Shae Jackson, Consultant Trainee Practitioner
When I started out on my quality improvement (QI) learning journey a few years ago, I thought QI was all about ‘PDSA’ cycles – Plan, Do, Study, Act. So, I take problem ‘x’, think of a solution, plan it, do it, study how it went, then refine and repeat. As I have since learned, this misses out some crucial steps which are necessary so that I can really get to the heart of the problem, be clear about my aim, and know when a change is an improvement.
I have been on placement with the Early Supported Discharge (ESD) team for the last 6 months as part of a Health Education England-funded Consultant Practitioner development programme. Whilst on placements, I have objectives to undertake QI and I have been working with ESD and the Community Neuro Rehab Team (CNRT) to look at improving the how patients transition between these services.
In this blog, I will talk about some of what I have learned through my QI projects and I will leave you with top tips from my experience of QI.
So what is QI? There are a number of different definitions of QI, but the key thing is it’s purpose, which is set out nicely in a British Medical Journal article you can find here. This is a great article if you’re wanting to get started with understanding QI and how it relates to other improvement methods. It’s a nice easy read and has some useful discussion on the relationship between QI and audit, service evaluation, clinical transformation and research.
According to the authors, QI is ‘a systematic continuous approach that aims to solve problems in healthcare, improve service provision and ultimately provide better outcomes for patients.’
For me, the key words there are ‘systematic’ and ‘continuous’. How often have you been involved in a project that despite your best efforts, you’ve struggled to progress and implement, let alone embed and evaluate? It’s probably not because you’re “rubbish” at these sorts of things, or even necessarily because you don’t have enough time. It might be that you have experienced some of the same pitfalls I have:
I’ve launched into the project thinking I already know the solution to the problem. I jumped right in to some PDSA cycles, without taking the time to clearly define the problem, the aim of the improvement work, and how to measure to demonstrate impact. More on the ‘Model for Improvement’ later.
Thinking waaayyyyy too big. It’s important to be realistic about what we can achieve with the resources we have (time, people, money). From my experience, there are lots of great reasons to start small. Firstly, when a change is implemented, it has an impact on things/events/people both up and down-stream from the change. It’s difficult to predict all the possible impacts, so starting small allows me to iron out any issues. Also, the nuts and bolts of what might seem like a small change are often much more complex than it would first appear. And finally, if I try to implement too many things at once, how will I know which change has made a difference? I found it much more effective to work with small incremental changes, to see what has worked, what hasn’t, and why. A colleague of mine employed a simple way of expressing this: ‘Keep, change, or chuck’. Did the change work? Do we like it? Is it not too burdensome? Then keep. If not, can we change it, or do we chuck it? Starting small e.g. with one patient, at one time point etc. will allow you to figure out what won’t work before you try to roll out a big change across a whole team or service.
So where does the ‘Model for Improvement’ fit in? This model incorporates PDSAs, along with a number of key steps prior to PDSA cycles.
The first step is to establish and clearly articulate your aim. To do this you need to have a good understanding of the problem. Have you talked to others about it? What do they think? What do patients say? Can your QI project be co-produced? (See Carl Adam’ blog on co-production here). What data do you and your team already collect that can help you understand the problem? (Let’s be honest, we collect loads of data, and we’re not always sure why we are collecting it!) Can you link in with Business Intelligence/analysts to help? (Hint: you can. They are so helpful.)
You then need to decide what measures you will use so that you know that your change has made a difference. Have a look at this resource to help you with measurement.
It is only now that the time is right to think about change ideas! And here I would encourage you to be bold! Perhaps have a ‘brainstorming’ session; think ‘BIG’, where any and all suggestions are welcome. Our thinking is very often constrained by what our service can/has always offered, which doesn’t always align perfectly with what our patients need. What would ‘great’ look like and what do our patients really want? Truly listen and involve them to find out. Remember to keep your work within the sphere of what you can influence, and in alignment with your aim. This will help to keep you focussed and also hopefully prevent you from becoming overwhelmed.
Then, and only then, are you really ready for a PDSA cycle - ‘cycle’ being the key focus here. This is not a one-off process where you try something and then job-done. Use what you learnt by implementing your one small change to inform the next cycle, and so on until you’ve achieved your aim, evidenced through your measures.
And in case I’ve managed to fool anyone reading into believing that I am a QI expert…I’m not. I’ve been really fortunate to have some training and mentoring in QI, which I would I’d highly recommend you seek. (Caveat: provided you are in a position to put it into practice; QI is a very practical ‘hands-on’ approach, which I found I didn’t really ‘get’ until I was able to apply it to a project.) But really, I’m just a clinician learning how I can use QI in my clinical practice to make a difference for my patients’ care and experience. If I can do it, you can do.
Finally, don’t forget to shout about it! Keep an eye out for conferences and events both within and outside the Trust so you can share and spread your great work, because if you have improved a problem, chances are that someone else somewhere else has a similar problem too.
So, to wrap things up, my 3 top tips for getting into QI are:
Clearly define your problem, taking care not to jump straight to solutions Think small – focus on small incremental changes
Mine the brilliance of others – you, your colleagues and your patients have a wealth of knowledge, so work together. Don’t re-invent the wheel, do share ideas, and do access the wealth of resources, training, coaching and mentorship that is out there.
Time invested in well-thought out and well-lead QI projects with patients at the heart of improvement, is time well spent.