How to start a Quality Improvement Project
Are you considering undertaking an Improvement Project?
The purpose of the Lothian Quality Website is to signpost you to the appropriate tools and templates you will need, and provide guidance on how and when these should be used. This will help you plan and progress improvement opportunities that meet your own local needs.
Following this page step-by-step will guide you through the whole process of starting an Improvement Project.
“Project Proposals”
Lothian Quality has created a flowchart to firstly let you determine if your improvement idea is Quality Improvement, Audit, Service Evaluation or Research.
We always encourage anyone undertaking an improvement project to inform their local Quality Improvement Team (QIT) Chair, or where there is not a functioning QIT, service management. This is to allow service leads to know what improvement work is ongoing in their area.
Your local Quality Improvement Support Team (QIST) will be able to offer further support and advice.
Improvement Project
When starting your improvement journey we encourage you to “size the problem”. Basically this means understanding what the current practice is.
NHS Lothian advocates a Quality Management System approach for all improvement work.
This consists of three phases:
Quality Planning – understanding and diagnosing what is happening in your ward/unit. This might include: whole case reviews, gathering staff feedback, auditing of documentation etc
Quality Improvement – conducting tests of change supported by the use of rapid Plan Do Study Act (PDSA) cycles and the use of data to inform change
Quality Control – continuous gathering of data (quantitative and qualitative) for quality assurance purposes, to ensure your changes are sustained.
Quality Planning Phase
What are you trying to improve?
This phase is an essential part of any improvement project. It allows you to identify opportunities for improvement which are appropriate to your ward/unit, the processes you have, and the patients and staff in your area. It is important that you do not skip this phase!
You should always try to align your project aim with local strategy, to maximise engagement and support
Before starting your improvement project, it is essential you gather data to understand what is happening in your area
It is also important to collect regular ward-level data. This will help you understand what area to focus on improving.
Appreciation of your system - How do you currently do things?
Process Map - Creating a process map will allow your team to see the actual, rather than the desirable flow or sequence of events in your process. Input from colleagues will ensure all steps in the current process are included. This tool will highlight any potential differences in approach across the team, and whether the process needs refined, so that everyone works cohesively. It may also highlight parts of the process that is redundant and could be removed.
It is important to ensure you have a clear beginning and end to the process, all key decision making steps are included and there is an understanding of who is responsible for carrying out each step.
Staff / Patient Feedback - Staff and patient (where appropriate) feedback, is key to understanding your current process. The following three simple questions will give you a wealth of information:
“What works well?”
“Even better if……”
“Suggested improvements?”
Use the best method of collecting this information for your audience. It might be an anonymous questionnaire, or use of flip chart paper and post-its.
Pareto Chart - Producing a Pareto Chart will allow you to quickly and easily see the key areas of your current process that isn’t working well and what you should focus on improving. The Pareto principle, also known as the 80/20 rule, states that 80% of the effects come from 20% of the causes.
Psychology of people involved – How to engage and involve colleagues in your Improvement Project
Project Team – Now you’ve identified what you want to improve, you should form a Project Team. Things to consider when doing this:
Members should have a shared interest in your improvement area
There should be representation from across the MDT (e.g. Nursing, Clinicians, Care Support Workers etc)
Consider members’ skills, capacity and capability, and what motivates them
Fishbone Diagram - Creating a Fishbone (Cause & Effect Diagram) will allow your team to identify, explore and visually display all the possible causes related to your problem. You would discuss and agree as a group a list of things that are stopping your ward/unit from doing these.
Quality Improvement Phase
Now you can develop your Project Aim.
Things to consider when creating your aim statement
Does your project align with the six aims for improvement; Safe, Effective, Efficient, Equitable, Person Centred and Timely.
Make your aim SMART (specific, measurable, achievable, relevant and time bound).
What will be improved? Who for? By how much? By when?
Driver Diagram - Once you have a clear Project Aim you can use this, along with the information in your Fishbone Diagram, to produce your Driver Diagram. This tool visually displays your theory of how you plan to achieve your Project Aim.
Your Fishbone Diagram detailed all the problems that were wrong with your process and the causes of those problems. Your Driver Diagram will detail all the things you think should happen to help resolve those problems and achieve your aim.
Every Driver Diagram should contain the following:
Primary Drivers – these are a small number of key components of the system / main areas of influence that need to change to help achieve your aim e.g. process, people, culture, environment. These are usually the main problem areas you identified in your Fishbone Diagram
Secondary Drivers – these break down your primary drivers into natural subheadings. They provide more detail on where interventions are required, to positively influence your primary drivers. These are usually the opposite to the individual causes of the problem areas identified in your Fishbone Diagram
Change Ideas – These are the specific ideas that your Project Team can test, to see if they influence your secondary drivers and ultimately your Project Aim.
How will we know that a change is an improvement?
The data you collected at the start of your project can be categorised as measures. There are 3 different types of measures;
Outcome – these measures help you to see if the changes you are making are having a positive impact on your project aim. Ideally, you should have no more than one outcome measure
Process – these measures help you to see if a specific process change is having the intended effect. Ideally, you should aim to have no more than 2-3 process measures
Balancing – these measures make sure that changes made to improve one part of your system, does not cause problems in other areas. This is also referred to as ‘unintended consequences’. Ideally, you should have no more than one balancing measure
In addition to these suggested measures, you should also consider further process measures that are particularly relevant to the change ideas that you are going to test.
Measurement Plan – Once you have identified the relevant measures for your improvement project, you should write a measurement plan. This tool will help you set out the specific details of each measure relevant to your project including:
the specific type of measures e.g. if they are percentages, count (number of something), days between
the purpose of each measure; what goals you are trying to achieve
the precise “operational definitions” for each measure, to help explain how they will be calculated
how and when the data will be collected, and by who
Run Chart – Data collected for each of your measures should be plotted over time on run charts. This will help you see at a glance, your system before and after changes are made and any improvements as a result of these changes. Collect as much baseline data as you can to start with (ideally a minimum of 12 data points), which will allow you to decide whether you have a stable system to start with.
You should continue to regularly collect and plot data, annotating your chart to show when your project started and when you tested each change idea. This will let you see at what point improvements began to take place.
What changes can we make that will result in an improvement?
You should now have a better idea of some of the specific change ideas you want to test that are relevant to your improvement project.
Change ideas should be identified by the Project Team as a group, and members encouraged to engage with and support testing these changes. It should not be the sole responsibility of the Project Lead to test change ideas. Progress, results and learning should also be fed back to the Project Team at regular intervals
Project Charter – You should now capture all your initial findings and information, including your proposed change ideas in a Project Charter. This document will help you keep track throughout your project of; what you are trying to achieve, how you plan to achieve it and what changes you are considering. Project Charters are a constantly evolving document
PDSA Plan – Now you’ve identified your change ideas, a PDSA Plan will help you track the details of testing these. A PDSA plan should be completed for every PDSA cycle you carry out.
Critical factors to think about when testing change ideas:
Consider if your change ideas are sustainable, or if you will revert back to your original process? Will patients in the future benefit from the improved process?
People should be at the centre of your change idea. Will your change improve patient or care experience?
Changes should make your process easier and/or help your process become smarter, not harder
Test one change idea at a time
Always start small and test quickly. Test each change idea with a single patient, reflect and make necessary adjustments. Test again on another patient / small group of patients
Stop and reflect. Are your changes making a difference
If a change isn’t making a difference, be prepared to abandon it, and test something else
While testing, continue to collect data regularly over time and plot on your run chart. The more data you have, the quicker you will see signals of change/improvement.
Don’t rush to spread until you are sure improvement is sustainable!
Quality Control Phase
Have your changes resulted in sustained improvement?
Now you have made your changes and they are showing signs of improvement, are they short lived or an ongoing success?
It’s important to ensure any improvement achieved from changes you make, continue to have an ongoing positive impact. This can be achieved by continuously monitoring your revised process. If you don’t do this, your process may return to how it was before you made the improvements. If you continue to monitor your process, you can act swiftly on anything which appears to be no longer working