Presentation on theme: "How to do a quality improvement (QI) project?"— Presentation transcript:
1 How to do a quality improvement (QI) project? And yes, this can also mean how to do a clinical audit using QI methodologyEmma Vauxclinical lead – Learning to Make a Difference2013
2 A Model for Learning and Change When you combine the 3 questions with the……the Model for Improvement.PDSA cycle, you get…2The Improvement Guide, API, 19962
3 Repeated Use of the PDSA Cycle Changes That Result in ImprovementWhat are we trying toaccomplish?How will we know that achange is an improvement?What change can we make thatwill result in improvement?Model for ImprovementAPSDSpreadDATADSPAImplementation of ChangeAPSDWide-Scale Tests of ChangeHunches Theories IdeasAPSDSequential building of knowledge under a wide range of conditionsFollow-up TestsVery Small Scale Testcale Test3
4 A QI project in a nutshell Identify a clear and focused SMART aimDecide what change(s) you are going to makeDecide what you are going to measure before you start to monitor the impact of any change
5 It is all about following a structured process The overview…It is all about following a structured processGuides to how to make this happenFor the traineeFor the supervisorAll accessed via the LTMD website5
6 Top tips Develop your project plan and discuss with your supervisor Involve the right stakeholdersIt is even better when there is multi-professional involvementThink of what might be the unintended consequences of any changePrepare to educate others in the MDT about using a QI approach to a problem
7 An example of a QI project AimTo reduce the number of inappropriate urinary cathetersinserted into patients admitted to the Clinical Decision Unit by50% by January 2011ChangeIntroduce a checklist to be completed prior to any catheter insertionMeasureThe number of cathetersinserted according totrust guidelinesmeasured on a weeklybasis….start withmeasuring the baselinebefore any change is made andthen measuring little andoften after any changeTest out the next change and keep measuring………….It is much better to measure 1 day a week, a 10% sample, on one bay ofone ward than try and measure everything all the time
9 Are you finding this confusing 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.
10 Data points - why measure little and often? The traditional clinical audit way of doing things!!
15 Use of run charts to track changes The change seems to be associated with an improvementThe 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 differenceThe change seems to be associated with an improvement initially but the effect does not appear sustainedRemember little andoften measurementPerla R. BMJ Qual Saf 2011; 20: 46-51
16 Dr Olivia Walker CMT Royal Berkshire NHS Trust Example of a Learning to make a difference QI project Anxiety and Depression in Acute Stroke PatientsDr Olivia WalkerCMT Royal Berkshire NHS Trust
17 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.Working on the stroke unit we often noticed that patients were low in mood and would consider starting anti-depressants of we would refer straight the neuropsychologist.It was likely that we were not detecting all the anxiety and depression in our patients.17
18 The objectiveTo develop a local protocol that can be used to screen all acute stroke patients for anxiety and depression.
19 Project Aim (1)100% of stroke patients should have a Depression Scale completed within 5 days of admission and recorded in the notes100% of patients will have a repeat DEPRESSION SCALE completed in the MDT after 2-3 weeks.
20 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
21 So Olivia is doing a clinical audit ie a quality improvement project against an agreed standardIn this case against NICE recommendationsBut by using a SMART aim and prospective and little and often measurement Olivia is using QI methodology to implement and test out her changes
22 Change 1The 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:Hospital Anxiety and Depression Scale (HADS)Numeric Graphic Rating Scale (NGRS)
23 Outcomes What was tested Need specific guidelines/flow chart to identify which scale to use.Completing the scales is time consuming, therefore a briefer assessment initially would be useful.Need additional scale for patients with aphasia/dysphasia.Patients with cognitive impairment need assistance with completing a scale.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.
24 Change 2 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
25 Outcomes What was tested Poor completion of the SDSS within 5 days Barriers identifiedfollowing discussion with OTsNot 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.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.
26 Change 3The SDSS is included in the initial patient assessment by the OTs.The SDSS is printed on yellow paper.
27 Outcome What was tested Improved completion of the SDSS but not yet 100% achieved.New issue identified-Only having an initial SDSS may miss patients who develop anxiety/depression later in their admission.What was tested2 weeks later the notes of 20 patients on the stroke unit were reviewed following the new changes.
28 Acute stroke unit mood assessment pathway Does the patient have a language problem?YesSALT input required to allow for comprehensive screening to take placeSADQDISCS/NGRSNoHADSScore ≥ 9 refer urgently to medical team and neuropsychologist
29 A run chart to demonstrate the change over time since the introduction of the SDSS Modified Flow Chart IntroducedSDSS IntroducedFlow chartSSDS printed on yellow paper
30 The differences madeAn 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.
31 Olivia’s learning points As a junior doctor you can make a difference to patient care.Change takes time and requires dedicated and enthusiastic colleagues to maintain them.It is important to be able to adapt the project as problems arise and accept that timescales often need to be modified.
32 Getting started!Go to LTMD website for ideas and inspiration and the toolkitsThink of your own ideaIdentify a consultant supervisorIdeally involve the MDTComplete the project plan templateYou can always run your project plan past LTMD teamGet started!Use the template on the website for your report and presentations