Your story - Delivering an organised quality improvement programme

This Future Hospital Programme case study comes from Withybush Hospital. It lays out the process for initiating an organised quality improvement project run by trainees, with the coordination of a lead doctor.

Key recommendations

Create a quality improvement (QI) forum to identify problematic areas within your service of care and draw up viable answers to these problems.
Appoint a QI lead so that the forum’s endeavours can be coordinated, with a singular point of contact to provide support and encouragement to forum participants. This will also help to ensure sustainability once the trainees have left.

Our story

The challenge

Historically at Withybush there was no organised process for initiating and recording any QI projects run by trainees. While trainees are encouraged to partake in audits and projects, these appear to be done at random with no prior consultation from peers or senior members of staff.

Until recently, data collection was the usual focus for junior doctors in audits. However a new era of endorsement from royal colleges such as the Royal College of Physicians’ symposium 'Learning to make a difference’ to local deanery initiatives are an encouraging platform for quality improvement projects run by junior doctors. It is now recognised that junior doctors are in an informed position to aid process mapping in QI projects and have the breadth of experience from hospital rotations to find solutions to process failings. Local ownership and recording of such projects are integral for the sustainability of local projects as well as for improvement through further plan, do, study, act cycles.

Our solution

Working alongside a fellow trainee, we devised a QI forum – a regular meeting to discuss issues regarding work practices and patient care – with the core aim to innovate solutions to any problems that may be highlighted through the forum’s exchanges.

The first meeting was an hour long and attended by trainees, the continuous improvement team, a consultant physician and the postgraduate department. As of yet, patients have not been invited to attend these forums which focus more on the support of the trainee in their own projects and development. A few of the most recent project ideas are looking to directly involve patients and the community in service improvement.

Outcomes

Thanks to the QI forum, new doctors now feel more engaged in the development of the service they are actively practicing in.

“The opportunity to highlight and actively manage problems within the place we work has been a great way to increase engagement with quality improvement. Being able to take control of things that aren’t working, change them, and see the effects has been a brilliant experience.” Dr Holly Kirk, the previous quality improvement lead for trainee doctors

The initial focus of this project was on improving the hospital environment and processes. As it has grown, trainees have used the support available to engage with patient-centred improvements. This has included improving venous thromboembolism prophylaxis and oxygen prescription. This work is ongoing.

Outputs

QI process developed

We developed a regular meeting between trainees, senior clinicians, the continuous improvement team and non-clinical staff. The format of the meeting allowed trainees to discuss barriers to delivering patient care. Typically it was the trainee who identified the problem who then decided on the PDSA cycles required to address the issue. Projects typically required no financial investment and were trainee led, with support from their supervising consultant and the continuous improvement team.

The forum was initially run as part of the handover process between rotations, at a time where trainees had been sharing their experiences of the job role. It had a good turnout due to this. They were in addition to education sessions and the formal handover, although trainees who did projects presented their projects at the departmental meetings. With more regular meetings it is hoped that turnout will be sustained when trainees see the success of projects run by their colleagues and the support received as part of this.

Via the QI forum, eight projects identified were handed over. These included:

oxygen wristbands: coloured wristbands introduced to improve target saturation prescription and oxygen titration
doctor’s trolleys: a standardised equipment trolley for medical and surgical wards has been created to help reduce the time taken to find equipment
e-discharges: the introduction of electronic discharges were led by trainee doctors. Mean time for a letter to reach primary care decreased from 32 days to 4 days, with 60% on the same day, compared with a baseline of nil.

Increased trainee engagement in QI

Seven projects were commenced through the forum, resulting in two audits and four QI projects presented at the forum or at hospital meetings. In total, eight projects (including those commenced outside of the forum) were formally handed over to new trainees at the August handover.

Sustainability of the changes

The recruitment of a lead doctor for QI and the handover process of projects to the new intake of doctors in August ensured sustainability of the forum and projects, including those that had commenced once the current trainees left.

Staffing

As our involvement with the project came close to ending, the decision was made to appoint a QI lead. This role would be filled by a foundation year two (FY2) doctor who would take over all lead duties for the duration of one year. An extract from the job specification is below:

‘During the pilot, it will be up to the candidate to shape the role throughout the year, taking opportunities for ongoing personal development. The following will be expected:

Coordinating the Trainee Doctor Quality Improvement Forum. You will meet with the current coordinator and plan the forum for the coming year to identify and develop projects from trainee doctors.
Attending the local Patient Flow Collaborative and being a trainee doctor representative on stakeholder groups.
Ensuring representation of Withybush Hospital in national QI forums, ideally through publications and presentations at a national level.

A short report or presentation will be expected from the candidate by the end of the year to guide the development and expansion of the role for the following year.’

This was sent out to all prospective FY2 doctors arriving in August across all specialties. A panel was appointed to rank applications. Dr Hannah Skipp was appointed to the role:

“There have been problems coordinating everyone to come together for the forums but now the dates have been set this should be easier. We have also attempted to get IQT Silver delivered during the F1 and F2 teaching programme but there have been problems finding a trained lead to run the sessions. There are hopes to run a 2 day course, but the F1 would not be able to attend as they do not get study leave. I hope we continue to make changes for the better and keep up engagement with quality improvement.”

Key learning

Although it is early to say, we are confident the introduction of a QI forum means that projects are more likely to succeed in improving services or patient care.

The project has changed the approach to QI at Withybush Hospital. The biggest challenge was trying to communicate this vision to trainee doctors and senior colleagues. However, once people understood our aims they engaged with the project because they realised the opportunities available to make a difference. New doctors now feel more engaged in the development of the service they are actively practicing in. The QI forum offers a structured way to develop the service and the utilisation of a lead doctor for the QI project gives other staff a point of contact, encouragement and coordination. Previously no QI projects were being handed over, and so this process gives any work done a chance to continue once a trainee doctor leaves. Trainee doctors are enthusiastic about indentifying areas requiring improvement and keen to make changes, but lack an organised framework. The forum allowed trainees to formulate ideas for projects and consider solutions. The original forum gave no training but ensured all had done IQT Bronze.

Vital to the process was involvement with other health professionals – quality improvement is a team sport.

For every project the team supporting the trainee doctor involved a multidisciplinary approach. In the future we would like to include different members of the teams in the forum process.

From one of the new cohort of doctors: “Part of the induction included a talk about the importance of quality improvement and examples of the projects that were being undertaken. I got to contact the team who had lead on the project the previous year and gave me such a head start. This helped me to have a framework and contacts and helped the project keep the momentum. It also showed to us how serious Withybush Hospital was about supporting trainees in quality improvement.”

Senior involvement in this process was vital to show respect to trainees, indentify obstacles early on and give validity to projects. Supervising consultants were engaged and willing to input into the process, though in general we noticed that there was poor identification of the need for QI and knowledge of methodologies, realising how this new approach is a cultural shift from previous approaches. We would like to work with the health board in the future for QI training to be offered at all levels in a team approach.

What next?

Ongoing projects are continued following the doctor changeover in August through a structured handover and contact with the previous leads. With a greater number of trainees involved with projects, we are working with 1000 Lives toward training through their Improving Quality Together silver programme. With support from the health board we are using the projects to showcase the advantage of trainee involvement in QI in other hospitals throughout Wales.

Who’s involved?

Dr Richard Gilpin is a Wales clinical leadership training fellow, Aneurin Bevan Continuous Improvement Unit (ABCi), Newport, Gwent.

Dr Holly Kirk, foundation year 2 doctor, Withybush Hospital, Haverfordwest

Dr Hannah Skipp, foundation year 2 doctor and quality improvement lead for trainee doctors, Withybush Hospital, Haverfordwest

For further information please contact

Nina Balachander | Future Hospital Programme Project Manager

Care Quality Improvement Department | Royal College of Physicians