How to lead a quality improvement project

Authors: Fiona Tasker

Publication date: 17 Jan 2013

Fiona Tasker examines the best way to undertake initiatives to improve

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 quality improvement 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 Deanerys website.[3] [4] When you have chosen your topic and
project, consider your aims, measures, and changes. In thinking about your
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
Deanerys 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, planyou 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, doput the
plan into action and document the changes using a run chart.[6] [7] Then
studyanalyse the data and compare what happened with the predictions
that were made. Finally, actadopt, 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 Networks annual casebook ( [Link] ).
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.