Quality Improvement (QI)
What is it?
In the NHS we deliver healthcare to patients, however our system is not perfect. There are always improvements that can be made to the way in which we work which will benefit patients and staff. As clinicians we want to be able to deliver the best care we can to our patients however this is not always easy and is particularly challenging in the complex nature of the NHS
Quality is a degree of excellence in healthcare which encompasses healthcare being safe, effective, patient-centered, timely, efficient and equitable.
Quality improvement is a process which aims to make a difference to patients by improving safety, effectiveness and experience of care by using the understanding of our complex healthcare environment and applying a systematic approach. It requires designing, testing and implementing changes using real time measurement for improvement.
All doctors need to be able to demonstrate a commitment to improving the quality of care we provide in the NHS. Quality improvement is a core component of the CREST form and all postgraduate training curriculums.
Expectations:
At a junior level e.g. SHO you are not expected to lead a project but to learn methodology and start to develop a curiosity in improvement capabilities within the NHS.
Once you become a registrar you are expected to take on a bigger role and potentially start to lead projects within your department.
As a consultant you are expected to be leading projects and supervising junior colleagues with their projects
What skills do you need?
Enthusiasm
Optimism
Curiosity
Perseverance
Interpersonal skills
Teamwork
Time management skills
The Difference between Audit, Quality Improvement and Research
Most doctors have been involved in audit, quality improvement or research at some point in their careers although the terms can often be confused and used incorrectly.
Audit: How are we currently performing?
Audit, in simple terms, compares the current practices in the department to an agreed standard of care which is often set out in local, national or international guidelines.
Quality Improvement: How do we improve our performance?
Quality improvement does not require a set standard, however describes the process of change when trying to improve patient care. It identifies a problem (which may have been identified during an audit) and works on processes within the department to improve patient care. Some quality improvement projects directly impact patient care by improving patient care e.g. falls prevention strategies, however others indirectly improve patient care by improving the systems that we work with. Quality improvement can involve a breadth of topics from preventing adverse events, reducing human factors, sustainability, education, wellbeing and more.
Research: What new knowledge can we discover?
Research seeks to find an answer about the best options to improve health and care for all of us. It starts with a hypothesis about which the answer is unknown or not fully understood and then utilises a process to try to answer this question. It can be quantitative or qualitative. It also often involves an ethics process for participants.
Origins of QI
Modern QI methods come from the work of Mr W. Edwards Deming, He was an engineer and statistician who after World War II championed the work of an earlier statistician, Walter Shewhart. This work focused on industrial quality control, and the use of the ‘Shewhart Cycle’ to maximize learning from changes to processes. Shewhart Cycles became PDSA (Plan, Do, Study, Act) cycles.
A group of individuals who had studied under Deming formed Associates for Process Improvement (API) and worked with other organisations to improve their processes. API built upon these by developing the Model for Improvement (MFI), a simple yet effective tool to bring about positive change.
Although the original methods were designed for industry, they can in theory be used to successfully improve any area. They are particularly useful in complex systems such as healthcare where the way to improve isn’t always obvious and there may be multiple influencing factors.
Don Berwick was the first person to establish the use of Deming’s methods in healthcare. He was a paediatrician who in 1991 founded the Institute for Healthcare Improvement (IHI) in Boston, USA.
Quality Improvement Processes and Tools
Most QI projects require the use of methodology to show the process that you have completed. This also helps you to understand the system in which you work more and where its flaws are. Not all tools are needed for every project but you might find some of these helpful.
8 Stage Change Model - The Steps of QI
Driver Diagrams
Force Field Analysis
Step Back Process
Model for Improvement and PDSA cycles
Run Charts and Data Collection
Completion of your Quality Improvement Project
Following completion of your Quality Improvement Project you may wish to present your project at a conference. This can be useful to gain points for applications and adds another skill into your repertoire. You will need to write up your project including the tools that have been used to demonstrate the project aims, drivers, and measures. Most conferences will ask you to submit an abstract of your project to them for evaluation. If successful you may be asked to provide a poster or oral presentation of your project. It is useful to discuss this with your supervisor prior to presenting as they can check your poster/presentation and provide feedback that may be useful.
Starting a Quality Improvement Project
Identifying a problem:
The easiest way to identify the problem is to think about the job that you currently do and what might make your job easier or improve care for the patients that you are seeing.
There are a multitude of projects that could be started but the project you choose will be determined by your personal interests, values and past experiences. Any project is easier to complete if you have a personal interest in its completion as your motivation will be higher.
Think about what motivates you, what your career goals are and whether a project can be tailored to this even if you aren’t working in that department or specialty.
Some ideas:
Interest in respiratory medicine - may want to improve asthma care for patients either in emergency or inpatient settings
Built relationship with a patient with sickle cell who struggled with pain management - may want to develop sickle cell pain pathway
Previous prescribing error - develop a process so the prescription is easier to complete, errors are avoided
Minor annoyances e.g. finding equipment - develop packs/grab-bags to find equipment more easily
Use national guidelines to help you identify gaps in patient care e.g. NICE CT head guidelines for trauma
Define the aim:
Think about what you are trying to achieve with your project. Be SMART!
Specific:
Consider scope of the project:
What do you really want to target? How many aspects of care are you trying to improve? This should only be 1 or 2.
Consider the scale of the project:
How many patients will be affected by your project? Does it affect just your department or is there crossover into another area?
Measurable:
Your aim must have something measurable. Try to set a goal % to improve something by rather than a vague measure but keep the % reasonable i.e. it would be unreasonable to expect a process to suddenly happen 100% of the time when it currently only happens 5% of the time.
Achievable:
Is your end outcome achievable based on your current understanding of your workplace? For example, ensuring patients have pain scores recorded every 15 mins is unlikely to be achievable unless it is limited to a particular time frame.
Realistic:
Is it realistic that the changes you envisage could be achieved? For example, whilst theoretically possible that every patient with chest pain receives a CT scan on arrival into an Emergency Department, it would be unrealistic to expect this to be achieved.
Timely:
Set a reasonable date by which you feel the changes could be made by. Remember it may take longer than you initially think to change the way in which colleagues are currently working.
Small changes are more likely to be successful initially, so even if your project involves big changes, the aim is to start small and then grow the project.
Building a team:
Whilst QI projects can be undertaken by an individual person, it is often easier to make a difference with a team-based approach. Talk to colleagues about your project idea, quite often you’ll find others who are interested in what you’re working on or trying to achieve and then bring them on board to help with the project. Involve other healthcare professionals in your department to gain multidisciplinary views and also to gain a larger set of opinions about possible strategies for improvement.
Engage stakeholders:
Think about who your key stakeholders are with the project. Some of these may be obvious: patients, doctors, nurses, allied healthcare professionals etc. However it is worth considering the wider hospital stakeholders:
Other departments/specialties
Finance
IT
Legal
Patient Advice and Liaison Services
Local Audit Departments
Gain support:
Remember with any project you will need the backing of your department before you can make any changes so liaise with your consultant to ensure that the project is viable before you start. Most hospitals will also require you to register the project with the Audit Department so that you can receive their support with your project as well.
