Quality Improvement

What is QI?

Not the TV show – Quality Improvement:

We should be aiming for patient care that is safe, timely, effective, efficient, equitable and cost effective. Quality improvement is the process by which we try to attain this goal.

In the RCEM Quality Improvement Guide, quality improvement is defined as:

“better patient experience and outcomes achieved through changing provider behaviour and organisation through using a systematic change method and strategies”.

Essentially quality improvement is about continually working to improve the quality of patient care. We have all felt that, at times, patient care has not been the best it could be. This could be because of delays: for example the wait for a bed, investigation or in finding equipment. If you’ve ever wanted to change things for the benefit of your patients then you will be interested in quality improvement.


How is quality improvement different from an audit?

Quality improvement aims to improve the quality of patient care, whereas an audit aims to ensure that care meets certain minimum standards.

Although many of the activities performed during both types of project may overlap, there is often a key difference in psychology and motivation. Traditional audits have been shown to have limited ability to improve patient care and organisational culture.

Quality improvement projects typically have a faster turnaround during which multiple ideas can be trialled, 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.


Methods of quality improvement

There are a number of different approaches to quality improvement, each with its own strengths and weaknesses.  The correct approach or combination of approaches should be selected for the task at hand. The more common methods are listed:

  • Model for improvement and the PDSA cycle
  • Lean
  • Six Sigma
  • Experience based co-design (EBCD)
  • Healthcare failure modes and effects analysis (HFMEA)
  • Model for Improvement and the PDSA Cycle – (link to floor resource)
  • Lean/Six Sigma

These are two separate approaches that share many similarities. They aim to analyse healthcare systems to eliminate waste and encourage efficiency and consistency. Although streamlining processes in this fashion is likely to be beneficial to patient care, this approach may not be patient centred.


Experience-based co-design (EBCD)

With this approach the patients and staff work in partnership to improve services. Data is gathered through interviews or group discussions and aspects of the service that are important to patients are identified. This is usually fed back to the staff through high-impact short films that highlight these issues, and the patients and staff co-design improvements. This is a truly patient-centred approach.


Healthcare failure modes and effects analysis (HFMEA)

The goal here is to analyse processes to identify potential failures and safety issues before they arise. An intervention to prevent system failures can then be instituted before patient safety is compromised. This preventative nature of this approach is especially useful when introducing a new system, but unfortunately it may be difficult to determine whether the intervention was necessary.

Regardless of which approach is chosen, engagement of the staff involved is crucial. A great idea will remain just that – an idea – if it is not adopted by the whole team who are caring for patients. Involve other staff members when designing solutions so that they feel invested, educate them about why an improvement is important and show them any successes that the changes generate.


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 currently this takes the form of a written component and a viva, though it is expected that only the written part will be required following the autumn diet of 2018.

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.


QIP Guidance

Guidance for RCEM QIP examination candidates can be found in the QIP Guide 1.


And from page 34 of QIP Guide 2.


How you can start your quality improvement project?

The project should aim, explicitly, to improve the quality of care of your patients.

The problem you decide to tackle should be important to you and your patients. The project will require your continued enthusiasm to maintain momentum.

Choose a small, achievable goal, at least initially.

Discuss with the quality improvement lead for your emergency department to ensure there is no duplication of work.


Writing up your quality improvement project

The RCEM suggests using the SQUIRE guidelines to assist writing up your quality improvement project.

SQUIRE is the Standards for Quality Improvement Reporting Excellence, and their guidelines provide a framework for reporting new knowledge about how to improve healthcare. The broad categories suggested are listed below, and you can find out more by clicking SQUIRE 1 or, for a very in depth explanation, see SQUIRE 2.

  • Title
  • Abstract
  • Introduction
  • Methods
  • Results
  • Discussion
  • Limitations
  • Conclusions
  • Funding


Disseminating your work

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

You can present your findings at conferences or publish them in academic journals – however this process can take a long time and the information may not meet the people that would benefit most.

Have someone your colleagues trust to deliver your message. It may be that a consultant or senior nurse’s voice will carry more weight than yours – enlist their help.

Identify shared concerns and priorities between yourself and the colleagues you wish to influence. Your colleagues may have different priorities which can conflict with the implementation of the quality improvement project, so try to find the areas in which you have common cause and make the most of them.

Go to the people you want to influence, do not expect them to come to you.

Pay attention to the more vocal sceptics and engage them in discussion. Someone who is willing to debate your findings is more likely to be won over than someone who is just ignoring them.



RCEM Quality Improvement Guide

Learn NES

BMJ Quality Safety

SQUIRE Statement

SQUIRE Statement 2

RCEM Quality Policy


More Weekly Themes

Hannah Bell