What is a QI project?

QI projects aim to improve patient safety, treatment effectiveness and efficiency, and the patient experience. They are real-time, dynamic processes involving focused, progressive, small-scale changes through a simple structured framework, which enable visible and effective change over a short period of time. QI projects are becoming increasingly important because of the limited resources available in the National Health Service (NHS). They can support service change and to achieve this may engage all professional groups, including trainees. Increasingly, evidence of QI is becoming a training requirement and is taking the place of audit as a subject to discuss at trainee reviews and job interviews.

Often the relationship between audit and QI projects is not clearly understood. Audit is also generally about quality improvement, beginning with identifying an audit subject, selecting audit standards and measuring the level of performance, then making improvements and re-auditing (Fig. 1). The focus is therefore on data collection. ^{Reference Nettleton and Ireland4} This area of practice has been criticised, as often the audit cycle has been left incomplete and the improvement part of the cycle left neglected. ^{Reference John, Mathew and Gnanalingham5,Reference Guryel, Acton and Patel6} QI projects are advantageously placed as they can be seen as part of the improvement element of the audit cycle, where the focus of the project is explicitly on making a service improvement instead of collecting data. ^{Reference Hillman and Roueche7} Although more complex than an audit, QI projects focus on changing complex adaptive systems and can empower doctors to investigate problems, identify solutions and work within a team to raise standards.

Fig. 1 Representation of the traditional audit cycle (based on Benjamin ^{Reference Benjamin8} ).

Practical steps to carrying out a QI project

The first step in developing a QI project is identifying a specific aspect of clinical practice that could be improved. This may be something that has been highlighted by an audit or identified by the wider team. It may be aligned to the local trust's quality and safety agenda, something that has been identified as a clinical incident or near-miss, or raised by patients or their families as a problem or idea to test. Finally, it may simply be an area recognised by local clinicians as something which is time consuming or frustrating and which could be improved. The project has a small focus initially, so rather than looking at 100 patient notes one might begin with just a single patient, or instead of trying to improve a whole hospital the focus may be on a single ward. Once an improvement has been proven to work on a small scale, it can be then tested on another patient or another ward, gradually being systematically scaled up and spread to become embedded in an entire hospital or trust. Depending on complexity, the projects can be undertaken within a 6-month training post.

The Institute for Healthcare Improvement recommend asking three questions ^{Reference Cohen and Reid9} based on the ‘model for improvement’ when planning a project:

1. 1 What are you trying to accomplish? This helps to set the aim of the project, which should be SMART (specific, measurable, achievable, realistic and timely).

2. 2 How will you know that a change is an improvement? This helps to think about what can be measured to illustrate the impact of the change. What would be an easy measurement? This needs to be done at baseline and then repeated at regular intervals so that the change can lead to learning and to show that it works.

3. 3 What changes can we make that will result in improvement? Possible ideas of changes to implement to make an improvement can be brainstormed. The current sequence of events already used can be examined and areas for improvement identified, for example by eliminating unnecessary tasks or steps, clarifying roles within the process, or by reducing delays and duplication.

Testing changes: the ‘plan, do, study, act’ (PDSA) cycle

The ‘plan, do, study, act’ (PDSA) cycles can be used as a way to develop, test and then implement a change on a small scale and in a real work setting (Fig. 2). ^{Reference Cohen and Reid9,Reference Deming10} Multiple PDSA cycles will be required to fully implement a QI project.

Fig. 2 The model for improvement is used as a framework to structure a quality improvement project (it includes going through several ‘plan, do, study, act’ (PDSA) cycles). ^{Reference Cohen and Reid9} Based on Langley et al. ^{Reference Langley, Nolan, Nolan, Norman and Provost11}

Stage 1: plan

The first stage is about planning a test of change. This involves taking a single idea and making a prediction as to what might happen when the change is implemented. A test and way of measuring whether what actually happens meets that prediction needs to be designed so that the impact of the change can be evaluated and learned from. This might be numerical data, such as increasing numbers of reviews of patients, or reducing numbers of critical incidents, and may also include patient and/or staff satisfaction scores or comments. Once you have determined what you are going to measure, make a baseline measurement. Determine what target you are aiming for: is it realistic? Plan the time you have available: for example, do you want to complete the project within the time frame of a training post? The planning stage can take time, but good planning will ensure a more successful project.

A useful tool for the early stages of planning a QI project is a driver diagram (Fig. 3), which can help to identify what steps could be taken to make an improvement. This has three columns: outcome (the aim of the project) and primary and secondary drivers. Primary drivers are the overall improvement areas that need to be addressed to achieve the desired outcome. Secondary drivers are the specific areas where changes or interventions can be made, motivated by the primary drivers.

Fig. 3 A driver diagram showing primary and secondary drivers for a quality improvement project trying to improve the time taken for referrals to be made to a psychiatry liaison service.

From this, ideas for change can be generated, such as producing a short guide of how to complete the referral form, providing a short training session for staff, or ensuring referral forms are located with other referral forms in the hospital. As well as measuring the time taken for referral forms to be completed at regular intervals to assess the impact of the change, staff satisfaction scores and qualitative data could also be gathered.

Stage 2: do

Following careful planning, one small area of change can be identified. The second stage of the PDSA cycle is where the change is actually implemented. Measures of the impact of change should be taken from an early point and frequently to monitor the effect of the change. Any problems or unexpected results are noted while the change is carried out.

Stage 3: study

The third stage involves analysing collected data and comparing that with the predictions made. A graphical representation of the measurements taken can be a useful way of plotting results to illustrate the pattern observed as changes are made. ^{Reference Perla, Provost and Murray12} A goal line can be shown so one can see at a glance where the work is in relation to achieving the aim. Changes or improvements that are made (in repeated PDSA cycles) can annotate the graph to clearly demonstrate the impact of those changes (Fig. 4).

Fig. 4 Plotting results for the example quality improvement project in Fig. 3.

The time taken to complete referral forms was measured by timing eight junior doctors; each point on the graph shows the average of these measurements. A goal line (of 180 s) is shown and interventions made at each ‘plan, do, study, act’ (PDSA) cycle are labelled on the graph so the effect of each change can be clearly seen.

Stage 4: act

In the final stage of a PDSA cycle you can ask whether the change you made achieved your aim. If not, what modifications to the change could be made? Or what other ideas can be put in place? When you are ready to make another change, the next PDSA cycle can be outlined.

Training in QI for the next generation of psychiatrists – a pilot programme

This is the first year of a pilot developed in the Severn Deanery to support core and advanced trainees to become involved in QI. The programme is being led by an advanced trainee (E.E.) as part of an Educational Fellowship awarded by the Deanery.

Until 2015 it has been a deanery requirement of trainees to carry out an audit project annually. This was amended so that all trainees are to be involved in either an audit or a QI project each year, and if an audit is undertaken trainees are encouraged to use QI methodology for the implementation of change part of the cycle. The structure of training and supporting trainees to undertake their own QI projects was adapted from the local Foundation School ^{Reference Bethune, Soo, Woodhead, Van Hamel and Watson1} and the Royal College of Physician's ‘Learning to make a difference’ programme. ^{Reference Vaux, Went, Norris and Ingham2} A half-day training session was developed to teach trainees about QI and project methodology, including using PDSA cycles in practical examples, so that they could undertake their own projects. This was delivered by E.E. alongside the local trust audit and QI department lead. Trainees were encouraged to come up with their own ideas for projects and to work with other trainees to implement changes, under the supervision of a higher trainee, specialty doctor or consultant. They were supported in including the wider multidisciplinary team in developing and implementing projects, as it was felt that this would be more likely to lead to successful and sustainable changes being made.

Training was initially targeted at trainees, but a growing number of specialist doctors and consultants requested to attend and they were invited to a second training session. A resource handbook was developed and a series of short follow-up sessions put in place to provide further advice about QI methodology and to help support trainees' projects. Trainees were asked to register their projects by completing a short online form on the local trust audit and QI academy webpage so the trust can monitor participation.