Quality Improvement Projects (QIPs)

Quality improvement is the application of a systematic approach that uses specific techniques to improve quality. In a healthcare context, it’s about improving the patient experience by changing the behaviours and processes of healthcare providers.

How is a QIP different from an audit?

QIPs and audit projects are similar; both try to measure an aspect of quality. Audits however generally focus more on information gathering than implementing change. An audit generally measures outcomes at fixed intervals and this data can often be used to compare outcomes between different locations. Furthermore, audits are usually measuring against set national standards, such as standards set out within NICE guidelines.

The results of an audit can often be a starting point for a QIP and QIPs will also measure outcomes (with the aim of seeing improvement).

One common framework for identifying what characteristics a healthcare system should aim for are the ‘Six Domains of Healthcare Quality’ (Committee on Quality of Health Care in America, 2001):

• Safe – do no harm; avoiding injuries from care aimed at helping patients
• Effective – produces desired results; services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
• Patient-centred – providing care that is respectful of and responsive to individual patient preferences, needs, and values.
• Timely – without undue delay both for those who receive and those who give care.
• Efficient – avoiding waste, including waste of equipment, supplies, ideas, and energy.
• Equitable – providing care that does not vary because of gender, ethnicity, disabilities etc. in the patient.

Form a team

A QIP is designed to change practice so involving other people will be an important step. If you already have an area you wish to act upon try to identify which parties would be affected and engage them to help bring new ideas and identify potential issues with your plan.

Gaining the help of a mentor or supervisor is also useful as they will be able to signpost you in the direction of useful resources and help the project from avoiding common pitfalls.

Coming up with ideas for quality improvement

A good starting point is to identify either a process or outcome you wish to change. From either these points you can then use a ‘Driver diagram’ to work in either direction to understand what your outcomes and drivers are.

Driver diagrams

In the diagram below you can see how an outcome (reduced BMI) can be mapped backwards to understand what drivers can affect that outcome and what changes may help those drivers. It is also useful to think of ways to measure something representative of both the outcome and the drivers as a method of understanding the impact your intervention is having.

Once you have a better understanding of your outcome and its drivers, you can use the ‘Model for Improvement’ (Langley GL, 2009) to formally state the answer to three questions:

1. What are we trying to accomplish?
   This will most likely be a change in your outcome identified in the driver diagram. This change should be specific, to time and population, and measurable. It is a statement that clearly sets the goal and needs to be agreed with the providers and the team of stakeholders.
2. How will we know that change is an improvement?
   In order to understand whether the change is an improvement you will need to have some form of outcome measures. There are different type of measures: some will focus on the end outcome, whilst others may be a measure of the drivers or processes that are being changed in order to affect the end outcome.
3. What change can we make that will result in improvement?
   You may already have an idea for what change you wish to make, if you don’t, then consider referring back to your driver diagram to work out what changes can be made to the drivers to give the desired change. Try and establish a plan which is clear and manageable.

QIPs generally follow Plan-Do-Study-Act (PDSA) cycles:

• Plan (planning the change that you want to implement)
  This encompasses the advice given in the previous section: define what and when the change is going to be made, and what you will measure. Make a prediction of what you expect to happen when you run the cycle.
• Do (temporarily implement the change and record your findings)
  Carry out the change in a controlled, localised setting and gather data to allow evaluation of the results.
• Study (evaluating the results of the test)
  This is where you analyse the data you have collected. It is often useful if you have some baseline data to compare it to. It is good to collect both quantitative and qualitative data.
• Act (acting on what has been learned from the test)
  Based on the results you may decide you want to make further changes to your intervention and repeat the PDSA cycle. If the intervention has gone well, you may decide to permanently implement the changes made. It is also important to try and share the results.