Quality Improvement Training

Quality Education for a Healthier Scotland

Quality Improvement Training

NES pilot project


Quality Improvement Project

Aims of this pilot project:

• To increase participants’ knowledge of the interrelated aspects of

• QI methods

• Patient safety

• Human factors in health care

• Leadership

• Teamwork

• To allow trainees to gain experience of leading a QI project


Quality Improvement - plan

Teamwork

Leadership

Human factors

QI tools

• Process mapping

• Criterion based audit

• Care bundles

• PDSA

Groupwork

• QI project

Work on your own QI projects


Pre course questionnaire


Ice breaker

Teamwork

Leadership

Introductions to human factors


Groupwork

Systems

Culture


What is Quality Improvement (QI)?

Multi disciplinary

Looks at the whole system

Driven by data

Sustained improvement

Becomes normal - examples


What is Quality Improvement (QI)?

Evidence based medicine

“Doing the right things”

Quality Improvement

“Doing things right”

Should be complimentary

“Doing the right things right”


Project

Aim is to get QI project published

Tight time scale – need to be realistic

Adult learning – many resources in hand out



QI reports - timescales

Project Time

Improving the quality of in-patient antibiotic prescription in Trauma and Orthopaedics

4 months

Service improvement system to enhance the safety of patients admitted on long-term warfarin

8 months

Improving the preoperative care of patients with femoral neck fractures through the development and implementation of a checklist

4 weeks

Saving the NHS one blood test at a time 4 weeks

Improving communication of inpatient blood transfusion events to GPs

Few weeks (not specified)


Group work

Pick a QI project for use in your group work today:

• There are a lot of missing prescriptions in your surgery and patients often complain verbally to you about the prescribing system. This also causes extra work for GPs with lots of extra prescriptions to sign each day. You plan a QI project to try and improve an aspect of the system.

• There have been problems with INR monitoring within your department. You wish to perform a QI project to improve the process.

• Patient satisfaction of information provided at outpatient clinic appointments has anecdotally been recorded as low. You are keen to improve this.

• Or one of your own??


Group work

Who would you need in your team?

How would this team have authority to make changes?

Consider teamwork and leadership issues.


Steps involved in a QI project

Define problem

Background

Literature and guidance

Local background eg practice or ward


Measurement

The most critical step for a successful project

Needs to be specific, precise, logical and measurable!! Also consider context

Group exercise on what makes a good measure and consider your group’s project:

What will you measure?


Measurement – results of group exercise

1. The number of missing prescriptions per day

2. The number of patients treated within 4 hours each day

3. How busy the clinic is

4. Patients receiving aspirin and dipyridamole following a stroke should be switched to clopidogrel

5. The percentage of over 65s who have a vaccination each year



6. The number of blood results that are actioned without delay

7. Hospital patients need to get venous thromboprophylaxis

8. Patients with secondary coronary heart disease will get evidence based care

9. All my patients are satisfied with the quality of care that I provide

10.Patients with type 2 diabetes should have their feet checked by a healthcare professional at least once every 12-months



11.The percentage of patients with gout and who take allopurinol in whom urate levels are monitored

12.The number of patients with COPD and an MRC dyspnoea score of 3 or more who are treated each day following the current NICE COPD guidelines

13.The percentage of patients who are prescribed a 4C antibiotic inappropriately

14. Increase the number of patients receiving optimal treatment of gout

15.The number of patients receiving all aspects of the sepsis 6 bundle within 1 hour


Group work 2

What measure would you use in your group’s QI project and why?


Sampling

Sampling may not be needed

Consider a sample that is manageable but has large enough numbers

Justify your choices!

Examples


QI tools

Process mapping

Criterion based audit

Care bundles

PDSA


Process mapping

Helps understand process

Identify critical steps

Consider safety of these steps

Identify redundant steps

Failure mode and effects analysis


Process mapping

Define the boundaries

Start with …..

Stop with ……

Realise I have a flat

tyre

Drive away with tyre fixed


Process mapping



Telephone request for prescription

Is prescription on repeat?

Print prescription

Have they had it

regularly?

Add to special request list for

next day

Print prescription

Don’t print prescription

Add to special request list for

next day

GP prints prescription

GP decides if issues

prescription

Prescription returned to

front desk for collection

Prescription destroyed and removed from

EMIS

Returned to prescribing team – not signed and

score through it

No

Yes

Yes

Yes

No

No

GP agrees to prescribe

Yes

No

Message to prescribing team – not being prescribed

Prescribing team contact patient to inform them



Continuous quality improvement method

1750 BC - King Hammurabi of Babylon introduced audit for clinicians

Evaluating structures, process and outcomes of healthcare against explicit criteria and agreed standards


Criterion based audit – audit cycle


Criterion based audit - example

Criteria

Simple, logical statements that describe specific and measurable health care items or activities

Patients on methotrexate should have FBC, UE and LFT in last 3 months

Standards

Quantify the level of care to be achieved for criteria

100% - but may not be 100% due to exclusions for contraindications


Criterion based audit - example

Patients on methotrexate should have FBC, UE, LFT in last 3 months

Standard 100%

Preparation and planning

Data collection 1

47 patients on methotrexate, 32 had FBC, UE and LFT in last 3 months

Results 32/47 = 62%

Implement change – how will this be system based?


Criterion based audit – data collection 2

Standard Data collection 1

Data collection 2

All patients on methotrexate should have FBC, UE, LFT in last 3 months

100% 68%(32/47) 98% (47/48)



1. Reason for choice of audit

2. Criterion or criteria chosen

3. Standards set

4. Preparation and planning

5. Data collection (1)

6. Change(s) to be evaluated

7. Data collection (2)

8. Conclusion

Consider sustainability of change


Care bundle

Several key components of a care process

Not a check list

All have to be present

Repeated small measure possible


Care bundle

All patients on methotrexate should have:

• FBC, UE, LFT in last 3 months

• Pneumococcal vaccination (ever)

• Annual education about drug and side effects


Care bundle - example

Diabetic patients:

Should have their BMI measured and recorded

Should have peripheral pulses examined and recorded

Neuropathy testing should be performed

A urine specimen should be tested for proteinuria

A fasting total serum cholesterol test should be requested and the result recorded

A HbA1c should be requested and the result recorded in patients’ records.


Care bundle

Patient BMI Pulses Neuropathy

Urine tested

Cholesterol

HbA1c All present

1 x x x x x x x

2 x x x x

3 x x x x x

4 x x x x x x x

5 x x x x

80% 80% 80% 80% 80% 100% 20%


Care bundles

Measure again after intervention

Sustainability


Criteria and Care bundle exercise

1. All patients on allopurinol for gout should have a urate level recorded in their notes in the last 12 months

2. Patients on warfarin should receive education

3. Patients with rheumatoid arthritis should have a record of a face to face review within the last year

4. Allergies should be recorded in all patients’ notes

5. When a prescription request comes in, the prescription will be available for collection or the patient will be contacted to inform of reason for not issuing, within 48 hours


Criteria and Care bundle exercise

1. All patients who attend for asthma review should have

Peak flow measured

Severity assessed using the RCPs 3 questions

Compliance discussed

Inhaler technique checked

2. All results that are returned should

Be stamped stating time returned

Added to doctors pile

Dealt with by the doctor quickly

3. Patients with dementia should

Have documentation of next of kin

Be nursed in a sympathetic way

Discharged within normal working hours


PDSA

Plan, do, study, act

Implement small scale change

and evaluate

Can be used with other QI tools

• Criterion based audit

• Care bundles

Aim statement – exercise

Satisfaction with doctor-patient communication


PDSA

Test, adapt and refine interventions

Specific problem or area for improvement

Act Plan

Study Do

Act Plan

Study Do

Act Plan

Study Do

Act Plan

Study Do

Act Plan

Study Do

Act Plan

Study Do

Implement in larger samples, spread to other areas and sustain improvement


PDSA - advantages

Frontline staff

Try small change

Rapid

Overcome resistance


PDSA - evidence

What makes PDSAs successful

• Fast, measureable and visible

• Small, stable units with a learning culture

• Knowledge of practitioner

• Resources


PDSA - example

Keen to cut unnecessary tests performed at rheumatology clinic

Plan

3 patients on DMARDs for near patient testing - collect copies of their results

Do

3 patients – followed up by phone

Study

2 patients collected copies. 1 still needed extra bloods. 3rd patient had no transport.

Act Providing copies of results may be a useful intervention, but would have to be adapted - larger sample of patients.


PDSA - example

Plan

Next 5 patients offered choice of collecting or posting results

Do

Performed in 5 patients – contacted by phone

Study

3 took results to clinic, 1 needed extra bloods.

Act

Cost of posting could be prohibitive


PDSA - example

Plan

GP contacts rheumatology to discuss what bloods may be needed and modifies NPT protocol to include these when appropriate

Do

Performed on 10 patients followed up after clinic

Study

No patients needed further bloods all had results at clinic

Act

Roll out to all DMARD patients


What QI tools could you use?

Discuss the project your group chose earlier.

What tools could you use?

Process mapping


Care bundles

PDSA cycles


Strategy

Implementation strategy - team formation and leadership (consider authority)

Discuss in groups possible strategies for implementation.

How would you make it happen in your work place?


Results

Criterion based audit – tables

Numbers and percentages and compare to standard

Run charts

Must show improvements sustainable


Run chart

Improvement takes place over time

Visual tool to aid teams in deciding if improving or not

Time series analysis

Plot variable we are measuring on y axis

Plot time on x axis


Run chart


Run charts - pattern


Run charts - annotate

PDSA 1

PDSA 2


Run chart – special cause variation

Common cause – usual variation in system

Special cause – something has caused change

Ways to find special cause:

Shift – 8 or more points that have moved over the centre line

Trend - 6 or more points that move in 1 direction


Run chart – trends and shifts

Shift

Trend


Run charts - groupwork

Describe data

Find trends and shifts


Run charts - groupwork

Trend –what happened here?

Shift – is this significant?Not a trend – but is it significant?


Control chart3 standard deviations from the mean

3 standards deviations from the mean


Control charts

3 standard deviations – 99.7% of results in a Gaussian distribution within controls.

Outliers may be a marker of special cause variation

annotate to explain what happened

UCL

LCL

Fire alarm went off


Results

How will you present results?


Conclusions

Lessons from completing project

Limitations of your project

Spread – would it work elsewhere? Can this be spread?


Critical appraisal

Review the project on Sepsis 6 from QI reports

Discuss in groups and feedback on each area of report and how it could be improved.

Handouts


Sepsis 6

Define problem

Background

Baseline measure chosen

Improvement method and design

Done well – but why chosen?

Useful evidence but what are local arrangements

Time to antibiotic

PDSA used

Was this a criterion based audit or a care bundle?

Would process mapping have helped?


Sepsis 6

Implementation strategy - team formation and leadership

Results

Lessons and limitations

Conclusions

Team formed – who was in it? Did they have backing from clinical effectiveness/management?

Run charts – consider care bundle (might not be ready for that)

Need more than education

Could you repeat what they have done?


Name badges

Does not need to be complicated


What makes a successful project?

Social determinants – how you get along with people, engage with them and encourage them.

Planning and buy in – showing value (not just to reach a target)

Real change and not “just” education

Empower and excite and maintain enthusiasm

Measure and make results visible

Embed in usual practice


BMJ QI reports

Video

http://quality.bmj.com/


QI reports - timescales

Project Time

Improving the quality of in-patient antibiotic prescription in Trauma and Orthopaedics

4 months

Service improvement system to enhance the safety of patients admitted on long-term warfarin

8 months

Improving the preoperative care of patients with femoral neck fractures through the development and implementation of a checklist

4 weeks

Saving the NHS one blood test at a time 4 weeks

Improving communication of inpatient blood transfusion events to GPs

Few weeks (not specified)


Report documentation

Based on QI reports

Define problem

Background

Literature and guidance

Local background eg practice or ward

Baseline measure chosen

Improvement method and design

Implementation strategy - team formation and leadership

Results

Lessons and limitations

Conclusions


Your own QI project

Any more background needed

Reading

Process mapping

Who will be in the team? Who will you inform that you are doing this? Who has authority to make it work?

What barriers do you perceive?

What measure will be used?

What sample will be used?

What tools will be used?

How will you present results?


Your own QI projects

Present idea for discussion

• What is the problem?

• How will you form your team?

• What measure will you use?

• What QI tools will you use?


Role of mentor

Ensure feasible

Ensure measure is logical

Ensure methods are valid

Feedback during write up


Feedback - what else is needed?

Have a discussion in groups and consider:

What has confused you today?

What further information do you need?


What next?

Further resources and contacts - handout

You will have access to all BMJ Quality resources

Produce1 page summary of plan

Send to Duncan BY 10th April

Feedback from us by 13th April

Get started and stay in touch

contact every 2-3 weeks

Final report by 14th July.



Thank you

Documents

Quality Improvement Training