Quality Improvement

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 “Constant improvement in the quality of care we provide for our patients lies at the very heart of what we do in the Emergency Department”

Taj Hassan, RCEM President

Quality Improvement is about continually working to improve the quality of patient care. Using recognised methods, tools and techniques we aim to provide patient care that is safer, timelier, more efficient, more effective, more equitable and more patient centred. Improvement to the quality of care will benefit your patients, staff and department.

How is QI different from Clinical audit?

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Clinical Audit, or Quality Assurance, assesses if we have met or maintained a certain clinical standard but has limited ability to improve patient care and organisational culture.

Quality Improvement involves making changes to improve the quality of patient care. Quality improvement projects typically have a faster turnaround during which multiple ideas can be trialed, discarded if ineffective, or adopted if useful. Quality improvement projects are often more concerned with engagement of the team, changing behaviour and the culture of the institution or department in which patients are being cared for.


How to start a Quality improvement project

Define the problem

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Is there something you have noticed in your department that you think could be done better? What is the problem and how might this be improved?

You may have baseline data or evidence to show that improvement is required.

Ask for help

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At St Mungos we have a new QI team who are here to help. Your department is likely to have someone who is responsible for audit and QI. Discuss with them early to get the help you need to get your project off the ground and to ensure that someone else has not already started this work.

Engage a team

Think about how you are going to make your changes and anyone who might be involved in your patients’ journey e.g. Nursing staff, medical staff, radiographers, porters, in-patient specialties etc. Most importantly - ask your patients! What is their opinion of the current system and what matters to them?

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Try to meet as a group and walk through the patients’ journey. This is called Process Mapping. This will give you a clearer idea of the current system and highlight any problems or inefficiencies within the system.

By discussing this as a team, you may discover a number of unforeseen potential barriers but also your team members may offer solutions you hadn’t thought of. If your team understands the problem and how they can help, they are more likely to engage in the process of improvement.

With your team you may want to create a Driver Diagram. This may help you determine your Change Ideas.


QI Methodology

There are a number of different QI methods and tools that are commonly used in healthcare in order to introduce and study your changes: Model for Improvement methodology (which uses PDSA cycles), Total Quality Management, Continuous Quality Improvement, Six Sigma and Lean Thinking. There is no one correct method to use and you may even use a blend of methodologies.

 IDENTIFY CHANGE IDEAS

Regardless of methodology you will need to identify what you are going to change.

ESTABLISH process MEASURES

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Think carefully about what data you are going to collect to ensure that it is the correct data to demonstrate if your changes are making an improvement.

Regular data collection is central to quality improvement. Electronically collected data can make data sampling much easier and therefore more sustainable. However, given our IT systems and paper based note-keeping, manual data sampling often our only option.

Implement your change ideas

Introduce your change idea and collect data to assess if you achieve the results you expected.

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If something works you may adopt this change. If it doesn’t work you need to think why it didn’t work. This idea can be adapted or discarded and a new idea trialed. This process is repeated until you have introduced sustainable changes that work for your department and your patients.

In this way you can determine what methods of introducing change work in your department and what doesn’t. You will learn a lot about how your department works and these experiences, positive and negative, all count towards learning for future projects.

Run Charts

In Quality Improvement, results are generally presented in Run Charts.

Run charts allow us to visually compare performance before and after implementation of changes and whether improved performance has been sustained. The run charts can be shared widely amongst your team to keep the team up to date with your project. By demonstrating improvement we aim to engage more people and instill a culture of improvement in our departments.

PDSA Cycles

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This methodology is commonly used in healthcare to structure improvement projects and is based on 3 key questions:

1.     What are we trying to accomplish?

-        Projects aims are set 

2.     How will we know that a change is an improvement?

-        Developing outcome measures        

3.     What change can we make that will result in an improvement?

-        In order to do this you need to engage stakeholders to understand the problems with the system and develop change ideas. This is done using a Driver Diagram.

The Plan, Do, Study, Act (PDSA) cycle outlines the steps for cyclical testing and refinement of change ideas:

Plan – What are you going to do differently?

Do – Carry out the plan

Study - Carry out data sampling & analyse your results (this can be presented in Run Charts). With your team, work out what worked and what didn’t work, and what changes should be adopted or abandoned

Act – Use this knowledge to plan the next test

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We continue testing in this way, using multiple PDSA cycles, until the process is refined and changes that will result in improvement can be fully implemented

disseminate learning

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If one area can benefit from quality improvement work then it is likely that other departments can benefit also.




Training requirements

It is expected that EM consultants will be involved in quality improvement work, and therefore participation in quality improvement projects is a necessary part of EM training. A quality improvement project forms part of the FRCEM final examination and takes the form of a written component.

Even those of you who are not in EM training will likely find that quality improvement is a required part of your training.

Ultimately, improving the quality of patient care is the responsibility of all healthcare staff and we should make an effort to get involved irrespective of training requirements.

QI Links

RCEM Quality Improvement Guide 

RCEM QI Resources page

Kings improvement science step 1, step 2 & step 3

the health foundation – quality made simple

BMJ Quality Safety


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