Getting Started with QI

A number of reports have been published over the recent decade highlighting issues with the quality of healthcare in the UK (including Keogh 2013, Berwick 2013, Francis report into Mid Staffs). Each has outlined the key concerns and provided relevant recommendations for improvement. Each report has also emphasised the importance of quality improvement in improving care.

The Institute of Medicine has identified six dimensions of healthcare quality where to focus improvements:

• safe
• effective
• patient-centred
• timely
• efficient

There are multiple external drivers or influences that are used to improve quality of care, including the Commissioning Quality and Innovation (CQUIN) payment framework and the Best Practice Tariff, currently used to compensate innovation in COPD and pleural disease treatment. However, there are a range of methods and tools that allow individuals and teams with good staff engagement, to use a systematic approach to implement change and monitor progress.

There is not a standard definition of quality improvement (QI), but one that captures the ethos of continuous improvement is by Batalden and Davidoff (2007):

"The combined and unceasing efforts of everyone to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)".

One key aspect in which QI differs from the audit process, is the use of tools or methods to continuously improve the quality of care and outcomes for patients via multiple interventions or cycles of them. Many organisations have championed various approaches as there are many competing tools and methodologies including Lean, Six Sigma and Plan, Do, Study, Act cycles many of which originated in industry. There is no evidence that one approach is more successful than another and all have overlapping principles including:

• understanding the problem
• understanding processes
• analysing demand
• choosing the correct tool for change
• evaluating and measuring impact of an intervention

However, evidence suggests that consistency in approach is key and a systematic analysis of the impact of changes is important.

During our training we are advised to undertake and lead at least 2 QI projects in Respiratory and 1 General Internal medicine project, all of which must be evidenced by a QI assessment and a project report uploaded to your personal library on your e-portfolio, then linked to the curriculum goals.

Additional reading to understand Quality Improvement

• Jones Bryan, Vaux Emma, Olsson-Brown Anna. How to get started in quality improvement BMJ 2019
• The Health Foundation - Quality improvement made simple: What everyone should know about health care quality improvement
• The Health Foundation - The improvement journey: Why organisation-wide improvement in health care matters, and how to get started
• Royal College of Physicians - RCPQI: RCP quality improvement resources
• Quality Improvement Essentials Toolkit - ​​​Institute for Healthcare Improvement
• Dr Mike Evans: An Illustrated Look at Quality Improvement in Health Care - Institute for Healthcare Improvement

Respiratory Quality Improvement Resources

• British Thoracic Society Quality Improvement Homepage
• National Respiratory Audit Programme (NRAP) 1 and 2.

Examples of Respiratory QI projects

• Designing and implementing a COPD discharge care bundle.
• Quality improvement in Respiratory Medicine: Designing and implementing a bronchoscopy checklist at Southend University Hospital
• Sherwood Forest Hospitals NIV QI programme (video)
• Worthing Hospital - Management of secondary spontaneous pneumothorax
• BTS NIV QI Tool
• BTS smoking Cessation tool

Training and post graduate qualifications

Several universities now offer a postgraduate certificate (PGCert), postgraduate diploma (PGDip) and masters (MSc/MA) in Quality Improvement and related fields. These can usually be undertaken on a part-time and flexible basis. Searching online will reveal a range of such courses. There are a wide range of online learning resources to learn the basics of Quality Improvement methodology.

• Quality Improvement in Healthcare: the Case for Change, University of Bath
• Quality and Safety in Healthcare CPD, Leicester University
• Healthcare Quality Improvement PgCert, University of the Highlands and Islands

How to develop a QI project

• Define the problem
  • Process mapping – NHS Improvement
• Set aims
  • Institute of Healthcare improvement
• Plan your project 
  • PDSA cycle. Institute for Healthcare Improvement. USA     

Image: The model of improvement, courtesy NHS Improvement

• Determine your method of measuring change
  • Statistical process quality control (SPC charts) – NHS Improvement
  • Statistical process quality control chart video – NHS Improvement
    
    
• Sustain your change
  • NHS England Change Model
  • Sustainability in QI – Centre for Sustainable Healthcare, Oxford.

Hints, tip and motivation

• The science of persuasion – The Influence Network
• How to start a movement – Derek Sivers – TED
• Got a wicked problem? First, tell me how you make toast – Tom Wujec – TED
• How great leaders inspire action – Simon Sinek – TED

 How do I share my learning?

There are many QI conferences available and the BTS has committed to making QI integral to its meetings. There is a QI award available at each Summer Meeting and successfully shortlisted applicants are invited to verbally present their work. There has also recently been an increase in the number of journals featuring QI and others dedicated to the science.

•  British Thoracic Society Summer Meeting
•  International Forum on Quality and Safety in Healthcare
•  Royal College of Physicians Future Healthcare Journal
•  BMJ Quality and Safety
•  BMJ Open Quality

Author: Dr Daniel Smith