2013 emma vaux [email protected] clinical lead – learning to make a difference how...
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2013
Emma [email protected] lead – Learning to Make a Difference
How to do a quality improvement (QI) project?
And yes, this can also mean how to do a clinical audit using QI methodology
The Improvement Guide, API, 1996
A Model for Learning and Change
When you combine the 3 questions with the…
…the Model for Improvement.PDSA cycle,
you get…2
Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A PS D
APS
D
A PS D
D SP A
DATA
Very Small Scale Testcale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Spread
Sequential building of knowledge under a wide
range of conditions
Sequential building of knowledge under a wide
range of conditions
A QI project in a nutshell
Identify a clear and focused SMART aim
Decide what change(s) you are going to make
Decide what you are going to measure before you start to monitor the impact of any change
The overview…
It is all about following a structured process
Guides to how to make this happenFor the traineeFor the supervisor
All accessed via the LTMD websitehttp://www.rcplondon.ac.uk/projects/learning-make-difference-ltmd
Top tipsDevelop your project plan and discuss with
your supervisorInvolve the right stakeholdersIt is even better when there is multi-
professional involvementThink of what might be the unintended
consequences of any changePrepare to educate others in the MDT
about using a QI approach to a problem
An example of a QI projectMeasure The number of cathetersinserted according totrust guidelinesmeasured on a weeklybasis….start withmeasuring the baselinebefore any change is
made andthen measuring little andoften after any change
Measure The number of cathetersinserted according totrust guidelinesmeasured on a weeklybasis….start withmeasuring the baselinebefore any change is
made andthen measuring little andoften after any change
Aim
To reduce the number of inappropriate urinary catheters inserted into patients admitted to the Clinical Decision Unit by 50% by January 2011
Aim
To reduce the number of inappropriate urinary catheters inserted into patients admitted to the Clinical Decision Unit by 50% by January 2011
Change
Introduce a checklist to be completed prior to any catheter insertion
Change
Introduce a checklist to be completed prior to any catheter insertion
Test out the next change and keep measuring………….It is much better to measure 1 day a week, a 10% sample, on one bay of one ward than try and measure everything all the time
Measurement8
Are you finding this confusing? So what is the difference between doing a quality improvement project or a clinical audit?
• Simply, clinical audit is doing a quality improvement (QI) project against an agreed standard or practice.
As trainees, the traditional way of doing a clinical audit has been a lengthy process, doing one data set collection, possibly having time to make a change and possibly collecting another data set.
A QI project uses QI methodology and a structured framework to enable change to happen in a real-time and dynamic way with little and often measurement.
By using QI methodology as part of the clinical audit cycle, clinical audit moves to a robust QI process with the focus on change and making a visible, timely difference to patient care.
Data points - why measure little and often?
The traditional clinical audit way of doing things!!
Use of run charts to track changes
Perla R. BMJ Qual Saf 2011; 20: 46-51
The change seems to be associated with an improvement
The change is not associated with an improvement; if there had been no baseline measurement before making the change, the change might have been mistakenly interpreted as making a difference
The change seems to be associated with an improvement initially but the effect does not appear sustained
Remember little and often measurement
Example of a Learning to make a difference QI project
Anxiety and Depression in Acute Stroke Patients
Dr Olivia Walker CMT Royal Berkshire NHS Trust
Reasons behind the Project
NICE guidelines - Agreed local policies and guidelines for screening patients with stroke within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance.
Meets the need identified in addressing mood in acute stroke patients in the biannual RCP National Sentinel Stroke Audit.
Research suggests that undiagnosed anxiety and depression can have a negative impact upon rehabilitation.
The objective
To develop a local protocol that can be used to screen all acute stroke patients for anxiety and depression.
Project Aim (1)
100% of stroke patients should have a Depression Scale completed within 5 days of admission and recorded in the notes
100% of patients will have a repeat DEPRESSION SCALE completed in the MDT after 2-3 weeks.
Project Aim (2)
100% of patients identified with anxiety and/or depression will be referred to the neuropsychologist.
All aims to be completed within 4 month time frame on the ASU
So Olivia is doing a clinical auditie a quality improvement project against an
agreed standardIn this case against NICE recommendationsBut by using a SMART aim and prospective and
little and often measurement Olivia is using QI methodology to implement and test out her changes
Change 1
The identification of an appropriate anxiety and depression tool which can be implemented in the Royal Berkshire Hospital (RBH) acute stroke unit.
Discussion with the neuropsychologist identified 2 suitable assessments:
oHospital Anxiety and Depression Scale (HADS) oNumeric Graphic Rating Scale (NGRS)
Review of 20 stroke patients notes on the unit, on one particular day, using the pro forma.
Assessing each patient using either the HADS or the NGRS in the stroke unit on one particular day.
1. Need specific guidelines/flow chart to identify which scale to use.
2. Completing the scales is time consuming, therefore a briefer assessment initially would be useful.
3. Need additional scale for patients with aphasia/dysphasia.
4. Patients with cognitive impairment need assistance with completing a scale.
What was tested
Outcomes
Change 2
1. The identification of additional scales The Signs of Depression Scale – to be completed for each patient
within 5 days of admission either by the occupational therapist (OT) or in the twice weekly MDT meeting.
HADS – to be used with patients without aphasia. If cognitive impairment the OT will go through each question with the patient.
NGRS or the DISCs Scale – for patients who struggle with the HADS. The Stroke Aphasic Depression Questionnaire – for patients with
aphasia.
2. The development of a flow chart
The notes of 20 patients on the acute stroke unit were reviewed after the implementation of the flow chart.
All stroke patients should have an SDSS documented in the notes by the OTs, within 5 days of admission to the acute stroke unit.
1. Poor completion of the SDSS within 5 days
2. Barriers identified following discussion with
OTs Not part of their routine
assessments and therefore can be forgotten.
Having the SDSS printed on white paper doesn’t highlight it resulting in it often being overlooked.
What was tested
Outcomes
Change 3
The SDSS is included in the initial patient assessment by the OTs.
The SDSS is printed on yellow paper.
2 weeks later the notes of 20 patients on the stroke unit were reviewed following the new changes.
1.Improved completion of the SDSS but not yet 100% achieved.
2.New issue identified- Only having an initial
SDSS may miss patients who develop anxiety/depression later in their admission.
What was tested
Outcome
Acute stroke unit mood assessment pathway
Does the patient have a language problem?
A run chart to demonstrate the change over time since the introduction of the SDSS
Modified Flow Chart Introduced
SSDS printed on yellow paper
SDSS Introduced
Flow chart
The differences made
An MDT approach to tackling anxiety and depression in acute stroke patients
The RBH Stroke Unit is now compliant with the NICE Guidelines and the biannual RCP National Sentinel Stroke Audit.
The new assessment tool identifies patients who may have previously remained undetected.
Olivia’s learning points
1. As a junior doctor you can make a difference to patient care.
2. Change takes time and requires dedicated and enthusiastic colleagues to maintain them.
3. It is important to be able to adapt the project as problems arise and accept that timescales often need to be modified.
Getting started!Go to LTMD website for ideas and inspiration and
the toolkitsThink of your own ideaIdentify a consultant supervisorIdeally involve the MDTComplete the project plan templateYou can always run your project plan past LTMD
team [email protected] started!Use the template on the website for your report
and presentations