Quality Improvement Training
NES pilot project
Quality Education for a Healthier Scotland
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 Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
Pre course questionnaire
Quality Education for a Healthier Scotland
Ice breaker
Teamwork
Leadership
Introductions to human factors
Quality Education for a Healthier Scotland
Groupwork
Systems
Culture
Quality Education for a Healthier Scotland
What is Quality Improvement (QI)?
Multi disciplinary
Looks at the whole system
Driven by data
Sustained improvement
Becomes normal - examples
Quality Education for a Healthier Scotland
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”
Quality Education for a Healthier Scotland
Project
Aim is to get QI project published
Tight time scale – need to be realistic
Adult learning – many resources in hand out
Quality Education for a Healthier Scotland
Quality Education for a Healthier Scotland
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)
Quality Education for a Healthier Scotland
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??
Quality Education for a Healthier Scotland
Group work
Who would you need in your team?
How would this team have authority to make changes?
Consider teamwork and leadership issues.
Quality Education for a Healthier Scotland
Steps involved in a QI project
Define problem
Background
Literature and guidance
Local background eg practice or ward
Quality Education for a Healthier Scotland
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?
Quality Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
Measurement – results of group exercise
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
Quality Education for a Healthier Scotland
Measurement – results of group exercise
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
Quality Education for a Healthier Scotland
Group work 2
What measure would you use in your group’s QI project and why?
Quality Education for a Healthier Scotland
Sampling
Sampling may not be needed
Consider a sample that is manageable but has large enough numbers
Justify your choices!
Examples
Quality Education for a Healthier Scotland
QI tools
Process mapping
Criterion based audit
Care bundles
PDSA
Quality Education for a Healthier Scotland
Process mapping
Helps understand process
Identify critical steps
Consider safety of these steps
Identify redundant steps
Failure mode and effects analysis
Quality Education for a Healthier Scotland
Process mapping
Define the boundaries
Start with …..
Stop with ……
Realise I
have a flat
tyre
Drive away
with tyre fixed
Quality Education for a Healthier Scotland
Process mapping
Quality Education for a Healthier Scotland
Quality Education for a Healthier Scotland
Telephone request for
prescription
Have they
had it
regularly?
Is prescription
on repeat?
No
Yes
No
Don’t print
prescription
Print
prescription
Add to special
request list for
next day
Yes
Add to special
request list for
next day
Print
prescription
GP agrees
to prescribe
No
Message to
prescribing
team – not
being
prescribed
Prescribing
team contact
patient to
inform them
Yes
Returned to
prescribing
team – not
signed and
score through it
GP decides if
issues
prescription
GP prints
prescription
No
Prescription
returned to
front desk for
collection
Yes
Quality Education for a Healthier Scotland
Prescription
destroyed and
removed from
EMIS
Criterion based audit
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
Quality Education for a Healthier Scotland
Criterion based audit – audit cycle
Quality Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
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?
Quality Education for a Healthier Scotland
Criterion based audit – data collection 2
All patients on
methotrexate
should have
FBC, UE, LFT in
last 3 months
Standard
Data collection
1
Data collection
2
100%
68%(32/47)
98% (47/48)
Quality Education for a Healthier Scotland
Criterion based audit
1.
2.
3.
4.
5.
6.
7.
8.
Reason for choice of audit
Criterion or criteria chosen
Standards set
Preparation and planning
Data collection (1)
Change(s) to be evaluated
Data collection (2)
Conclusion
Consider sustainability of change
Quality Education for a Healthier Scotland
Care bundle
Several key components of a care process
Not a check list
All have to be present
Repeated small measure possible
Quality Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
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.
Quality Education for a Healthier Scotland
Care bundle
Patient
BMI
Pulses
Neurop Urine
athy
tested
Cholest HbA1c
erol
All
present
1
x
x
x
x
x
x
2
x
x
x
3
x
x
x
x
x
x
x
x
x
x
x
4
x
x
5
x
x
80%
80%
x
80%
80%
x
x
80%
100%
20%
Quality Education for a Healthier Scotland
Care bundles
Measure again after intervention
Sustainability
Quality Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
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
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PDSA
Implement in larger samples, spread to
other areas and sustain improvement
Test, adapt and refine
interventions
Act
Plan
Study
Do
Act
Plan
Study
Do
Act
Plan
Study
Do
Act
Plan
Study
Do
Act
Plan
Study
Do
Act
Plan
Study
Do
Specific problem or area for
improvement
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PDSA - advantages
Frontline staff
Try small change
Rapid
Overcome resistance
Quality Education for a Healthier Scotland
PDSA - evidence
What makes PDSAs successful
•
Fast, measureable and visible
•
Small, stable units with a learning culture
•
Knowledge of practitioner
•
Resources
Quality Education for a Healthier Scotland
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.
Quality Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
What QI tools could you use?
Discuss the project your group chose earlier.
What tools could you use?
Process mapping
Criterion based audit
Care bundles
PDSA cycles
Quality Education for a Healthier Scotland
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?
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Results
Criterion based audit – tables
Numbers and percentages and compare to standard
Run charts
Must show improvements sustainable
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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
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Run chart
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Run charts - pattern
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Run charts - annotate
PDSA 1
PDSA 2
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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
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Run chart – trends and shifts
Shift
Trend
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Run charts - groupwork
Describe data
Find trends and shifts
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Run charts - groupwork
Trend –what happened here?
Not a trend – but is it significant?
Shift – is this significant?
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Control chart
3 standard
deviations
from the
mean
3 standards
deviations from
the mean
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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
Fire alarm went off
UCL
LCL
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Results
How will you present results?
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Conclusions
Lessons from completing project
Limitations of your project
Spread – would it work elsewhere? Can this be spread?
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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
Quality Education for a Healthier Scotland
Sepsis 6
Define problem
Done well – but why chosen?
Background
Useful evidence but what are local
arrangements
Baseline measure chosen
Time to antibiotic
Improvement method and design
PDSA used
Was this a criterion based audit or a
care bundle?
Would process mapping have
helped?
Quality Education for a Healthier Scotland
Sepsis 6
Implementation strategy - team
formation and leadership
Team formed – who was in it? Did
they have backing from clinical
effectiveness/management?
Results
Run charts – consider care bundle
(might not be ready for that)
Lessons and limitations
Need more than education
Could you repeat what they have
done?
Conclusions
Quality Education for a Healthier Scotland
Name badges
Does not need to be complicated
Quality Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
BMJ QI reports
Video
http://quality.bmj.com/
Quality Education for a Healthier Scotland
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)
Quality Education for a Healthier Scotland
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
Quality Education for a Healthier Scotland
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?
Quality Education for a Healthier Scotland
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?
Quality Education for a Healthier Scotland
Role of mentor
Ensure feasible
Ensure methods are valid
Ensure measure is logical
Feedback during write up
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Feedback - what else is needed?
Have a discussion in groups and consider:
What has confused you today?
What further information do you need?
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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.
Quality Education for a Healthier Scotland
Quality Education for a Healthier Scotland
Thank you
Quality Education for a Healthier Scotland