{"id":192,"date":"2013-10-28T11:21:06","date_gmt":"2013-10-28T11:21:06","guid":{"rendered":"https:\/\/blogs.bmj.com\/quality\/?p=192"},"modified":"2014-05-16T14:56:31","modified_gmt":"2014-05-16T14:56:31","slug":"how-to-run-a-quality-improvement-project-whilst-working-full-time-as-a-junior-doctor","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/quality\/2013\/10\/28\/how-to-run-a-quality-improvement-project-whilst-working-full-time-as-a-junior-doctor\/","title":{"rendered":"How to run a Quality Improvement Project (whilst working full time as a junior doctor)"},"content":{"rendered":"
\"Photo

Rob Bethune<\/p><\/div>\n

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Rob Bethune<\/strong>\u00a0is<\/strong>\u00a0a surgical registrar in the Severn Deanery. He was a founding board member of The Network (www.the-network.org.uk ) an on-line social media site for healthcare professionals wanting to share their learning and connect with other quality improvers around the world. He has been involved in a regional wide programme facilitating junior doctors to run quality improvement projects.\u00a0This blog is brought to you by\u00a0BMJ Quality<\/a>. For more quality improvement resources go to\u00a0quality.bmj.com<\/a><\/em><\/strong><\/strong><\/p>\n

Effecting change as a junior doctor with little time, power and influence can be daunting.\u00a0 However there are ways of working through those difficulties.\u00a0 In this article I describe a few pointers that have helped junior doctors facilitate real change.<\/p>\n

Establish a team and allow time
\n<\/b><\/p>\n

This is crucial, you cannot do this alone.\u00a0 Most of us do 4 or 6 month placements and this often not enough time to run a successful project and embed the changes, so develop a team of 6-10 people who will rotate through the clinical area throughout the year. \u00a0As we shall see continuously collecting small samples of data is crucial to quality improvement (QI) and practically you need a group to collect this. Working in a team also makes it fun and gives you opportunities to bounce ideas of each other.<\/p>\n

Get help<\/b><\/p>\n

Ideally you want to find a permanent member of staff to mentor your project who has experience of QI and has spare time to meet with you and your team.\u00a0 In practice this is difficult unless you are in one of the few hospitals that has formal QI programmes for juniors.\u00a0 The BMJ Quality programme <\/a>\u00a0has a system of virtual mentors who can give QI advice.\u00a0 It also walks you through running a QI project and there are many previous examples on the open access on-line journal<\/a>. Before you start your project you really must search this journal to see if others have run similar projects elsewhere and learn from them; try not to reinvent the wheel, let alone reinventing the flat tyre.<\/p>\n

<\/b>Use the Model for Improvement<\/b><\/p>\n

This is the key.\u00a0 Clinical audit run by junior doctors has been overwhelmingly unsuccessful1-3<\/sup>. There are a multitude of tools for improving quality of systems (Lean and Six Sigma are examples) but the most tried and tested model for frontline clinical care is The Model for Improvement<\/p>\n

It consists of three steps that are outlined below; set an aim, measure progress and make changes.\u00a0 The BMJ quality site has a lot more information and there are also a series of short videos<\/a> on The Network YouTube site that explain the underlying methodology.<\/p>\n

Aim: <\/b>What is it you want to improve?\u00a0 It is really important to carefully define exactly what you are trying to improve. \u00a0Make your aim SMART (Specific, measurable, assignable, realistic and time limited ).\u00a0 An example of this would be \u2018Ensuring that by March 2014 95% of discharge summaries from the medical admission unit reach the GP within 24hrs\u2019.\u00a0 Getting the aim right can be surprisingly difficult and may well change as you develop a deeper understanding of the system you are analysing. It is tempting to say \u2018we want to improve discharge summaries\u2019 but the lack of detail will make the next steps impossible.<\/b><\/p>\n

Measure: <\/b>\u2018Data, data, data\u2019 goes the drumbeat of a quality improvement project.\u00a0 Without out it you will not be able to see if your changes are an improvement. But more importantly during the process of collecting good data you will develop a deeper understanding of the system you are trying to improve. We often oversimplify problems and think that solutions are obvious.\u00a0 These simple solutions often fail as we don\u2019t really understand the system we are dealing with.\u00a0 The very action of measuring a system gives us much more detailed understanding.<\/p>\n

Then display the data using a run chart (see chart below).\u00a0 Collect small samples of data (10 each time is a good number) and do it as often as feasibly possible.\u00a0 Try and collect 10 sets of data before you start test of change, this will allow you to get a baseline and see if changes really are an improvement.<\/p>\n

\"rob's<\/a>The plan-do-study-act-cycle (PDSA)<\/strong><\/p>\n

Now you have your background data collection and a more profound understanding of the system you are ready to make some changes. \u00a0These are done in the form of PDSA cycles.\u00a0 It is a simple and intuitive as it sounds; come up with a plan, trial it out on one day, study the effect and act upon the result.\u00a0 One of the keys is to trial the change over a short time period in one area. If it works you can spread it but if it does not work and needs refining then you can do that easily.\u00a0 If you implement your idea widely from the beginning (as we have seen so often in healthcare) and you get it wrong it is expensive both on terms of time and resources to undo it.\u00a0 Make your first tests small.\u00a0 You can label you PDSA cycles on your run chart as in the example graph. Almost always multiple tests of change are needed , rather than just one intervention \u2013 this might explain why audit failed.<\/p>\n

Publish<\/b><\/p>\n

If you have run a QI project and improved care and equally importantly if your interventions did not work then you must share this with the wider healthcare community.\u00a0 The BMJ quality<\/a> improvement journal is the perfect place to do this.\u00a0 Provided you have used the above methodology and have created a coherent story of change that others can adapt and translate elsewhere your project will be published.<\/p>\n

<\/b>It\u2019s up to you<\/b><\/p>\n

Improving the systems we work in is crucial to improving the care we give to our patients.\u00a0 As junior doctors we are in a unique position to see the problems in the delivery of frontline healthcare and affect the solutions.\u00a0 No-one else is going to do this, therefore do not send to know for whom the bell tolls, it tolls for thee.<\/p>\n

References<\/b><\/p>\n

1. Greenwood JP, Lindsay SJ, Batin PD, Robinson MB. Junior doctors and clinical audit. J R Coll Physicians Lond<\/i> 1997;31(6):648-51.<\/p>\n

2. Guryel E, Acton K, Patel S. Auditing orthopaedic audit. Ann R Coll Surg Engl<\/i> 2008;90(8):675-8.<\/p>\n

3. Hillman T, Roueche A. Clincal audit is dead, long live quality improvement. BMJ Careers<\/i> 2011\u00a0 http:\/\/careers.bmj.com\/careers\/advice\/view-article.html?id=20002524<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"

  Rob Bethune\u00a0is\u00a0a surgical registrar in the Severn Deanery. He was a founding board member of The Network (www.the-network.org.uk ) an on-line social media site for healthcare professionals wanting to share their learning and connect with other quality improvers around the world. He has been involved in a regional wide programme facilitating junior doctors to […]<\/p>\n","protected":false},"author":178,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5,3],"tags":[],"class_list":["post-192","post","type-post","status-publish","format-standard","hentry","category-opinion","category-quality"],"_links":{"self":[{"href":"https:\/\/blogs.bmj.com\/quality\/wp-json\/wp\/v2\/posts\/192","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.bmj.com\/quality\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.bmj.com\/quality\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.bmj.com\/quality\/wp-json\/wp\/v2\/users\/178"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.bmj.com\/quality\/wp-json\/wp\/v2\/comments?post=192"}],"version-history":[{"count":0,"href":"https:\/\/blogs.bmj.com\/quality\/wp-json\/wp\/v2\/posts\/192\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.bmj.com\/quality\/wp-json\/wp\/v2\/media?parent=192"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.bmj.com\/quality\/wp-json\/wp\/v2\/categories?post=192"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.bmj.com\/quality\/wp-json\/wp\/v2\/tags?post=192"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}