Blog post: Improving Quality of Quality Improvement

• Are you befuddled by acronyms in quality improvement?
• Can you tell your audit from your elbow? Or your Fishbone from your Driver diagram?
• Would you like to know more about change in the NHS?

This short article is a beginner’s guide to QI and a pitch as to why it is a cornerstone of clinical practice in neonatology.

What is QI?

QI at its core is making sure that evidenced-based advances in science are translated into routine clinical practice to improve outcomes for our babies.

In neonatal medicine, QI opportunities are abundant, thanks to our specialty’s strong relationship with research.

Here are a few examples:

• interventions to keep babies warm in the delivery room
• interventions to reduce catheter-associated blood stream infections
• interventions to ensure the group most likely to benefit receive hypothermia in a timely manner

The Phases of QI

• Step One: Define the problem

How do you know if your unit is a “good” unit?

What does a “good” neonatal unit look like?

If data is collected accurately according to standardised definitions, it can then be used for comparison. For example this can be with a historical dataset from the same unit (before and after an intervention) or with other, similar units. Large datasets from NNAP (National Neonatal Audit Programme) and VON (Vermont Oxford Network) are used to tell us if we are on the right track for key quality indicators. If you are not already familiar with these, you might want to have a guess at what these could be, for example for infants <1500g- have a think about what we can easily measure and collect.

So first of all we need to identify where we may have a problem area at which to target our QI interventions- this is why all those painful hours completing audits and collecting data are worth it!

How did we get here?

A Driver Diagram can be used to show how different systems and problems interact

A Fishbone Diagram looks at cause and effect

Pareto Charts can help to decide which areas to focus your energy- based on what problems are the most frequent and significant.

Process Maps look in detail at all stages of the process- it is important to consider critical steps from other team members here eg the pharmacist, the porter.

• Phase 2: Develop a Shared Purpose

So using data we have clearly defined our problem. Now the teamwork begins! This requires great enthusiasm, tenacity and a good dose of diplomacy- to ensure that the other key stakeholders in the department understand that a problem area for improvement has been identified. Other team members will have different perspectives on problems and solutions, the result will be a shared plan of action.

Some examples of stakeholders:

• Medical team: junior and senior
• Nursing team: junior and senior
• Wider MDT pharmacy, physios
• Non clinical staff: ward clerks, portering services
• Parents and families

• Phase 3: Plan and Implement Change

Formulate ideas, prioritise and test. In this phase, change ideas are launched and then continuously reviewed through PDSA (Plan, Do, Study, Act) cycles. Again, data collection and tracking at this stage are essential.

• Phase 4: Test and Measure Improvement

Run charts are used to track your outcomes as close to “live” as possible- so you can see if changes are working and adapt as needed.

• Phase 5: implement, Embed and Sustain
• Spread the word!
• Look in detail at when and why your change hasn’t happened- exception reports
• Explore barriers and how they change over time
• Keep people motivated

So there we have it, a beginner’s guide to QI. Hope you enjoyed it, I’m off to clean the cafetiere…

Other useful resouces:

BAPM Toolkits/ QI https://www.bapm.org/pages/2-quality

NHS improvement website: https://improvement.nhs.uk/

NHS Scotland Quality Improvement Hub: http://www.qihub.scot.nhs.uk/qi-basics/quality-improvement-glossary-of-terms.aspx