Quality Improvement Training

1. Quality Improvement Training NES pilot project

2. Quality Improvement Project • Aims of this pilot project: • To increase participants’ knowledge of the interrelated aspects of • QI methods • Patient safety • Human factors in health care • Leadership • Teamwork • To allow trainees to gain experience of leading a QI project

3. Quality Improvement - plan • Teamwork • Leadership • Human factors • QI tools • Process mapping • Criterion based audit • Care bundles • PDSA • Groupwork • QI project • Work on your own QI projects

4. Pre course questionnaire

5. Ice breaker • Teamwork • Leadership • Introductions to human factors

6. Groupwork • Systems • Culture

7. What is Quality Improvement (QI)? • Multi disciplinary • Looks at the whole system • Driven by data • Sustained improvement • Becomes normal - examples

8. What is Quality Improvement (QI)? • Evidence based medicine • “Doing the right things” • Quality Improvement • “Doing things right” • Should be complimentary • “Doing the right things right”

9. Project • Aim is to get QI project published • Tight time scale – need to be realistic • Adult learning – many resources in hand out

11. QI reports - timescales

12. Group work • Pick a QI project for use in your group work today: • There are a lot of missing prescriptions in your surgery and patients often complain verbally to you about the prescribing system. This also causes extra work for GPs with lots of extra prescriptions to sign each day. You plan a QI project to try and improve an aspect of the system. • There have been problems with INR monitoring within your department. You wish to perform a QI project to improve the process. • Patient satisfaction of information provided at outpatient clinic appointments has anecdotally been recorded as low. You are keen to improve this. • Or one of your own??

13. Group work • Who would you need in your team? • How would this team have authority to make changes? • Consider teamwork and leadership issues.

14. Steps involved in a QI project • Define problem • Background • Literature and guidance • Local background eg practice or ward

15. Measurement • The most critical step for a successful project • Needs to be specific, precise, logical and measurable!! Also consider context • Group exercise on what makes a good measure and consider your group’s project: • What will you measure?

16. Measurement – results of group exercise • The number of missing prescriptions per day • The number of patients treated within 4 hours each day • How busy the clinic is • Patients receiving aspirin and dipyridamole following a stroke should be switched to clopidogrel • The percentage of over 65s who have a vaccination each year

17. Measurement – results of group exercise • 6. The number of blood results that are actioned without delay • 7. Hospital patients need to get venous thromboprophylaxis • 8. Patients with secondary coronary heart disease will get evidence based care • 9. All my patients are satisfied with the quality of care that I provide • 10. Patients with type 2 diabetes should have their feet checked by a healthcare professional at least once every 12-months

18. Measurement – results of group exercise • The percentage of patients with gout and who take allopurinol in whom urate levels are monitored • The number of patients with COPD and an MRC dyspnoea score of 3 or more who are treated each day following the current NICE COPD guidelines • The percentage of patients who are prescribed a 4C antibiotic inappropriately • Increase the number of patients receiving optimal treatment of gout • 15. The number of patients receiving all aspects of the sepsis 6 bundle within 1 hour

19. Group work 2 • What measure would you use in your group’s QI project and why?

20. Sampling • Sampling may not be needed • Consider a sample that is manageable but has large enough numbers • Justify your choices! • Examples

21. QI tools • Process mapping • Criterion based audit • Care bundles • PDSA

22. Process mapping • Helps understand process • Identify critical steps • Consider safety of these steps • Identify redundant steps • Failure mode and effects analysis

23. Process mapping • Define the boundaries • Start with ….. • Stop with …… Realise I have a flat tyre Drive away with tyre fixed

24. Process mapping

26. Telephone request for prescription Have they had it regularly? No Yes Is prescription on repeat? No Don’t print prescription Print prescription Add to special request list for next day Yes Add to special request list for next day Print prescription GP agrees to prescribe Returned to prescribing team – not signed and score through it No Yes GP decides if issues prescription Message to prescribing team – not being prescribed GP prints prescription No Prescription returned to front desk for collection Yes Prescription destroyed and removed from EMIS Prescribing team contact patient to inform them

27. Criterion based audit • Continuous quality improvement method • 1750 BC - King Hammurabi of Babylon introduced audit for clinicians • Evaluating structures, process and outcomes of healthcare against explicit criteria and agreed standards

28. Criterion based audit – audit cycle

29. Criterion based audit - example • Criteria • Simple, logical statements that describe specific and measurable health care items or activities • Patients on methotrexate should have FBC, UE and LFT in last 3 months • Standards • Quantify the level of care to be achieved for criteria • 100% - but may not be 100% due to exclusions for contraindications

30. Criterion based audit - example • Patients on methotrexate should have FBC, UE, LFT in last 3 months • Standard 100% • Preparation and planning • Data collection 1 • 47 patients on methotrexate, 32 had FBC, UE and LFT in last 3 months • Results 32/47 = 62% • Implement change – how will this be system based?

31. Criterion based audit – data collection 2

32. Criterion based audit • Reason for choice of audit • Criterion or criteria chosen • Standards set • Preparation and planning • Data collection (1) • Change(s) to be evaluated • Data collection (2) • Conclusion • Consider sustainability of change

33. Care bundle • Several key components of a care process • Not a check list • All have to be present • Repeated small measure possible

34. Care bundle • All patients on methotrexate should have: • FBC, UE, LFT in last 3 months • Pneumococcal vaccination (ever) • Annual education about drug and side effects

35. Care bundle - example • Diabetic patients: • Should have their BMI measured and recorded • Should have peripheral pulses examined and recorded • Neuropathy testing should be performed • A urine specimen should be tested for proteinuria • A fasting total serum cholesterol test should be requested and the result recorded • A HbA1c should be requested and the result recorded in patients’ records.

36. Care bundle

37. Care bundles • Measure again after intervention • Sustainability

38. Criteria and Care bundle exercise • All patients on allopurinol for gout should have a urate level recorded in their notes in the last 12 months • Patients on warfarin should receive education • Patients with rheumatoid arthritis should have a record of a face to face review within the last year • Allergies should be recorded in all patients’ notes • When a prescription request comes in, the prescription will be available for collection or the patient will be contacted to inform of reason for not issuing, within 48 hours

39. Criteria and Care bundle exercise • 1. All patients who attend for asthma review should have • Peak flow measured • Severity assessed using the RCPs 3 questions • Compliance discussed • Inhaler technique checked • 2. All results that are returned should • Be stamped stating time returned • Added to doctors pile • Dealt with by the doctor quickly • 3. Patients with dementia should • Have documentation of next of kin • Be nursed in a sympathetic way • Discharged within normal working hours

40. PDSA • Plan, do, study, act • Implement small scale change • and evaluate • Can be used with other QI tools • Criterion based audit • Care bundles • Aim statement – exercise • Satisfaction with doctor-patient communication

41. PDSA

42. PDSA - advantages • Frontline staff • Try small change • Rapid • Overcome resistance

43. PDSA - evidence • What makes PDSAs successful • Fast, measureable and visible • Small, stable units with a learning culture • Knowledge of practitioner • Resources

44. PDSA - example • Keen to cut unnecessary tests performed at rheumatology clinic • Plan • 3 patients on DMARDs for near patient testing - collect copies of their results  • Do • 3 patients – followed up by phone • Study • 2 patients collected copies. 1 still needed extra bloods. 3rd patient had no transport. • Act • Providing copies of results may be a useful intervention, but would have to be adapted - larger sample of patients.

45. PDSA - example • Plan • Next 5 patients offered choice of collecting or posting results • Do • Performed in 5 patients – contacted by phone • Study • 3 took results to clinic, 1 needed extra bloods. • Act • Cost of posting could be prohibitive

46. PDSA - example • Plan • GP contacts rheumatology to discuss what bloods may be needed and modifies NPT protocol to include these when appropriate • Do • Performed on 10 patients followed up after clinic • Study • No patients needed further bloods all had results at clinic • Act • Roll out to all DMARD patients

47. What QI tools could you use? • Discuss the project your group chose earlier. • What tools could you use? • Process mapping • Criterion based audit • Care bundles • PDSA cycles

48. Strategy • Implementation strategy - team formation and leadership (consider authority) • Discuss in groups possible strategies for implementation. • How would you make it happen in your work place?

49. Results • Criterion based audit – tables • Numbers and percentages and compare to standard • Run charts • Must show improvements sustainable

50. Run chart • Improvement takes place over time • Visual tool to aid teams in deciding if improving or not • Time series analysis • Plot variable we are measuring on y axis • Plot time on x axis