Paresh Dawda
ASSESSMENT OF
FEBRILE CHILDREN
Please note this improvement project was submitted for
the Advanced Improvement in Quality and Safety programme
by the NHS Institute for Innovation and Improvement
Page | 0
Paresh Dawda
Table of Contents
List of figures: ....................................................................................................... 1
Abbreviations ........................................................................................................ 2
Introduction ........................................................................................................... 3
Context of Practice................................................................................................ 3
Sustainability ......................................................................................................... 4
Quality Improvement Tools ................................................................................... 6
Results ................................................................................................................ 13
Conclusions ........................................................................................................ 15
Appendices ......................................................................................................... 18
Appendix 1 – Project Plan ............................................................................... 18
Appendix 2 - The practice as a system ............................................................ 19
Appendix 3 – Driver Diagram for Patient Care Process ................................... 20
Appendix 4 – Process Map .............................................................................. 21
Appendix 5 – Sustainability Analysis ............................................................... 23
Appendix 6 – Results of Surveys ..................................................................... 24
Appendix 7 – Log of a selection of PDSA Cycles ............................................ 28
Appendix 8 – FMEA ......................................................................................... 40
Appendix 9 – Measurement ............................................................................. 41
References ......................................................................................................... 43
Page | 1
Page | 2
List of figures:
Figure 1: Impact of 5S Intervention .................................................................... 30
Figure 2: 5S table top visual management card ................................................. 31
Figure 3: 5S visual management card + equipment ........................................... 31
Figure 4: Tympanic thermometer with memory prompt ...................................... 33
Figure 5: Digital thermometer with memory prompt ........................................... 33
Figure 6: Mouse mat .......................................................................................... 35
Figure 7: Mouse mat enlarged ........................................................................... 35
Figure 8: Screenshot of intranet with traffic light system reference .................... 35
Figure 9: Screenshot of data recording template ............................................... 37
Figure 10: Diagram of algorithm for redundancy check with screen shot of
prompt ...................................................................................................................... 39
Figure 11: Run chart of % of febrile children with all four components completed
................................................................................................................................. 41
Figure 12: : Pareto analysis - baseline data ...................................................... 41
Figure 13: Number of measurements for each patient ....................................... 41
Figure 14: Balancing measure ........................................................................... 41
Page | 1
Paresh Dawda
Abbreviations
AIQS
CRT
EFQM
FMEA
GP
HCA
NICE
PDSA
PR
RR
UAT
Advanced Improvement in Quality and Safety
Capillary refill time
European Foundation for Quality Management
failure modes and effects analysis
General Medical Practitioner
Healthcare Assistant
National Institute for Health and Clinical Excellence.
Plan, Do, Study, Act cycle
Pulse Rate
Respiratory rate
Urgent Access Team
Page | 2
Introduction
The translation of evidence into practice has been a challenge for all healthcare
organisations. The reliability of providing patients with known evidence based
interventions in healthcare is poor and occurs just over half of the time (McGlynn et
al. 2003). The first step in translating research into practice is to summarise the
evidence (Pronovost et al. 2008). In the UK, the National Institute for Health and
Clinical Excellence (NICE) reviews and makes recommendations on standards of
care.
In general practice children presenting with an acute febrile illness is a common
reason for consultation. The prevalence of serious illness is low (Van den Bruel et
al. 2007), however, more than half of the children with a serious febrile illness are not
identified at first presentation (M. J. Thompson et al. 2006). A recent review of
childhood mortality with primary care involvement identified 27% of deaths were
attributed to acute infections (Harnden et al. 2009). GPs have a challenging task to
identify those children with a serious illness from a large number of children who will
have minor illnesses that are often self-limiting. NICE have published guidance on
the assessment and management of children with febrile illness (NICE 2007). The
aim of this project was to ensure that in the GP practice 95% of children under the
age of 5 presenting with a febrile illness were assessed in accordance with NICE
guidelines by October 2011.
Context of Practice
Page | 3
This project was conducted at a large teaching General Practice in East
Hertfordshire. The surgery has a registered list size of 20,000 patients, and employs
over 50 staff, which includes a number of learners from multiple disciplines. The
practice has been on an organisational development programme since 2006. This
development programme has seen the practice restructure itself as a 'system' as
shown in Appendix 2 - The practice as a system. As a result of this organisational
development journey, the practice is increasingly aligned with quality improvement
approaches such as Lean and Six Sigma and indeed achieved the European
Foundation for Quality Management's (EFQM) Committed to Excellence Award in
2008 in recognition. Hence, a drive for excellence is increasingly embedded into the
culture of the organisation, and in some respects reduces the impact of potential
barriers in the context of this improvement project. However, the practice is still
relatively early in its journey. The experience of quality improvement approaches
has been with administrative processes that support provision of clinical care rather
than clinical care processes. Indeed, a review of past projects directly related to
clinical care demonstrates the standard approach used has been clinical audit.
Many of the previous interventions to improve the quality of clinical care relied on a
combination of hard work, vigilance, clinical guidelines, education and training.
These are all necessary improvement concepts. They are, however, all concepts
know to deliver less than 80% reliability (Resar 2006). Furthermore, the outcomes
from previous audits have not been sustained. It was essential that this project
therefore demonstrated innovation and interventions consistent with providing more
reliable and sustainable solutions.
Sustainability
Page | 4
The evidence suggests that very few improvement projects are sustained in the
long run with some suggesting up to 70% of improvement projects are not sustained
(Anon 2009). Reasons often cited for this are employee resistance to change,
management behaviour not supporting the change and inadequate resources. This
project therefore needed to overcome those obstacles. Furthermore, in the context
of general practice there is a great deal of overlap between management and
partnership behaviour as many partners will assume aspects of the management
function. This was particularly significant in this practice which has 12 partners. An
attribute of sustainable projects is alignment with the practice’s aim, mission, vision
and philosophy or the ‘strategic fit’. This project was predominantly in the “patient
care process" of the system. The mission of the patient care process is to "provide
evidence-based patient centred care treating the person in a safe and
compassionate manner". The driver diagram (Appendix 3 – Driver Diagram for
Patient Care Process) visual illustrates how this project aligns with the mission of the
patient care process and how that then aligns with the mission of the organisation in
"delivering excellence in healthcare." The swim lane process map (Appendix 4 –
Process Map), however, also illustrates that this project does also impact another
process of "recording and monitoring" in the system.
Attributes of sustainable project may be categorised into process, staff and
organisation. The sustainability model (Maher et al. 2010) provides a structured
framework for assessing a project against the various components that are known to
positively correlate with a more sustainable project. An analysis of this project
against those components is illustrated by the radar chart in Appendix 5 –
Sustainability Analysis.
Page | 5
This tool is ideally administered at several stages of the project, including at the
beginning, at mid-points, and finally at the end. Furthermore, it is ideally rated
against the components by others in the improvement team. However, I became
aware of this tool after I had started the improvement project, and as it was the first
time I was utilising this tool, I rated it myself and only at the point I became aware of
it. It provided a really useful insight into areas to explore to increase the probability
of having a more sustainable project. In future projects I will leverage the utility of
this tool further by using it at several points in the lifecycle of the project.
A review of the sustainability analysis confirmed the alignment discussed above
which scored highly. Areas where there were significant gaps included the criteria of
“benefits beyond helping patients” and “staff behaviours towards the change”. These
insights were particularly helpful in understanding the planning of the project to
include aspects that would reinforce and maximise the engagement of staff and
reduce resistance to change.
Quality Improvement Tools
A structured and systematic approach to improvement utilises a data driven
informed approach to change where each of the solutions are selected and identified
on the basis of a diagnosis phase. The solutions are tested and refined in the real
world and when shown to be effective implemented. The approaches used in this
project include a series of tools known to help engagement thereby trying to embed
the change into routine practice (Wilcock et al. 2003; Hawkins & Lindsay 2006;
Baker 2000; Beckman & Frankel 1984; Institute for Healthcare Improvement 2004;
Pronovost et al. 2008; Langley et al. 2009). These include:
Page | 6

use of patient stories

use of data

involvement of staff in the diagnosis, through leadership walk arounds,
staff surveys and observations

involvement of as wide a range of people as possible in testing and trying
out ideas and PDSA

use of regular communication on progress of the project through updates
and reports which were programmed in the project plan (Appendix 1 –
Project Plan).
A personal reflection on the use of these tools was on the whole extremely
positive. Particularly, the use of the staff survey in the 'diagnostics' was invaluable
and this is supported by comments such as "until i started to look at this as an improvement
project I was not that aware of the guidance”
and “interested to find out how you are going to use the
survey -great idea! Made me read the guidelines and ?change practice".
The use of patient
stories did not have as much impact as suggested in the literature (Wilcock et al.
2003; Hawkins & Lindsay 2006) and from anecdotal evidence of others that have
used it. Perhaps, one of the reasons for this is because the attitude of the clinicians
towards the project was very favourable (Appendix 6 – Results of Surveys), where in
response to the question “How relevant do you think the following measures are in
the assessment of febrile children and how often do you measure them?” everyone
rated it as either "strongly agree" or "tend to agree". This hypothesis is further
supported by strong correlation with the criteria in the sustainability assessment on
“clinical leadership engagement and support”. This was unexpected and is in
contrast with published literature (M. Thompson et al. 2008).
Page | 7
The use of data was particularly powerful in combination with both the leadership
walk rounds where the approach was a combination of an appreciative enquiry and
round of influence (Reinertsen & Johnson 2010). NICE guidance on assessment of
febrile children recommends all febrile children under the age of five have their
temperature, pulse rate, respiratory rate and capillary refill time measured (NICE,
2007). The baseline data showed that ALL four aspects of the assessment of febrile
children were never done (Appendix 9 – Measurement). During leadership walk
rounds some staff often demonstrated their awareness of the guidance and stated
that they always measure the four components. The baseline data was powerful in
that it provided an objective non-judgmental challenge, that subsequently led on to
an appreciation that non-conformance with the guidance was a routine violation. A
further benefit of involving staff in the diagnosis was it helped provide education, and
offered an opportunity for staff to make suggestions, and indeed a number of those
suggestions were actually tested as ideas for change (Appendix 7 – Log of a
selection of PDSA Cycles). This was a direct result of recognising the need to
improve staff behaviours identified through the sustainability analysis. A criticism of
guidelines such as those produced by NICE is that recommendations made are not
directly related to behaviours (Michie & Johnston 2004). Hence asking a number of
different members of the team to conduct and test ideas for change helped to
translate the recommendations into change behaviours. These included other
doctors, nurses, and healthcare assistants. The use of PDSA and involving staff in
testing is said to offer a number of advantages by demonstrating whether change
ideas may work in the real world or not, refine change ideas and enhancing
engagement, through providing opportunities for others to be involved in change
project. This correlates well with human motivational theory that suggests human
Page | 8
motivation is influenced by autonomy, mastery and sense of purpose (Pink 2009).
The use of driver diagram (Appendix 3 – Driver Diagram for Patient Care Process)
provides the purpose and the use of PDSA provides a sense of autonomy and
mastery.
Regular communication throughout the scope of the project was through use of
email and intranet, as well as personal opportunistic face to face communication.
This strategy proved enormously successful in maintaining the will of others but
moreover gave the opportunity to seek feedback and further ideas for change.
The staff survey and leadership walk arounds identified a need for education and
training. This was provided by an online learning tool, hosted on the practice's
intranet and then further signposting to an online tool offered by BMJ learning in
association with NICE. The literature on reliability in healthcare identifies two sets of
change concepts. The first set that includes training and education, reliance on hard
work, vigilance, personal checklists etc is provides the opportunity to achieve
reliability unto 80% (Resar 2006; IHI 2007). A second group of change concepts
however raises the bar and provides the opportunity for a reliability of 95%. These
change concepts include process standardisation, a focus on human factors and the
redundancy checks. In this project, in order to achieve the 95% reliability standard
set, it was imperative that change concepts from both groups were tested and
implemented if successful.
The literature on human error confirms the inevitability of human error, particularly
when weaker aspects of cognition such as short term memory are relied upon (J. T.
Reason 1990; J. Reason 2000; HSE n.d.). Another cause of 'care delivery problems'
is violations or deliberate deviation from policy and protocol (Amalberti et al. 2006).
Page | 9
The reasons for violations are varied and include perception of productivity and
efficiency gain, as well as attitudes towards perceived risk and harm from noncompliance that is often reinforced by the resilience of biology. The accident
causation model (Charles Vincent et al. 1998) suggests that to reduce the risk of
care delivery problems, one may look at a range of error producing conditions that
include a range of factors that includes a review of the task and then environmental
factors. The insights from observation were confirmed from direct questioning on the
staff survey. These showed that often the omission arose as a result of absent
equipment, a failure to remember to check all four components, a lack of confidence
in interpretation or failure to record the assessment. Leadership walkarounds also
confirmed that violations took place. That is staff admitted to not always checking,
for example, the pulse rate, and reasons they cites included a sense that the child
did not look unwell or that it was time consuming and felt to be unnecessary. In
keeping with the philosophy of "make it easier to the right thing and harder to do the
wrong thing" a series of human factors interventions were tested and implemented
(Appendix 7 – Log of a selection of PDSA Cycles).
The first aspect of the change was to ensure equipment was easily available. In
other quality improvement projects the ease of availability of equipment has been an
issue (Pronovost et al. 2008). The organisation of the workplace and environment
using the ‘5S’ lean tool (Amnis 2011) offers a solution to this problem. Through a
series of iterative cycles the tool was tested and subsequently implemented (Figure
3: 5S visual management card + equipment). Measurement of equipment
availability showed that it was more consistently available after implementation of 5S
(Figure 1: Impact of 5S Intervention). A further benefit of this tool was that it that its
approach is being considered for wider use in the consulting room.
Page | 10
A key change concept associated with high reliability is the suggestion of linking
interventions with existing habits. A Pareto analysis of the baseline data (Figure 12,
page 41) showed that of the four components in the ‘bundle’ the temperature was
being measured just over 80% of the time. This was confirmed again during
observation. Observing the task also showed that the temperature was checked
using a tympanic thermometer, which required the value of the temperature to be
read on a digital LCD display. A memory prompt sticker was tested and placed just
underneath the LCD display as a symbolic barrier to prevent clinicians forgetting to
check the other aspects of the assessment (Figure 4 and Figure 5, page 33).
The purpose of the assessments is to use a risk based approach to identify children
with possible underlying serious illness. The staff survey (Appendix 6 – Results of
Surveys) showed a wide variation of clinician’s confidence in interpreting the
measurements from the assessment and specific free text comments in the survey
suggesting better compliance “if a card / sheet in rooms” was available and therefore “making it
easier to refer to”.
PDSA cycles were used to test the potential solutions. The final
solution was informed by the observation of the task and qualitative feedback. This
identified that reminder cards on noticeboards, or on desk would very quickly
become misplaced. The common aspect in the task in every room was the use of
the computer and mouse. Hence, the normal values were placed on a mouse mat
(Figure 7: Mouse mat enlarged) specifically designed with a picture of a little girl
having her temperature checked to further provide a memory prompt, to check the
temperature, as well as serving the need to have easily accessible normal values.
Supplementary information was place on the front page of the practice intranet, as
well hyperlinks to relevant menus and identified in the search engine for ease of
reference (Figure 8: Screenshot of intranet with traffic light system reference).
Page | 11
A further human factors issue again identified from the survey was a series of
prompts to make the data recording easier so once values are measured it is easier
for clinicians to record them. An advantage of computerised records is that it offers
the potential for IT solutions. A template was created with fields for the four
parameters and also a field to assess the outcome of traffic light assessment (Figure
9: Screenshot of data recording template). This template was inserted into a further
template commonly used for recording of ‘acute respiratory infections’.
Hence, a series of interventions in keeping with the principle “make it easier to the
right thing and harder to do the wrong thing” were tested. A criticism of this
approach is that there were multiple interventions being made and the model for
improvement approach recommends that each change is tested and refined, and the
outcome measured before making further changes. This implies that the changes
should be sequential in nature. However, the accelerated model for improvement
suggests that more rapid change may be achieved through parallel use of multiple
PDSA cycles (Langley et al. 2009). This was the experience in this project where
the approach of parallel PDSA cycles actually enabled it to be completed earlier than
scheduled. Moreover, by involving a great number of people in testing of the PDSA
cycles, there was an anecdotal sense of greater engagement.
A final principle of reliable design recognises that despite a range of interventions
there will still be a failure leading to a care delivery problem. Therefore interventions
to “spot and stop” the failure, before it causes harm to patients, are required. The
use of a standardised recording template facilitated an automated solution for the
redundancy check (IHI 2007). The clinical system offers the facility for an electronic
algorithm to be programmed that can be activated by a read code trigger. The
Page | 12
algorithm (Figure 10: Diagram of algorithm for redundancy check with screen shot of
prompt) was programmed into the clinical system and tested using a series of test
patients and refined until it functioned as expected. The algorithm was triggered on
the basis of Read codes entered as a problem title in the electronic medical records.
On conducting a FMEA of this intervention it became apparent that there were
several points at which the intervention may fail (Appendix 8 – FMEA). In order to
mitigate these failures an analysis of the read code usage for children presenting
with a fever was undertaken on a daily basis (as the data for the output metric was
being collated). These read codes were then linked to the algorithm. If the data had
not been recorded a prompt would appear forcing the clinician to enter the data or
actively quit from the algorithm. Hence, the only other failure mode that remained
was if the clinician did not enter any read code. To mitigate against this a further
intervention was designed. This was a personalised feedback. The feedback would
be given in writing on a postcard. The front of the postcard was designed to have
the picture of the same girl having her temperature taken together with the normal
values and the traffic light system.
Results
A series of interventions were used in parallel. Each one of these interventions was
tested and assessed individually using a combination of subjective and objective
measures as detailed in Appendix 7 – Log of a selection of PDSA Cycles. The aim
was to have 95% of febrile children under the age of five assessed using all four
parameters recommended by NICE. The measurement strategy was to use daily
measures and express it as a percentage (Figure 11, page 41). This shows that the
percentage of children assessed using all four parameters started to improve but the
Page | 13
process had not become stable yet. However, the denominator was small and
hence only one or two patients would significantly alter the percentage and cause
wide swings. This was a disadvantage in retrospect of having a small denominator
and using a daily measurement. However, a big advantage of having daily
measurements was to provide a large number of data points and therefore provide a
good understanding of the variation using statistical process control. In order to
better understand the variation a second process control chart was used for each
consecutive patient thereby giving many more data points. Each patient was
assigned a score of 1,2,3 or 4 based on the number of items recommended by NICE
that were measured. Analysis using this methodology (Figure 13, page 41) provides
greater clarity of the improvement achieved. It is recommended that improvement
projects have measures that include outcome measures, process measures and
balancing measures (Clarke et al. 2010). The purpose of this project was to ensure
the assessments were conducted as per national guidance. This is the output being
sought and whilst not an direct outcome measure, it may be considered as a proxy
outcome measure. Ideally, the outcome measure would include percentage of
children with serious illness identified at first presentation. However, the low
prevalence of serious illness in primary care makes this a difficult measure over a
short period of time. A possibility is to use a trigger tool methodology to identify
omissions causing harm, however, there is no such validated tool. A concern was
that requiring clinicians to do the assessment in all febrile children would lead to
longer consultations and during the walk around it was identified that this was one of
the reasons for the violation of not measuring all four aspects. Hence, a balancing
measure of consultation length was used. This showed no change in the
consultation time following the improvements (Figure 14: Balancing measure).
Page | 14
Conclusions
The purpose of this project was to improve quality of care by implementing
guidelines produced by NICE. The project used a series of quality improvement
tools designed to provide a structured approach to the improvement and maximise
the opportunities to make the changes sustainable. The improvements were in the
context of an organisation well versed with change management approaches. A key
learning for the organisation was the benefit of embracing the human factors
elements of the improvement project. These human factors e.g. 5S approach,
elements have provided the opportunity to spread generic solutions to improve care
and productivity generally.
The project was also carried in the context of an educational programme, AIQS. The
active personal engagement in the programme, through the philosophy and actions
outline in the learning agreement served to enrich and embed the learning more
deeply that would otherwise have been the case.
This is an on-going project and the first step was to ensure the assessment was
done as per NICE guidelines. The early indicators are positive, however, the
process needs to be monitored to ensure the change is sustained. There are further
sections of the NICE guidance on this subject that can now be implemented. This
includes the assessment of patients remotely assessed and the quality of advice
given to patients, particularly those who have a risk of green or amber on the traffic
light system.
Given the exponentially increasing medical knowledge (Smith 1978) individualistic
approaches to deliver reliable evidence based care cannot be sustainable or
effective given the volume of new knowledge. Whilst the need for guidelines, hard
Page | 15
work, vigilance and individualistic approached are necessary, a systems based multifacet approach incorporating the cultural of the organisation, the task, environment,
the team, the individual and the patient, provides the potential to translate evidence
into practice reliably. There has been much debate and discussion of whether
quality improvement approaches are effective and the evidence answering that
question is limited (Boaden et al. 2008). In the absence of evidence it is important
improvements are made and it has been suggested that organisation will gain more
from identifying and utilising an approach to quality improvement (Walshe 2002).
Page | 16
Page | 17
Appendices
Appendix 1 – Project Plan
Page | 18
Paresh Dawda
Appendix 2 - The practice as a system
Page | 19
Paresh Dawda
Appendix 3 – Driver Diagram for Patient Care Process
Page | 20
Paresh Dawda
Appendix 4 – Process Map
Page | 21
Page | 22
Appendix 5 – Sustainability Analysis
Your score
Your total score for this review period is: 63.2
Preliminary evidence suggests a score of 55 or higher offers reason for optimism.
Scores lower than 55 suggest that you need to take some action to increase the likelihood that your improvement
initiative will be sustainable.
Page | 23
Paresh Dawda
Appendix 6 – Results of Surveys
Which statement applies
best to your awareness of
this guidance?
Relevance:
How relevant do you think the
following measures are in the
assessment of febrile children
and how often do you measure
them ?
Measure:
Page | 24
How often do you not measure
the temperature because you
cannot find a working
thermometer to hand ?
Do you know where to find an
electronic axillary thermometer
in the surgery ?
What is your level of confidence
in interpreting the values for
temperature, pulse rate,
respiratory rate and capillary
refill time for different age
groups of children ?
Freetext comments

Until i started to look at this as an improvement project i was no that
Page | 25
aware of the guidance

question 3 always have a thermometer.

question 5 confident in interpretation when i have looked up the
relevant values need easy prompt to fill in examination onto records
please.

Interested to find out how you are going to use the survey -great idea!
Made me read the guidelines and ?change practice

Re question 3 I always measure temperature as keep a thermometer
as part of my personal equipment. This is not an option and cannot
complete form unless tick a box so have ticked one but this is not the
true answer. Would formally use traffic light system if a card / sheet in
rooms making easier to refer to.

I do need to review the guidance more regularly

I generally need to look up values for pulse and resp rate in very
young infants

I find tympanic membrane thermometer unreliable at times - this may
be due to uncooperative child, wax in ear, narrow canal. no always
necessary to measure respiratory rate accurately if child appears well
and breathing rate looks normal. sometimes do not measure temp if
child seems well otherwise.
Page | 26
Page | 27
Appendix 7 – Log of a selection of PDSA Cycles
Date
Plan
Do
Study
Act
What are we trying to accomplish?
To develop a data collection strategy so data collection is quick and efficient
How will we know that a change is an improvement?
If the data collection can be done quickly and easily without taking too much time. Qualitative feedback.
What change can we make that will result in improvement?
Design a search strategy to identify the population of patients under the age of five with a fever
21.1.201
1
Design a spread
sheet to collect
data on children
under the age of 5
who have
presented with a
view to
establishing
baseline measure
of % of patient
who have
complied with
NICE guidelines. I
will collect data
from those
patients who were
seen on one day.
I will assess if the
spread sheet and
the operation
I performed this task
on 24 Jan. I did a
search on patients
under the age of five
who presented on
Friday 21st and
reviewed their notes
and completed the
draft spread sheet
On reviewing these patients I
identified a group who had been
assessed remotely and they
therefore did not have the
parameters on the spreadsheet
completed. Of the 49 patients
identified in my search strategy a
large number had been seen for
other reasons e.g. immunisations
etc. This led to unnecessary time
being wasted in reviewing their
notes.
I reviewed the operational definition and decided that I
need to look at data for two populations those remotely
assessed and those assessed face to face. For those
remotely assessed I need to do a literature review exercise.
I also reviewed the search strategy to group by clinics to
minimise time spent on reviewing unnecessary case notes
Page | 28
Paresh Dawda
definition are
workable.
29.1.201
1
I will redesign the
search strategy to
group by clinics
and review case
notes to ensure
minimal amount of
time wasted. I will
also focus on the
those seen by face
to face
consultation at this
stage.
I redesigned the
search strategy. The
patients are now
grouped by session
(GP Surgery, Minor
illness, UAT AM and
UAT PM) and I can
select the relevant
ones quickly
This enabled me to identify the
group of children to look at much
quickly.
I will use this search strategy
What are we trying to accomplish?
To ensure thermometers of both types are available in each consulting room
How will we know that a change is an improvement?
audit of equipment
What change can we make that will result in improvement?
Check stock and inventory, Identify stock and site, Try visual management (5S)
Page | 29
13.5.201
1
There are
occasions when
absence of
thermometer
prevents the task
from occurring. I
will therefore test
and try out a 5S
type of approach
to make place the
thermometer in
same place in
different consulting
rooms with a
visual
management
system if it is not
there. I will design
the base for the
visual
management and
show it to the HCA
and ask them for
feedback.
Two type of layout created and HCA will action and apply
to all rooms week commencing 31 May. A snapshot audit
to be carried out 1-2 weeks after implementation of this.
I designed this and
showed it.
There was some scepticism but
HCA were happy to try out
(Interestingly they saw how it could
be applied to other aspects of room
layout). We need two type of
template one with BP monitor on
outside and one on inside
depending on the layout of the
room.
Figure 1: Impact of 5S Intervention
Page | 30
Figure 2: 5S table top visual management card
Figure 3: 5S visual management card + equipment
What are we trying to accomplish?
In ever consultation with feverish child all four parameters of assessment happen reliably
How will we know that a change is an improvement?
% of children with all four assessments completed, Subjective feedback
What change can we make that will result in improvement?
Memory prompt on thermometers
Page | 31
31.5.2011
Measurement of
temperature is
occurring 80% of
the time. I will
therefore try a
human factors
intervention and
see if by stick a
label on the
thermometer to
remind to check
PR/RR/CRT has
any impact. I will
do it at the surgery
in the morning
session with a
member of the
UAT team and see
if that improved
the recording of
the 4 measure at
the end of the
morning
I tried this with two
people during a UAT
morning clinic
The qualitative feedback was this is
helpful. They measured the items
for the patients their saw that
morning but they said recording it
was a problem.
I will use this solution and look at testing solutions to make
recording of data easier. The solution was implemented
during week of 31.5.2011 by HCA.
Page | 32
Figure 4: Tympanic thermometer with memory prompt
Figure 5: Digital thermometer with memory prompt
What are we trying to accomplish?
Trying to ensure once they make the measurements clinicians apply them and interpret them correctly.
How will we know that a change is an improvement?
Qualitative feedback & Hit rate
% of children who have had all four measurements done having traffic light system assessment recorded (Green, Amber, Red) in the notes
What change can we make that will result in improvement?
Make the normal values and traffic light systems easily available for all clinicians, Normal values as a mouse mat.
12.5.201
1
The questionnaire
suggested people
do not always
remember the
normal values. I
therefore will see if
the normal values
on a 4x6 card on
the noticeboard is
helpful
I asked 2 members of
the UAT to team to
review this and
feedback.
They found I useful. They
identified that there was scope for
adding normal CRT time there as
well. They also said that whilst
helpful there is so much on notice
boards
I observed the task process and noted that the consistent
item always visible is the Mouse Mat. The first batch was
printed together with taking account of traffic light system
but these were too small in print to be of use. Hence only
normal values used and solution implemented 9 June
2011.
Page | 33
What are we trying to accomplish?
Trying to ensure once they make the measurements clinicians apply them and interpret them correctly.
How will we know that a change is an improvement?
Qualitative feedback & Hit rate
% of children who have had all four measurements done having traffic light system assessment recorded (Green, Amber, Red) in the notes
What change can we make that will result in improvement?
Make the normal values and traffic light systems easily available for all clinicians, Normal values as a mouse mat
12.5.201
1
The questionnaire
suggested that
people also did not
generally apply the
traffic light system
and there was one
specific request for
prompts. I will test
out during one
UAT clinic and ask
Nurse/GP whether
an A5 double
sided prompt is
helpful with traffic
light system on
one side and
management on
the other. I will
ask the questions:
1) Does it make
sense 2) Is there
sufficient/too little
or too much nfo 3.
Is it helpful and
any other
comments
I asked two member of
the UAT team to test
this out. One was a
nurse and one a GP.
The feedback was that this was
helpful. It was suggested that the
abnormal values could be in bold to
highlight them more. It was also
suggested that pieces of
paper/prompts on noticeboards get
mislaid/lost.
I made visual changes to the prompts as advised. Instead
of paper on noticeboard I thought about having an easily
referenced page on the intranet. I also thought about
placing it on a mouse mat but the print was too small.
Hence only the normal values were placed on the mouse
mat.
Page | 34
Figure 6: Mouse mat
Figure 7: Mouse mat enlarged
Figure 8: Screenshot of intranet with traffic light
system reference
What are we trying to accomplish?
Improve the recording of (and make it easier to interpret) the assessments
How will we know that a change is an improvement?
% of consultation with febrile children where template has been used.
What change can we make that will result in improvement?
Create a template for recording so data entry can be easily entered (and coded)
Page | 35
14.5.201
1
The questionnaire
suggests that
there is belief in
the value of the
measurements in
general and the
statement is
people say they
measure it more
than what is
actually recorded.
Is this therefore a
recording issue? I
will devise a
recording template
to try and make it
easier to record.
I created a recording
template with the
following Read code
structure:
Template Title temperature symptoms
(165)
Temperature: 2E3
Pulse Rate: 242
Respiratory Rate: 235
CRT: 24J0
(abbreviated to CRT)
The template was
linked to the read code
temperature symptoms
and also inserted as a
sub template in the
Acute Respiratory
Infections template.
The template was
programmed so this
information was only
requested if the patient
was less than 5 years
of age.
The template was tested. I looked
at the one days use of the
template. I learnt that people use a
whole range and variety of read
codes so the template may not be
called up every time. Also the
entire template is voluntary and
there is no forcing function.
However, if the will is there it does
make it easier to read code
Another solution (redundancy) required to help with this.
The template worth maintaining and may be able to build
on e.g. add the outcome of traffic light assessment.
Page | 36
Figure 9: Screenshot of data recording template
What are we trying to accomplish?
Trying to make sure that there is a redundancy check in the process to make capture where the assessment has not taken place
How will we know that a change is an improvement?
% of occasions when redundancy check implemented
What change can we make that will result in improvement?
Create and electronic “Protocols” such that when the electronic record is saved it checks to make sure assessments have been recorded (& prompts)
Page | 37
29.5.201
1
Hypothesis:
Redundancy
check could be
done using an
electronic protocol.
The protocol was
designed (see
chart) and tested
on a test patient.
The Read Code
acute respiratory
infection was
linked to the
protocol. I will
review the next
day’s data to see
what percentage
of people who use
the problem title
for consultation on
that day in children
complete the
template. An
FMEA was also
conducted on this
redundancy check
(Appendix 8 –
FMEA)
This is an automated
protocol which will be
performed on
31.5.2011 and I will
review the results at
the end of the day.
No patients with acute respiratory
infection problem title seen today
Reassess tomorrow. Add cough as another problem title.
This became and iterative process as so many different
codes being used so data collection expanded to review
read code usage, and each time a new code was used it
was linked to the protocol.
1.6.2011 - five further triggers added to redundancy
protocol
Page | 38
Figure 10: Diagram of algorithm for redundancy check with screen shot of prompt
Page | 39
Appendix 8 – FMEA
Step
1
2
Failure Mode
Triggers
Protocol performing
Causes
Consequence
Liklihood
(1-5)
Risk
Liklihood
*
Consequ
ence
Consequ
ency (1-5)
Mitigation
Read code not linked to algorithm
redundacy process fails
4
x
2
=
8
review read codes used in daily search and proactively
link with electronic protocol
Clincian does not use a read code at all
redundacy process fails
2
x
2
=
4
design postcard to provide individual feedback
Clinician escapes from the protocol
redundacy process fails
3
x
2
=
6
designed a step into protocol to advice clinician that they
areviolating NICE guidance
Clinican free texts data
redundacy process unnecessarily activated
3
x
2
=
6
data entry template will minimise this occuring. Consider
activating template based on read codes also
x
=
x
=
x
=
x
=
x
=
x
=
x
=
Page | 40
Appendix 9 – Measurement
Figure 12: : Pareto analysis - baseline data
Figure 11: Run chart of % of febrile children with all
four components completed
Start of
PDSAs
Implementation of
Redundancy
Read code
human factors PDSA
check
not linked
Locum
Figure 13: Number of measurements for each patient
Change
introduced
Figure 14: Balancing measure
Page | 41
Paresh Dawda
Page | 42
Paresh Dawda
References
Amalberti, R. et al., 2006. Violations and migrations in health care: a framework for
understanding and management. Qual Saf Health Care, 15 Suppl 1, pp.i66-71.
Amnis, 2011. Safe and Effective Service Improvement: Delivering the safety and
productivity agenda in healthcare using a Lean approach. , 43(1).
Anon, 2009. How do I create a distinctive performance culture ?, McKinsey & Company.
Baker, R., 2000. Managing quality in primary health care: the need for valid information
about performance. Qual Health Care, 9(2), p.83. Available at: 2 - baker - managing
quality qhc.pdf.
Beckman, H.B. & Frankel, R.M., 1984. The effect of physician behavior on the collection of
data. Annals of Internal Medicine, 101(5), pp.692-696.
Boaden, R. et al., 2008. Quality improvement : theory and practice in healthcare, Coventry:
NHS Institute for Innovation and Improvement.
Clarke, J., Davidge, M. & Lou, J., 2010. The how to guide for measurement for improvement,
Harnden, A. et al., 2009. Child deaths: confidential enquiry into the role and quality of UK
primary care. The British journal of general practice : the journal of the Royal College
of General Practitioners, 59(568), pp.819-24.
Hawkins, J. & Lindsay, E., 2006. We listen but do we hear? The importance of patient
stories. British journal of community nursing, 11(9), pp.S6-14.
HSE, Reducing Error and Influencing Behaviour (Guidance Booklets), HSE Books.
IHI, 2007. Designing Reliability into Healthcare Processes. , (January), pp.1-9.
Institute for Healthcare Improvement, 2004. Patient Safety Leadership WalkRounds.
Available at: http://www.ihi.org/NR/rdonlyres/53C62FFD-CC4A-4DEA-A86983B575DCEED8/640/WalkRounds1.pdf.
Langley, G. et al., 2009. The improvement guide : a practical approach to enhancing
organizational performance 2nd ed., San Francisco: Jossey-Bass.
Maher, L., Gustafson, D. & Evans, A., 2010. Sustainability Model and Guide.
McGlynn, E.A. et al., 2003. The quality of health care delivered to adults in the United
States. The New England journal of medicine, 348(26), pp.2635-45.
Page | 43
Paresh Dawda
Michie, S. & Johnston, M., 2004. Changing clinical behaviour by making guidelines specific.
BMJ (Clinical research ed.), 328(7435), pp.343-5. Available at:
NICE, 2007. Feverish illness in children under 5 years assessment and initial management in
children younger than 5 - Guidelines. , 93(CG47).
Pink, D.H., 2009. Drive: The Surprising Truth about What Motivates Us, Canongate Books.
Pronovost, P.J., Berenholtz, S.M. & Needham, D.M., 2008. Translating evidence into
practice: a model for large scale knowledge translation. BMJ, 337(oct06 1), p.a1714a1714.
Reason, J., 2000. Human error: models and management. BMJ, 320(7237), pp.768-770.
Available at: http://www.bmj.com/cgi/doi/10.1136/bmj.320.7237.768 [Accessed
November 13, 2010].
Reason, J.T., 1990. The nature of error. In Cambridge: Cambridge University Press.
Available at: Human error - 1 - The nature of error.doc.
Reinertsen, J.L. & Johnson, K.M., 2010. Rounding to influence: Leadership method helps
executives answer the “hows” in patient safety initiatives. Healthcare Executive, 25(5),
pp.72-75.
Resar, R.K., 2006. Making noncatastrophic health care processes reliable: Learning to walk
before running in creating high-reliability organizations. Health services research, 41(4
Pt 2), pp.1677-89. Available at:
Smith, E.P., 1978. Measuring professional obsolescence: a half-life model for the physician.
Academy of management review. Academy of Management, 3(4), pp.914-7.
Thompson, M.J. et al., 2006. Clinical recognition of meningococcal disease in children and
adolescents. Lancet, 367(9508), pp.397-403.
Thompson, M. et al., 2008. Using vital signs to assess children with acute infections: a survey
of current practice. The British journal of general practice : the journal of the Royal
College of General Practitioners, 58(549), pp.236-41.
Van den Bruel, A. et al., 2007. Signs and symptoms for diagnosis of serious infections in
children: a prospective study in primary care. The British journal of general practice :
the journal of the Royal College of General Practitioners, 57(540), pp.538-46.
Vincent, Charles, Taylor-Adams, S. & Stanhope, N., 1998. Framework for analysing risk and
safety in clinical medicine. BMJ, 316(7138), pp.1154-1157.
Walshe, K., 2002. Effectiveness of quality improvement: learning from evaluations. Quality
and Safety in Health Care, 11(1), pp.85-87.
Wilcock, P.M. et al., 2003. Using patient stories to inspire quality improvement within the
NHS Modernization Agency collaborative programmes. Journal of clinical nursing,
12(3), pp.422-30.
Page | 44