Dr. Anita Jayadev is currently a respiratory registrar and QI training fellow with a passion for teaching. As well as supporting colleagues and students with QI initiatives, she enjoys leading QI projects, for which she has won several accolades including the HSJ Rising Star Award 2014.
Having spent part of my Darzi Fellowship training clinicians and medical students in developing and completing a quality improvement project, I’ve found that the most frequent concern is, “I don’t know how to start.”
A good place is to think about, “what drives you nuts?” Being frontline, we have a unique insight into the inefficiencies and potential safety issues for patients, from streamlining the way we order blood tests in clinic, to changing surgical equipment packs to reduce waste, or improving patient experience. It doesn’t matter how small the idea seems, the best projects are those that individuals have passion for and the ability to contribute to.
In fact, aside from passion there are a few useful tips to bear in mind when starting to think about your project:
- Start with why:
Why do you think it’s a problem? It’s useful to have somebody else who is familiar with your department or who may know more about politics and processes to discuss your idea with before you decide it needs “fixing”. We often use the “5 Why” technique in our project surgeries to ensure that the individuals really understand what it is that needs improving. For example, is it a process problem or a people problem? How much influence will you have over either?
- Think SMART:
Once you have decided on your project aim, make it SMART (specific, measurable, attainable, realistic, and timely). This is particularly important if you are only on a three or four month rotation; what can you realistically achieve in that time? Even if it is a project that is handed over between trainees as they rotate, it is still useful to define your own aim and contribution in this time. For example, “we will eliminate all pressure ulcers in the trust” may be the over-arching goal but, “to reach 50 continuous days with no pressure ulcers >grade 1 on Ward X by March 2015” may be more SMART.
- Plan:
It may be useful to use a driver diagram to map out your project plan. I find it easier to understand what I need to do and in which order, but if you haven’t done one before it might be easier to agree this with other stakeholders. It helps decide priorities early!
- Stakeholder mapping and engagement:
This is quite a useful exercise to do early on to try and limit potential obstacles along the way. The idea is to firstly identify your stakeholders, i.e. anybody that you need involved or who has an interest in your project. This will range from patients to healthcare assistance, pharmacists, executive directors, managers, supervising consultants etc. You can prioritise or map them out according to their level of power and interest. A quick internet search will reveal lots of advice about how you “manage” each category of stakeholder. Although I personally find the most useful part of this exercise is highlighting who I need to involve, common sense and instinct usually dictates the level of engagement needed.
The other useful thing about involving stakeholders early is that they often have helpful insights into what has worked, what hasn’t, and why. Usually we are not the first person that has come along and tried to improve a particular service, process, or experience. If you can understand context and expectations of those that your project may affect, it will help you appreciate and plan for unintended consequences. For example, introducing “quiet prescribing desks” to reduce medication errors made in busy environments may work. However, if we were no longer able to prescribe on the ward round will patients potentially have missed or delayed doses of medications? Speaking to stakeholders early might help you consider consequences that might not have occurred to you. It also gets the potentially “difficult people” onside early and you can use their experience and ideas.
It sounds like a lot to think about, but if the first steps are done right then you’re ready for the D in PDSA (plan/predict, do, study, act)! This is the fun bit, and actually nothing to be afraid of as it’s all trial and error! It doesn’t matter if it doesn’t work, just log it as a PDSA cycle; think about why it didn’t work (study) and then try a slightly different approach next time.
Given pressured clinical rotas, hectic and often unpredictable work environments with mounting commitments, finding the time to fit in what can seem like another “tick box” exercise can be stressful. It is perhaps more feasible and productive not to work in isolation. A project where a nurse, pharmacist, ward clerk, manager etc. is buddied up will be a lot less stressful and the project itself more sustainable. If you can find someone that shares the passion, it’s easier to keep the momentum going, coach each other, and help with data!