CAREERS

CAREERS
How to lead a quality improvement project
Fiona Tasker examines the best way to undertake initiatives to improve the quality of patient care
The General Medical Council (GMC)
expects all doctors to take part
in systems of quality assurance
and quality improvement that
will form part of their assessment
in the upcoming appraisal and
revalidation process.1
Quality improvement is best
thought of as the process by which
better patient experience and
outcomes are “achieved through
changing provider behaviour
and organisation through using
a systematic change method and
strategies.”2
Quality improvement projects
should be led by trainees, who
should find a supervisor to support
setting up and implementing the
project. This could be a clinical or
educational supervisor or someone
who works in the field of your
chosen topic; there is a pack for
supervisors on the Royal College of
Physicians’ website.3
Ultimately you should work as
a team with a number of faculty
members, including senior
members of staff, to create a
sustainable change.
Setting up a project
To choose your topic, think of
something on your ward or in
your department or hospital that
frustrates you and ultimately has an
impact on the safety of patients. This
could be a process or system, clinical
care issue, or educational initiative.
Now turn this frustration into
a quality improvement project.
For example, you could improve
prescribing for thromboprophylaxis,
improve needle safety when taking
bloods, or improve weekend
handover. Examples of quality
improvement projects are listed on
the “Learning to make a difference”
section of the Royal College of
Physicians’ website and the “Beyond
audit” section of the London
Deanery’s website.3 4 When you
have chosen your topic and project,
consider your aims, measures, and
changes. In thinking about your
BMJ CAREERS | 19 JANUARY 2013
Think of something on your
ward or in your department
that frustrates you and
ultimately has an impact on
the safety of patients
aims, consider what you are trying to
accomplish. Set a clear and focused
aim, and keep your goal “SMART”
(specific, measurable, achievable,
realistic, and timely).5
When it comes to the measures
you will be using, think about how
you will know that a change is an
improvement. You will need to
measure the impact by measuring
the baseline, setting a target, and
measuring progress.
Changes can be demonstrated
using a run chart of data over time.6
Plot the number being measured on
the y axis against a time period on
the x axis. For example, this could be
the percentage of patients prescribed
appropriate thromboprophylaxis on
one ward, measured every week for
several months.
Plot the data values before and
after implementing changes and
annotate the chart to indicate when
tests of change were initiated.
The effect of changes can then
be easily viewed. A link for a run
chart template is on the London
Deanery’s website.7
Implementing a project
When you have considered your
aims and measures, you need to
think about what changes you can
make that are likely to result in an
improvement. It is worth bearing
in mind that a small number of
changes are most likely to succeed.
When you have chosen your aim,
measure, and change, you should
follow the PDSA (plan, do, study,
and act) cycle.
Firstly, plan—you need to think
about what tasks you need to do
to test this change. You also need
to consider who will do what,
and when and where the work
should be done. Then try to predict
what will happen when the test is
carried out. Secondly, do—put the
plan into action and document
the changes using a run chart.6 7
Then study—analyse the data and
compare what happened with the
predictions that were made. Finally,
act—adopt, reject, or modify the
change plan. Then describe what
modifications to the plan should be
made for the next cycle.
It is best to make simple
and intuitive changes over a
short period of time. Through
a series of small scale changes
and continuous data collection,
you will hopefully be able to
show that your solutions have
resulted in improvement in the
area being evaluated. Refine the
change until it is ready for broader
implementation. Then you should
aim to embed this change in
everyday practice. For example, you
could expand the new way of doing
things from just one ward to the
entire hospital.
When you have achieved
successful quality improvement
changes within your team, share
your ideas with other organisations
to spread best practice. The
Standards for Quality Improvement
Reporting Excellence guidelines
provide a framework for designing
and writing up an improvement
study.8 You could also think about
presenting your work at meetings
such as the Patient Safety Congress
or the International Forum on Quality
and Safety in Healthcare.9 10
Publishing results of your project
You could consider submitting your
work to BMJ Quality & Safety, which
encourages innovation and creative
thinking to improve healthcare,
or Quality Improvement Reports.
The Department of Medicine at the
University of California also includes
a comprehensive list of quality and
safety journals under the “Quality &
safety” section of its website.11
There is an online community
of healthcare professionals in the
United Kingdom, known as The
Network, who are engaged in quality
improvement. The team behind this
community encourages people to
submit completed projects to the
website and some of these projects
are then selected for publication in
The Network’s annual “casebook”
(www.the-network.org.uk).
After you have completed your
first project, try to continue to
be involved with other quality
improvement projects. Share your
successful changes throughout
your career because better patient
experience and outcomes are
achieved through changing
provider behaviour.
Competing interests: None declared.
References are in the version on
careers.bmj.com
Fiona Tasker, core medical trainee,
Royal Sussex County Hospital,
Brighton BN2 5BE
fionatasker@doctors.org.uk
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