‘All improvement needs change, but not all change is an improvement’ Eli Goldratt, physicist

What is Quality Improvement and why is it important?

Anyone working in healthcare will appreciate that we are facing ever-increasing challenges on a day to day basis such as increasing demand, stretched resources and economic limitations

QI in healthcare is an ongoing effort to improve the quality of services to deliver efficient, high quality and patient-centered care. It involves everyone who has a part to play in delivering healthcare, including the patients themselves. It utilisies simple and effective methodology to identify whether things are working well and how and why this is.

GP Trainee QI Project

Throughout the NHS QI methodology is being increasingly recognised as a necessary part of healthcare development and transformation.

Part of the requirement for GP trainees is to have undertaken a full cycle of audit or a quality improvement project (QIP) by the end of ST3. We would encourage all trainees to undertake a QIP as part of their training.

One of the benefits of being a trainee is having additional time and resource to develop skills in change management that can be taken forward into the workplace after completion of training, and QI provides a process for doing this.

Learning

In order to help you to undertake this, the following resources will be available to you:

  • Online learning modules designed by leading QI organisations (see the ‘how do I do QI?’ section below)
  • Devoted time in your HDRC
  • TPD support
  • QI leads in each patch
  • QI training day (limited places, details to follow)
  • End of year project presentations

See the FAQ section if you have any further questions or speak to your TPD/QI lead.

Recording

As part of your project, we’ve provided a project template (see downloads), which has been designed to help guide and record your project. We recommend you then upload it onto your e-portfolio and attach it to a reflective log entry in time for your ST3 ARCP.
 

Project Timeline

Consider the below timeline utilising the framework of the RCGP cycle of change as a potential guide to help you undertake your QI project over the course of 12 months. You will want to discuss this with your clinical or educational supervisor early on in the process.
 

Month

Step

Months 1-3

e.g. August - October

1) Design your project

  • What improvements do you think could be made to improve services and patient care?
  • Could you collect any baseline data?
  • What QI tools might help you in your design process?
  • Discuss your thoughts with your CS/ES
  • Involve practice staff
  • Present your change ideas to your HDRC cohort – does anyone have similar thoughts or contributory ideas?

 

Months 4-9

e.g. November - April

2) Plan and Test your Project

  • Establish aims and methods
  • How will you measure your change?
  • PDSA cycles
  • Discuss your progress with your CS/ES
  • Involve practice staff
  • Present your project to-date to your HDRC cohort

 

Months 10

e.g. May

3) Implement and Embed

  • Analyse your data
  • Evaluate the success of your project
  • Could it be implemented into practice protocol?
  • Present your findings at a practice meeting

 

Months 11-12

e.g. June -July

4) Sustain and Spread

  • Present your project to your peers
  • Is there scope for ongoing/wider application?
  • Could you present your work at a conference/regional meeting?

 

 
Sharing

One of the key aspects of QI is to share our innovations across our health care system. On a local level this will likely take the form of presenting our projects with in our training patches. It may also mean publications/presentations at conferences.

Networking and collaborative working is positively encouraged as part of QI.

How do I do QI?

The idea of large-scale change can often be daunting and progress often stops there. This can arise due to resistance from others, lack of solutions, lack of time and being demoralized by past failures.

QI methodology uses evidence-based processes to enable efficient and sustainable change is delivered.

Take a look at a simple example of a QI project in primary care taken published in the RCGP QI guide. You will find it on page 12.

Hopefully that example has illustrated an effective way of how change can be implemented.
 

RCGP Quality Improvement Wheel for Primary Care


The QI team at the RCGP has put together some very useful resources, particularly their QI guide. In order to help in the design, delivery and evaluation of your project they have put together a simple visual representation to illustrate the elements of QI.

We shall briefly consider their QI cycle:

  • Step 1: Diagnose – what requires improvement? Collecting baseline data may help at this point.
  • Step 2: Plan and Test – establish aims, methods and how you will measure change. This stage also includes PDSA cycle (see below)
  • Step 3: Implement and Embed – take the successful changes and integrate them into practice.
  • Step 4: Sustain and Spread – Is there larger scale application for your change?

 
There are many QI tools to help at each stage of your project (see RCGP QI Guide page 20).
  

The Model For Improvement

A well-known and widely used method is ‘ the model for improvement’, created by Edwards Deming. This provides a framework for developing, testing and then implementing changes with the aim of improvement. This process can form part of step 2 in the RCGP cycle of change in planning and testing your change.

 At the outset you ask three questions:

  1. What are we trying to accomplish? i.e. what is our aim? 
  2. How will we know that a change is an improvement? i.e. what data do we need to collect in order to measure and therefore demonstrate improvement?
  3. What change can we make that will result in improvement? i.e. what ideas for change are we going to test/measure to achieve the improvement?

The Plan DO Study Act (PDSA) cycle is a trial-and-learning methodology, which enables you to test and develop change ideas on a small scale before large scale implementation.

PDSA cycle simply allows:

  1. PLAN –Ask the what, why, who, how and when questions. E.g. what data will be collected by whom and when? What are your objectives?
  2. DO – carry out the trial and collect data
  3. STUDY – analyse the findings and reflect on the process.
  4. ACT – implement changes or does it need further refinement?
     

Successive PDSA cycles allow for evaluation of change ideas on a small scale which can help prevent disruption, reduce resistance, learn from successful ideas and see larger improvements made through smaller, quicker steps. It enables you to refine change ideas in order to achieve your aim.

Measuring change can be done quantitatively or qualitatively. Quantitative data collection can be done through ‘Run Charts’, for example. This involves multiple points of measurement over a period of time and allows you to identify the variation seen on a day-to-day basis and identify any anomalous or random results. Qualitative data collection may look at the impact and experience of change.

QI Resources 

The above however is just a starting point and there are lots of other resources to enable you to achieve your aims. On the QI Resources sub-page you will find a list of excellent resources all of which provide free and interactive learning to equip you in QI methodology.