CAREERS How to lead a quality improvement project Fiona Tasker examines the best way to undertake initiatives to improve the quality of patient care The General Medical Council (GMC) expects all doctors to take part in systems of quality assurance and quality improvement that will form part of their assessment in the upcoming appraisal and revalidation process.1 Quality improvement is best thought of as the process by which better patient experience and outcomes are “achieved through changing provider behaviour and organisation through using a systematic change method and strategies.”2 Quality improvement projects should be led by trainees, who should find a supervisor to support setting up and implementing the project. This could be a clinical or educational supervisor or someone who works in the field of your chosen topic; there is a pack for supervisors on the Royal College of Physicians’ website.3 Ultimately you should work as a team with a number of faculty members, including senior members of staff, to create a sustainable change. Setting up a project To choose your topic, think of something on your ward or in your department or hospital that frustrates you and ultimately has an impact on the safety of patients. This could be a process or system, clinical care issue, or educational initiative. Now turn this frustration into a quality improvement project. For example, you could improve prescribing for thromboprophylaxis, improve needle safety when taking bloods, or improve weekend handover. Examples of quality improvement projects are listed on the “Learning to make a difference” section of the Royal College of Physicians’ website and the “Beyond audit” section of the London Deanery’s website.3 4 When you have chosen your topic and project, consider your aims, measures, and changes. In thinking about your BMJ CAREERS | 19 JANUARY 2013 Think of something on your ward or in your department that frustrates you and ultimately has an impact on the safety of patients aims, consider what you are trying to accomplish. Set a clear and focused aim, and keep your goal “SMART” (specific, measurable, achievable, realistic, and timely).5 When it comes to the measures you will be using, think about how you will know that a change is an improvement. You will need to measure the impact by measuring the baseline, setting a target, and measuring progress. Changes can be demonstrated using a run chart of data over time.6 Plot the number being measured on the y axis against a time period on the x axis. For example, this could be the percentage of patients prescribed appropriate thromboprophylaxis on one ward, measured every week for several months. Plot the data values before and after implementing changes and annotate the chart to indicate when tests of change were initiated. The effect of changes can then be easily viewed. A link for a run chart template is on the London Deanery’s website.7 Implementing a project When you have considered your aims and measures, you need to think about what changes you can make that are likely to result in an improvement. It is worth bearing in mind that a small number of changes are most likely to succeed. When you have chosen your aim, measure, and change, you should follow the PDSA (plan, do, study, and act) cycle. Firstly, plan—you need to think about what tasks you need to do to test this change. You also need to consider who will do what, and when and where the work should be done. Then try to predict what will happen when the test is carried out. Secondly, do—put the plan into action and document the changes using a run chart.6 7 Then study—analyse the data and compare what happened with the predictions that were made. Finally, act—adopt, reject, or modify the change plan. Then describe what modifications to the plan should be made for the next cycle. It is best to make simple and intuitive changes over a short period of time. Through a series of small scale changes and continuous data collection, you will hopefully be able to show that your solutions have resulted in improvement in the area being evaluated. Refine the change until it is ready for broader implementation. Then you should aim to embed this change in everyday practice. For example, you could expand the new way of doing things from just one ward to the entire hospital. When you have achieved successful quality improvement changes within your team, share your ideas with other organisations to spread best practice. The Standards for Quality Improvement Reporting Excellence guidelines provide a framework for designing and writing up an improvement study.8 You could also think about presenting your work at meetings such as the Patient Safety Congress or the International Forum on Quality and Safety in Healthcare.9 10 Publishing results of your project You could consider submitting your work to BMJ Quality & Safety, which encourages innovation and creative thinking to improve healthcare, or Quality Improvement Reports. The Department of Medicine at the University of California also includes a comprehensive list of quality and safety journals under the “Quality & safety” section of its website.11 There is an online community of healthcare professionals in the United Kingdom, known as The Network, who are engaged in quality improvement. The team behind this community encourages people to submit completed projects to the website and some of these projects are then selected for publication in The Network’s annual “casebook” (www.the-network.org.uk). After you have completed your first project, try to continue to be involved with other quality improvement projects. Share your successful changes throughout your career because better patient experience and outcomes are achieved through changing provider behaviour. Competing interests: None declared. References are in the version on careers.bmj.com Fiona Tasker, core medical trainee, Royal Sussex County Hospital, Brighton BN2 5BE fionatasker@doctors.org.uk 3