Quality Improvement Training for Post-graduate Clinical Education

Quality improvement training is a 4-6 month programme comprising of face-to-face teaching and implementation of a small project. Trainees will be taught to use a methodology called Model for Improvement, which will enable them to achieve their learning objectives. Teaching is interactive and delivered in two half-day small group face-to-face sessions.

Trainees are expected to have a topic in mind before starting training and work through the idea during the teaching sessions. The teaching sessions are held one month apart and trainees should continue to plan their projects in-between sessions. By the time the teaching has been completed, the trainee should have a draft project plan developed and be ready to start executing their project over approximately 4 months.

Trainees are expected to work through some pre-training preparation (read articles and watch a short video), which will enable them to develop a basic understanding of the methodology to assist them in choosing a suitable topic.

Trainees are encouraged to participate in quality improvement training during their 2nd or 3rd year of post-graduate studies. To help prepare trainees for QI training, they will attend an introductory presentation at their first year induction.

Model for Improvement

There are many quality improvement methodologies. These include Lean, Six Sigma, Total Quality Management (TQM) and clinical audit. The Model for Improvement was developed based on the work of W. Edwards Deming who is an American engineer, statistician and management consultant. It is a continuous improvement methodology where changes are tested in small cycles, which involves planning, doing, studying and acting (PDSA), before returning to planning and so on. Each cycle starts with hunches, theories and ideas and helps them evolve into knowledge that can inform action and, ultimately, produce positive outcomes.

This QI methodology is based on approaching change through four lenses, in accordance with Deming‘s „System of Profound Knowledge“:

1. Psychology – All improvement ultimately involves the change in behaviour of people. To be successful, it is essential to understand how people think and act.
2. Systems – The work that people do is part of a process, and each process is connected to other processes. This network of processes forms a system. Different people participate in making systems work. Changing part of one process affects another and disrupts the wider system. One needs to understand how systems work to be able to make sustainable improvements.
3. Variation – Understanding variation in how people work within a system and reducing it as much as possible is necessary for improvement. Therefore, data for improvement needs to be informative about variation.
4. Theory – One cannot fully learn about the psychology of people, how systems work and variation without testing changes. Testing enables the formation of theories by investigation into how people behave and complex systems are affected by changes. Forming and testing theories in cycles enables sustainable solutions to be found and is underpinned by the approach of „learning by doing“.

Not all quality improvement project ideas may be appropriate for trainees to implement as their very first project while still developing core competencies. Some problems may be more complex and difficult to resolve than others. This checklist may be used as a guide to assess whether the topic may or may not be appropriate.

1. Overview of the Model for Improvement Methodology (10:00 min)
2. Model for Improvement Part 1 (02:55 min)
3. Model for Improvement Part 2 (03:01 min)
4. Static versus Dynamic Data (06:40 min)
5. Run Charts (07:29 min)
6. Types/Family of Measures (07:53 min)
7. Flowcharts / Process maps (07:46)
8. Fishbone Analysis / Cause and Effect Diagram (05:16 min)
9. PDSA Cycles (04:46 min)

• A3 project template (excel document)
• Fishbone analysis (Cause and Effect Diagram)
• PDSA tracker (word dokument) 
• Run Chart Template
• Interpreting Run Charts
• Guidance on setting medians and rephasing on the Run Chart

• Improving labelling of PAP smear samples (Excel document) - Hulda Þorsteinsdóttir, Resident in gynaecology
• Mænuvökvataka á Minnismóttöku Landakot (Excel document) - Berglind Árnadóttir og Guðbjörg Erla Guðmundsdóttir, Residents in Internal Medicine
• Improvement of cardioversions for patients in Hjartagátt - Hrafnhildur Gunnarsdóttir, Ívar Sævarsson og Jóhanna Rúnarsdóttir, Residents in Internal Medicine
• Increase vital signs taken for children in the emergency department (Excel document) - Kristín Júlía Erlingsdóttir and Urður Jónsdóttir, Residents in paediatrics
• Reduce preparation time for pleural drain placement on internal medicine wards (Power Point document) - Gunnar Baldvin Björgvinsson, Resident in internal medicine
• Reduce unnecessary blood gas sampling in the ICU (Excel document) - Hallfriður Kristinsdottir, Resident in Anaesthetics
• Improving review and confirmation of daily instructions for paediatric inpatients (Excel document) - Hildigunnur Þórsdóttir and Elín Óla Klemenzdóttir, Residents in Paediatrics
• Reducing non-urgent phone calls and unnecessary interruptions for the on-call resident (Excel document)- Hrafn Hlíðdal Þorvaldsson and Helga Þórunn Óttarsdóttir, Residents in Paediatrics
• Increase the number of Parkinson’s Disease (PD) patients that receive their first PD medication dose </=1 hour from their schedule after being admitted acutely to cardiology (Excel documet) - Snædís Jónsdóttir, Postgraduate clinical nurse specialist trainee
• Improving the number of medication reconciliations by clinical pharmacists for admitted patients in the emergency department (Power Point document) - Ingibjörg Sigurðardóttir, Post-graduate trainee in clinical pharmacy

Download Roles and Responsibilities of Project Supervisor (Checklist) (word document) 

• It is not necessary to seek data protection approval to pull data from Landspítali‘s health records for quality improvement purposes.
• It is permissible for junior doctors to look into patients‘ health records and to manually collect data on a separate data collection form or spreadsheet as long as they do not record kennitalas or other patient identifiable information.
• Always ask: do you absolutely need to include kennitalas in your data collection?
• Once kennitalas are recorded this data is no longer anonymised and may require approval from the data protection authority.
• The health informatics team (Hagdeild) will generally not provide patient identifiable information when data is requested for and they may ask for evidence of ethics approval.
• The HUT department may include kennitalas in their spreadsheets and may not ask for proof of data protection (or ethics) approval.
• Rules are gradually tighening up.
• Residents and QI project supervisors therefore have a responsibility to make a concerted effort to always protect the identity of patients when conducting QI projects.

It is not necessary for QI projects to receive ethics approval from the Bioethics Committee, however it is important for ethical issues to be considered before starting any project. The screening tool below provides a guide for trainees and supervisors to be able to carry this out in a structured way. The trainee and supervisor should complete this together and have it signed by the QI Lead for the training programme. A signed copy should then be kept by the trainee. This will then fulfill the ethics screening criteria if the trainee chooses to publish his/her work in the future.

Download:

• Quality and ethics screening tool for quality improvement projects (word document)

Download:

• Checklist of QI Competency Sign-off
• Quality Improvement Project Assessment Tool (QIPAT) (word document)