How to do a Quality Improvement Project

Introduction

As a trainee you are in good position to identify things in practice that ‘frustrates’ you and has an
impact on safety of patients. This guide has been developed to help you complete a quality
Improvement project -otherwise known as a QiP during your training, as required by the RCGP. QiPs
are very similar to audit – both look at the quality of care provided and aim to improve it. Both
require measurements to demonstrate change. QiPS are about making small incremental changes
and measurements can be done weekly or even daily to test the impact of the changes. In contrast
audits have set criteria, each with their own defined standards to measure against and tend to have
two sets of measurements over a longer time period. Doing a QiP allows changes to be tested both
quickly and successfully and is easier to do in a short time frame (such as a four to six month trainee
post). The QiP should be written up in the relevant section on the e- portfolio and done in ST1 or ST2
(unless you have no GP post). As well as this guide, there is further advice available on the marking
schedule, examples of QiP projects and further learning resources on the RCGP website and you are
strongly advised to read this advice as well before starting your project.

The Model for Improvement is a recognised tool for doing a Quality Improvement Project in a health
care setting and be used as a framework to help you do your QiP. More Details are available on
www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Whiteboard3.aspx. It asks
three questions.

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Aim

First of all you need to decide what the aim of your project is going to be. Trainees often identify
things they think should change to improve patient care. Projects can also be chosen following a
significant event; complaint; an area of care you feel passionate about or inspiration from other QiPs.
The project should aim to improve patient safety or care and be ‘SMART’
Specific - do not make it too broad and chose something you are interested in. Words such
as increase /reduce help to set a clear goal.
Measurable – ensure that there is something you can easily measure to demonstrate any
change. It can be qualitative data (descriptive) as well as quantitative data (numerical data).
Achievable - ensure the data is easily collectable and keep the aims simple.
Relevant - project should be focused on patient safety
Time defined – choose something that can be done in time frame –you need to be able to
complete at least two sets of data measurement.

For example a ‘SMART’ aim looking at doing 6 week baby checks in a timely manner could be ‘To
improve the percentage of 6 week baby checks performed between start of week 6 and end of week
8’.

What are you trying to accomplish

You should also include in your write up what triggered you to choose your QiP, a brief summary of
the current evidence/guidance supporting good practice in this area and how your QiP will improve
patient care.

How are you going to engage the team, patients and other stakeholders.

Once you have decided on your project, you need to consider who you need to involve in the project
to achieve your aim. Ask

- Who will be affected by any change proposed

- Who will be involved in the implementation of the change
- Who will be responsible for ensuring that any changes will be sustained when you leave.
- Who may you need for advice

Possible stake holders include other doctors, administrative staff, practice manager, pharmacists,
health visitors, nursing team and patients. You need to think how you plan to engage them and
communicate the impact of changes with the rest of the team. Using doing 6 week baby check by
end of week eight as an example, not only were the practice team involved, but other primary health
care teams were contacted to share their policies and mothers of young babies were asked about
their experiences of booking a six week baby check.

Describe what baseline data or information you gathered

The next stage of the model of improvement is to ask how you will know that a change is an
improvement. For any project it is important to undertake some form of measurement to
demonstrate the impact of any changes, as not all change leads to improvement. Measurement can

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 be both quantitative (numerical) or qualitative (descriptive) data. Examples of qualitative data
include questionnaires and interviews. Your project should include data both before and after the
implementation of any change. Data at the beginning of the project could be collected
retrospectively.

In the example of the baby check, quantitative data included the percentage of baby checks
completed by eight weeks. Qualitative data was also collected in the 6 week baby check example by
asking patients of their experiences – a mother commented ‘it was difficult to change appointment
as I did not want to bring the other two children with me’.

Quality Improvement Tools or Techniques Used

The final question in the Model for Improvement asks what changes can we make that will lead to an
improvement?

There are several quality improvement tools that you could use to help generate change ideas
including process maps and driver diagrams.

Process maps are a really useful tool to help you understand exactly what is currently happening to
help identify any problems. The process map shown below looks at how babies are invited for a six
week check in one practice. It identified that there was no formal system of following up patients
who had not attended, and so generating a suggested change to the process.

Practice
Attends Check
books 6 week Yes done
Yes check
appointment

No

Practice
Birth
informed of
birth

Admin No check
Yes No done
chase
No

Practice aware of Yes

birth using EDD

No action
No taken

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Driver diagrams can also be used to generate ideas for change. Ideally generating a driver diagram
should be done with the rest of the team who are familiar with the different aspects of the problem
you are trying to improve. Not only can this approach generate a lot of different ideas, but it is a
great way to involve the team. You can also involve patients – both the patient participation group
and patients affected by the problem can suggest ideas. You can ask everyone to think of as many
solutions as possible to achieve the aim and then add the drivers. You can then decide on one or two
potential solutions (also known as change projects) and do a series of measures to see if they are
successful.

Your Aim Factors that you need to Potential solutions

Influence in order to achieve
your aim (‘drivers’)

Practice to continue to book 6

week check when aware delivery
To book
appointment
for 6 week Patient to be asked to book app
Improve check themselves for 6 week check
percentage
of six week
baby Ensure enough appointments
checks available for 6 week checks at
performed range of times
To ensure
by end of
attends 6
week eight
week check Text reminder of appointment

Chase up DNAs.

Another quality improvement tool is the PDSA cycle. This is similar to the audit cycle, but tends to
involve making a small change, studying the effect (including any unintended consequences) and
then planning the next change. The changes in a QiP can be small and ideally there should be at least
two PDSA cycles for each QiP project.

1. Plan – document the objective, the initial plan, identify who will be doing the test, how will it
be done, and when the change will be made
2. Do – undertake the change, gather the data and document any problems,
3. Study - analyse the data and summarise learning
4. Act - what changes will you make based on the outcome of the first change and develop a
plan for the next cycle to make it better.

The PDSA cycles illustrated below demonstrated 2 changes made in the process of 6 week baby
checks in the practice.

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 Improve percentage of 6 week baby checks done
by end of week 8
Cycle 1
• Discussed at
• Develop system practice meeting
to follow up did • System set up to
not attend text reminder to
mother about
appointment day
before
act plan

study do
• Small increase in •Record weekly change in
percentage checks done percentage done
•Patient mention difficulty •Ask 2 patients about their
of rearranging experience
appointment

Improve percentage of 6 week baby checks done

by end of week 8
Cycle 2
• Review timing • Set up system to
for premature follow up
babies. patients who do
not attend for
check up.

act plan

study do
•Further improvement in
percentage baby checks • Record weekly
done. percentage of
•Confusion about when
check should be done
checks done
for premature babies • Ask patient
about being
followed up

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Describe the data or information gathered to demonstrate the impact of the change used

There are many ways to present your measurements. One of the best ways is to plot measurements
each time they are taken on a run chart - a line graph of data plotted over time. Run charts measure
data frequently and demonstrate if changes are leading to an improvement. Further details about
run charts are available on www.ihi.org/resources/Pages/Tools/RunChart.aspx.The package will even
plot your run chart for you. Using the 6 week baby check again, the run charts below illustrate the
impact of the two changes introduced.

Chase
Text DNAs
reminder

Summarise and Sustainability

At the end of your project, you should summarise the changes made as a result of your project. This
could include exploring why the change has been ineffective. Ideally you should present your
findings to the team at a practice meeting and reflect on the process and any feedback you receive.
An important part of any quality improvement, especially if the changes have improved quality, is
ensuring that the process will continue once you leave the job.

Reflection

The final process involved reflecting on the process of undertaking a QiP – what have you learnt,
what worked well, how did you work with others and what would you do differently in the future.

Resources
Institute for Health Care Improvement www.ihi.org

NHS Scotland Quality Improvement Hub https://learn.nes.nhs.scot/741/quality-improvement-zone

RGCP QI Guide 2015 http://www.rcgp.org.uk/clinical-and-research/our-programmes/quality-

improvement/quality-improvement-guide-for-general-practice.aspx

East Midlands Website on Quality Improvement http://tiny.cc/resourcesqi