QI toolkit presentation from The Christie

1. QI toolkit
Content
• Definition and overview of QI journey
• Getting started and planning to measure improvement
• Driver diagrams, The Model for Improvement
• Aims and measures
• Testing changes with the PDSA cycle
• Measurement - demonstrating change with SPC charts
• Reporting and publishing QI
• Top Tips
• Key QI tools and when to use them
• Further QI education
Last updated Nov 2020

2. Healthcare quality
• There are 6 dimensions of healthcare quality:
– Safe
– Effective
– Patient-centred
– Timely
– Efficient
– Equitable
• Topics for improvement come from a wide variety of
sources including:
– clinical incidents, claims, complaints, clinical audits, peer review,
staff concerns, surveys, benchmarking, national best practice,
new technology, research and innovation….

3. What is quality improvement?
• Use of a structured process and tools to
systematically measure and improve outcomes and
experience for patients …. and staff!
– Popular tools include Clinical audit, the Model for Improvement…
• Purpose of measurement for QI differs:
Research:
tests if an
intervention works
(aims to derive
new knowledge)
Assurance:
tests performance
against an agreed
standard
(assurance of
quality of care)
Improvement:
small tests of change,
measures variation over time
(drives improvement,
may be innovative)

4. Summary of the Improvement journey
Thanks to BTS Quality Improvement Methodology Overview / NHS Education for Scotland
Build will and
conditions for
change
Understand current
system
Develop aim and
change theory
Identify specific
change ideas, test
and refine in
context
Implement locally,
using PDSA cycles to
build in
sustainability
Scale up and spread
where relevant
Start with a situation you
want to improve…
1.
4.
2. 3.
5. 6.

5. Getting started
Build the will and conditions for change
• Build a , including data support
• Agree a Lead, consider an Exec sponsor
• Identify those affected (stakeholders)
• Think about patient involvement
• Consider a name for the project
• Plan communications
• Raise awareness of the need for change
• Work with enthusiasts
• Proposal form
Don’t forget to register
the project!
Help is available!
1.
Teamwork is
associated with
higher quality
care, better staff
wellbeing and
levels of patient
satisfaction and
lower avoidable
patient mortality*
*Caring for doctors, Caring for patients, GMC, Dec 2019

6. Planning to measure improvement in care
Understand the system
• Healthcare is complex
• Consider outcomes of care and processes involved
• Outcomes are usually dependent on processes
• Process mapping is an insightful tool
• Potential for unintended consequences of change!
2.

7. The Model for Improvement
Develop aim & change theory Develop change ideas and test
Aim
• What?
• How
good?
• By when?
Measures
• Outcome
• Process
• Balance
Changes
• Ideas?
• Test and
measure
Plan Do
StudyAct IHIOpenSchool...The
Model for
Improvement Part 2
This is not the only QI tool,
but it is a simple approach to
continuous improvement,
testing changes in small cycles
3.

8. Agreeing an improvement aim
• Reason for undertaking QI project
– What problem/gap are you trying to resolve
– Do you have all the information you need?
• SMART goals
– Keep it focused: start small and scale up
– Maintain motivation to improve
• It’s ok to refine the aim as you go
• Need to measure progress towards aim….

9. Driver diagram:
a ‘theory of change’ and a plan on a page
Develop aim and change theory
• Guidance on Driver Diagram
• Christie Driver Diagram template
Highly recommended
QI tool as an aid to
planning and
communication
• Agree SMART aim
• Identify influences
(drivers) on aim
• Develop change
ideas to impact on
drivers
• Start testing and
measuring!
3. 4.

10. Developing change ideas
• Use your understanding of the current system
• Understand the causes of problems(try fishbone analysis)
• Can you describe the ideal system?
• What works elsewhere? Use networks, do lit search
• What ideas do the team have?
• Seek patient feedback (their experience, what matters to them)
• Ask staff, eg try a whiteboard
• Try QI tools to help with problem solving and creativity
– eg Root cause analysis using the 5 Whys, Six Thinking Hats©
4.3.
https://improvement.nhs.uk/resources/quality-service-
improvement-and-redesign-qsir-tools-type-task/#thinking

11. Plan
DoStudy
Act
Test with the PDSA cycle
• Methodical process to test improvement ideas
• Record results over time (eg line or SPC graph)
• Study is the element least often completed:
– Did the test achieve the results you expected?
– If not, why? What else could you try?
• Plan next test or change to implement
• It is a cycle; refine and repeat to increase
assurance
4. Test and refine in context

12. Testing ideas:
repeated use of
the PDSA cycle
Testing and
refining ideas
Implementing new
procedures & systems
- sustaining change
Bright
idea!
Picture courtesy of NHS Scotland
• Start small and build
• Reduce risk
• No cycle is too small
• “Trial and learning”
• Rapid change
5. Implement locally, using PDSA cycles to build in sustainability

13. Scale up, spread and sustainability
Scale up and spread where relevant6.
• Scale up: changes tested in other teams/locations
to increase degree of belief that they work
• Spread: best practice distributed consistently across
a system
• Sustainability: new way of working becomes the
norm
– NHS Innovation and Improvement
sustainability model can be
considered throughout to help
strengthen elements
– Communications support
sustainability

14. Measuring change (1)
• Measurement is a key element supporting the
improvement journey
• Identify what should and can be measured
• What measures will enable you to demonstrate
improvement?
• Measure baseline before implementing changes
• Understand and act on variation over time
• Include data expertise in project team

15. Measuring change (2): Collecting data
• Plan your data collection in advance
• Sources: What structured data is available electronically?
Eg CWP, Christie Data Insights
• Manual data collection is time consuming, so only collect
data that is really needed to meet aims & measures
• Consider who will collect data
• Aim for consistency: ensure data definitions are clear to all
• Consider online data collection tool (support is available!)
• Pilot data collection tools whenever possible
– Check the data collected answers your questions
– Modify the tool to make the data as robust and easy to collect as
possible

16. A family of measures
Examples:
• % patients completing planned treatment
• No. patients with a treatment plan
• No. patients starting treatment
• No. patients with no treatment
• Average waiting time
Measuring change (3):

17. Demonstrating a change
Using Statistical Process Control (SPC charts)
• SPC chart - line graph with mean, process control
limits and rules to identify non random changes
• At least 15 data points for robust conclusions
• 99% of data will occur between process limits
• Annotate to record when changes were made
Measuring change (4):

18. Key tools and when to use them
Image Recommended
common QI tools
When to use and link to further
information
Driver diagram Visual map of drivers towards identified
aim, aid to planning changes and
communication
Driver Diagram
Process mapping Understand the system, identify
problems
Process mapping
Fishbone analysis Understand the causes of a problem
Fishbone analysis
PDSA cycle
(plan, do study, act)
To test changes and review effectiveness
PDSA
SPC chart
(statistical process
control)
To show variation in measures over time
and identify special causes
SPC charts

19. Top tips for successful QI project
• Clearly defined, focused statement of intent
– Driver diagram recommended for plan on a page!
• Manageable scope for available resources – start small!
• Committed lead and mix of staff with time to undertake and Exec
support
• Engage and communicate with staff
• Data support
• Clearly defined measures
• Just enough data to measure tests of changes over time

20. Share learning! Celebrate success!
Reporting and publishing QI
Share learning internally first but….
• Worth considering publication at outset to ensure all
elements of best practice included
• Likely to need evidence of governance and ethical
considerations addressed (eg QICA approval of project)
• See SQUIRE guidelines (Standards for Quality Improvement
Reporting Excellence)
• See Q health blog re common pitfalls
– Frequently seen:
“Further research is needed…..”
There is
learning in
sharing
what didn’t
work too!

21. Quick educational resources
• The Science of Improvement on a Whiteboard
– Institute for Healthcare Improvement
– The Model for Improvement (Part 1)
– Watch the video
Read the transcript
– And more short videos…
• Short E-learning course on ESR
– Harm Free Care 01: An Introduction to The Model for
Improvement
For further information see QICA pages on HIVE or contact the QICA team