peer feedback method was feasible (100%) and fair (92.5%) and would add value to appraisal (95.5%). Peer feedback on criterion audits (n = 15) was believed to be acceptable and fair (93.3%) and it was thought it would be a useful educational tool (100%). Completing a consultation video (n = 8) was perceived to be feasible as part of normal general practice (n = 5). It was unanimously agreed that assessment of videos by peers has educational impact and would help improve appraisal. This group of GP appraisers strongly supported the role of external and independent feedback by trained peers as one approach to strengthening the existing appraisal process.

External feedback in general practice: a focus group study of trained peer reviewers of significant event analyses

Peer feedback is well placed to play a key role in satisfying educational and governance standards in general practice. Although the participation of general practitioners (GPs) as reviewers of evidence will be crucial to the process, the professional, practical and emotional issues associated with peer review are largely unknown. This study explored the experiences of GP reviewers who make educational judgements on colleagues' significant event analyses (SEAs) in an established peer feedback system. Focus groups of trained GP peer reviewers in the west of Scotland. Interviews were taped, transcribed and analysed for content. Consensus on the value of feedback in improving SEA attempts by colleagues was apparent, but there was disagreement and discomfort about making a dichotomous 'satisfactory' or 'unsatisfactory' judgement. Differing views on how peer feedback should be used to compliment the appraisal process were described. Some concern was expressed about professional and legal obligations to colleagues and to patients seriously harmed as a result of significant events. Regular training of peer reviewers using several different educational methods was thought essential in enhancing or maintaining their skills. Involvement of the participants in the development of the feedback instrument and the peer review system was highly valued and motivating. Acting as a peer reviewer is perceived by this group of GPs to be an important professional duty. However, the difficulties, emotions and tensions they experience when making professional judgements on aspects of colleagues' work need to be considered when developing a feasible and rigorous system of educational feedback. This is especially important if peer review is to facilitate the 'external verification' of evidence for appraisal and governance.

The Peer Review Pilot Project: A Potential System to Support GP Appraisal in Nhs Scotland?

GP appraisal may, in future, have to include objective and verifiable elements. This condition could be achieved by developing peer review of core areas of clinical practice. The setting for the study was two regions of NHS Education for Scotland (NES) without existing peer review systems (Figure 1). The South East region was further divided into South and East areas. A triangulation methodology was adopted to reflect the perspectives of peer reviewers, GPs submitting materials and the GPs appraising them (Figure 2). Outcomes measures included peer reviewers' feedback, learning needs identified by peer review, feedback from contributors and appraisers' perception of making judgements within GP appraisal. 1 Peer reviewers were recruited, trained and allocated to provide feedback on significant event analysis (SEA), criterion audit or video consultation submitted by professional colleagues. 2 GP appraisers voluntarily submitted materials for peer review then commented on feedback provided by peer reviewers. 3 A focus group of appraisers examined issues relating to professional judgement and national standards within appraisal. 4 All 15 peer reviewers recruited considered the project successful. Peer reviewers thought the model piloted could be delivered nationally if adequately resourced and supported by GPs. 5 Twenty six items (14 SEAs, nine audits and three videos) were submitted for peer review, which demonstrated moderate or high levels of learning need among GP participants. 6 In the focus group, most appraisers expressed difficulty making 'professional judgements' within appraisal but demonstrated a clear willingness to accept peer-reviewed material as evidence for discussion and development. Appraisers identified a range of educational material with the potential to conform to a national standard. There is potential for peer review to contribute to the development of objective and verifiable elements in GP appraisal, encouraging GPs to achieve agreed educational standards independent of the appraisal process. This small study suggests that a national system of peer review to support GP appraisal may be desirable among relevant stakeholders and should be explored further. Additional resources would clearly be required. A comparative review of different systems in other countries suggests further research is necessary to provide greater evidence of feasibility, acceptability and educational benefit of such a system in the UK.

Acceptability and educational impact of a peer feedback model for significant event analysis

A model of independent, external review of significant event analysis by trained peers was introduced by NHS Scotland in 1998 to support the learning needs of general practitioners (GPs). Engagement with this feedback model has increased over time, but participants' views and experiences are largely unknown and there is limited evidence of its educational impact. This is important if external feedback is to play a potential role in appraisal and future revalidation. The study aimed to explore aspects of the acceptability and educational impact of this external feedback model with participating GPs. Semi-structured interviews were carried out with nine GPs. Participants were sampled to reflect their level of learning need (low, moderate or high) to gain a range of views and experiences. Transcribed interviews were analysed for content. This system of external peer feedback is generally acceptable to participants. It complemented and enhanced the appraisal process. External feedback had positive educational outcomes, particularly in imparting technical knowledge on how to analyse significant events. Training issues for peer reviewers were suggested that would further enhance the educational gain from participation. There was disagreement over whether this type of feedback could or should be used as supporting evidence of the quality of doctors' work to educational and regulatory authorities. The findings add to the evidence for the acceptability and educational impact of external review by trained peers. Aligning such a model with the current national appraisal system may provide GPs with a more robust demonstration of participation in reflective learning.

Judging the quality of clinical audit by general practitioners: a pilot study comparing the assessments of medical peers and NHS audit specialists

Clinical audit informs general practitioner (GP) appraisal and will provide evidence of performance for revalidation in the UK. However, objective evidence is now required. An established peer assessment system may offer an educational solution for making objective judgements on clinical audit quality. National Health Service (NHS) clinical audit specialists could potentially support this system if their audit assessments were comparable with established medical peer assessors. The study aimed to quantify differences between clinical audit specialists and medical peer assessors in their assessments of clinical audit projects. A comparison study of the assessment outcomes of clinical audit reports by two groups using appropriate assessment instruments was conducted. Mean scores were compared and 95% confidence intervals (CIs) and limits of agreement calculated. A two-point mean difference would be relevant. Twelve significant event analysis (SEA) reports and 12 criterion audit projects were assessed by 11 experienced GP assessors and 10 NHS audit specialist novice assessors. For SEA, the mean score difference between groups was <1.0. The 95% CI for bias was -0.1 to 0.5 (P = 0.14). Limits of agreement ranged from -0.7 to 1.2. For criterion audit, a mean score difference of <or=1.0 was calculated for seven projects and scores between 1.1 and 1.9 for four. The 95% CI for bias was 0.8 to 1.5 (P < 0.001). Limits of agreement ranged from -2.5 to -0.0. The study findings suggest that a sample of NHS clinical audit specialists can give numerically accurate feedback scores to GPs on the quality of their clinical audit activity compared with established peer assessors as part of the model outlined.