How to do a quality
improvement (QI) project?
And yes, this can also mean
how to do a clinical audit
using QI methodology
Emma Vaux
emma.vaux@royalberkshire.nhs.uk
clinical lead – Learning to Make a Difference
2013
A Model for Learning and Change
When you
combine
the 3
questions
with the…
PDSA cycle,
you get…
…the Model for
Improvement.
The Improvement Guide, API, 1996
2
Repeated Use of the PDSA Cycle
Changes That
Result in
Improvement
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
A P
S D
What change can we make that
will result in improvement?
Spread
Implementation of
Change
Hunches
Theories
Ideas
A P
S D
Very Small Scale Testcale
Test
Wide-Scale Tests of
Change
Follow-up
Tests
Sequential building of
knowledge under a wide
range of conditions
A QI project in a nutshell
Identify a clear and focused SMART aim
Decide what change(s) you are going to
make
Decide what you are going to measure
before you start to monitor the impact
of any change
The overview…
It is all about following a
structured process
Guides to how to make this
happen
For the trainee
For the supervisor
All accessed via the LTMD
website
http://www.rcplondon.ac.uk/projects/lear
ning-make-difference-ltmd
Top tips
Develop your project plan and discuss with
your supervisor
Involve the right stakeholders
It is even better when there is multiprofessional involvement
Think of what might be the unintended
consequences of any change
Prepare to educate others in the MDT
about using a QI approach to a problem
An example of a QI project
Aim
To reduce the
number of
inappropriate
urinary catheters
inserted into
patients admitted
to the Clinical
Decision Unit by
50% by January
2011
Change
Introduce a
checklist to be
completed prior
to any catheter
insertion
Measure
The number of catheters
inserted according to
trust guidelines
measured on a weekly
basis….start with
measuring the baseline
before any change is
made and
then measuring little and
often after any change
Test out the next change and keep measuring………….
It is much better to measure 1 day a week, a 10% sample, on one bay of
one ward than try and measure everything all the time
8
Measurement
Are you finding this confusing? So what is the
difference between doing a quality improvement
project or a clinical audit?
•
Simply, clinical audit is doing a quality improvement (QI) project
against an agreed standard or practice.

As trainees, the traditional way of doing a clinical audit has been a
lengthy process, doing one data set collection, possibly having time
to make a change and possibly collecting another data set.

A QI project uses QI methodology and a structured framework to
enable change to happen in a real-time and dynamic way with little
and often measurement.

By using QI methodology as part of the clinical audit cycle, clinical
audit moves to a robust QI process with the focus on change and
making a visible, timely difference to patient care.
Data points - why measure little and often?
The traditional clinical audit way of doing things!!
Use of run charts to track changes
The change seems to be
associated with an
improvement
The change is not associated with
an improvement; if there had been
no baseline measurement before
making the change, the change
might have been mistakenly
interpreted as making a difference
The change seems to be
associated with an
improvement initially but the
effect does not appear
sustained
Perla R. BMJ Qual Saf 2011; 20: 46-51
Remember little and
often measurement
Example of a Learning
to make a difference QI
project
Anxiety and Depression
in Acute Stroke Patients
Dr Olivia Walker
CMT Royal Berkshire NHS Trust
Reasons behind the Project
NICE guidelines - Agreed local policies and guidelines for
screening patients with stroke within 6 weeks of diagnosis,
using a validated tool, to identify mood disturbance.
Meets the need identified in addressing mood in acute
stroke patients in the biannual RCP National Sentinel
Stroke Audit.
Research suggests that undiagnosed anxiety and
depression can have a negative impact upon
rehabilitation.
The objective
To develop a local protocol that
can be used to screen all acute
stroke patients for anxiety and
depression.
Project Aim (1)
 100% of stroke patients should have a
Depression Scale completed within 5 days of
admission and recorded in the notes
 100% of patients will have a repeat
DEPRESSION SCALE completed in the MDT
after 2-3 weeks.
Project Aim (2)
100% of patients identified with anxiety and/or depression
will be referred to the neuropsychologist.
All aims to be completed within 4 month time frame on
the ASU
So Olivia is doing a clinical audit
ie a quality improvement project against an
agreed standard
In this case against NICE recommendations
But by using a SMART aim and prospective and
little and often measurement Olivia is using
QI methodology to implement and test out
her changes
Change 1
The identification of an appropriate anxiety and
depression tool which can be implemented in the
Royal Berkshire Hospital (RBH) acute stroke unit.
Discussion with the neuropsychologist identified 2
suitable assessments:
oHospital Anxiety and Depression Scale (HADS)
oNumeric Graphic Rating Scale (NGRS)
What was tested
Review of 20 stroke
patients notes on the
unit, on one particular
day, using the pro
forma.
Assessing each patient
using either the HADS or
the NGRS in the stroke
unit on one particular
day.
Outcomes
1. Need specific
guidelines/flow chart to
identify which scale to use.
2. Completing the scales is
time consuming, therefore
a briefer assessment
initially would be useful.
3. Need additional scale for
patients with
aphasia/dysphasia.
4. Patients with cognitive
impairment need assistance
with completing a scale.
Change 2
1.
The identification of additional scales

The Signs of Depression Scale – to be completed for each patient
within 5 days of admission either by the occupational therapist (OT)
or in the twice weekly MDT meeting.
HADS – to be used with patients without aphasia. If cognitive
impairment the OT will go through each question with the patient.
NGRS or the DISCs Scale – for patients who struggle with the HADS.
The Stroke Aphasic Depression Questionnaire – for patients with
aphasia.



2.
The development of a flow chart
What was tested
The notes of 20 patients
on the acute stroke unit
were reviewed after the
implementation of the
flow chart.
All stroke patients should
have an SDSS documented
in the notes by the OTs,
within 5 days of admission
to the acute stroke unit.
Outcomes
1. Poor completion of the
SDSS within 5 days
2. Barriers identified
following discussion with
OTs
 Not part of their routine
assessments and therefore
can be forgotten.
 Having the SDSS printed on
white paper doesn’t
highlight it resulting in it
often being overlooked.
Change 3
The SDSS is included in the initial patient
assessment by the OTs.
The SDSS is printed on yellow paper.
Outcome
What was tested
2 weeks later the
notes of 20 patients
on the stroke unit
were reviewed
following the new
changes.
1.Improved completion of
the SDSS but not yet 100%
achieved.
2.New issue identified Only having an initial
SDSS may miss patients
who develop
anxiety/depression
later in their admission.
Acute stroke unit mood assessment
pathway
Does the patient have a language problem?
No
Yes
SALT input required to allow for
comprehensive screening to take
place
SADQ
DISCS/
NGRS
Score ≥ 9 refer urgently to medical
team and neuropsychologist
HADS
A run chart to demonstrate the
change over time since the
introduction of the SDSS
Modified Flow Chart Introduced
SDSS Introduced
Flow chart
SSDS printed on yellow paper
The differences made
An MDT approach to tackling anxiety and
depression in acute stroke patients
The RBH Stroke Unit is now compliant with the
NICE Guidelines and the biannual RCP National
Sentinel Stroke Audit.
The new assessment tool identifies patients who
may have previously remained undetected.
Olivia’s learning points
1. As a junior doctor you can make a
difference to patient care.
2. Change takes time and requires dedicated
and enthusiastic colleagues to maintain
them.
3. It is important to be able to adapt the
project as problems arise and accept that
timescales often need to be modified.
Getting started!
Go to LTMD website for ideas and inspiration
and the toolkits
Think of your own idea
Identify a consultant supervisor
Ideally involve the MDT
Complete the project plan template
You can always run your project plan past
LTMD team LTMD@rcplondon.ac.uk
Get started!
Use the template on the website for your
report and presentations