Article Text

Download PDFPDF

Supporting colleagues to improve care: educating for quality improvement
  1. Jane Runnacles1,
  2. Alice Roueché2
  1. 1Department of Paediatrics, Royal Free Hospital, London, UK
  2. 2Department of Paediatrics, Evelina London Children's Hospital, St Thomas' Hospital,London, UK
  1. Correspondence to Dr Jane Runnacles, Department of Paediatrics, Royal Free Hospital, Pond Street, London NW3 2QG, UK; Jane.runnacles{at}gmail.com

Abstract

Clinicians at the front line of healthcare delivery are very well positioned to identify and improve the system in which they work. Training curricula, however, have not always equipped them with the skills or knowledge to implement change. This article looks at educational approaches to support clinicians to be actively involved with quality improvement (QI). It looks at the role of doctors in postgraduate training (DrPGT) and their educational supervisors and builds on the topics discussed throughout the ‘EQUIPPED’ article series. Factors for success of a QI education programme and practical ideas for overcoming barriers to supporting clinicians in QI are discussed. We present examples of educational initiatives and a framework for evaluating such programmes, and we examine the role of faculty development to help inspire and support colleagues to improve care.

  • Medical Education
  • Paediatric Practice

Statistics from Altmetric.com

Introduction

This article aims to support clinicians (doctors, nurses and allied health professionals) to be actively involved with quality improvement (QI). It is intended for all child health professionals with an interest in QI who want to develop their own skills as well as support their colleagues to undertake QI and spread QI learning. It specifically looks at the huge potential for doctors in postgraduate training (DrPGT) to be agents for change in healthcare and how we can support this through education and educational supervision. This paper is not a full systematic review but outlines successful approaches to QI learning with practical advice on developing and evaluating QI education in your own organisation.

Why support front-line clinicians in QI?

Clinicians at the front line of healthcare delivery are optimally positioned to identify and carry out improvements to the system in which they work.1 In much of the world, this front-line workforce includes DrPGT as well as junior nursing staff and other colleagues in training. Unfortunately, training curricula make little reference to QI and so junior clinicians are often ill-prepared to make effective changes. Time is wasted on data collection for compulsory audits but without real change.2 When DrPGTs move between organisations, they have the potential to bring a fresh perspective and share best practice from other places but this opportunity is usually missed. Hospitals and healthcare systems are therefore missing out on harnessing a potential improvement workforce.1

With a growing emphasis on clinical leadership worldwide and developments like the National Health Service (NHS) Leadership Competency Framework in the UK, the bodies that oversee and regulate postgraduate medical training are realising the importance of QI work as part of professional development. In the USA, the Accreditation Council for General Medical Education (ACGME) published new standards for residency training in 2011. These include stipulations for residents to be ‘integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programmes’.3 The UK General Medical Council now cites in its Duties of a Doctor that doctors must ‘take part in systems of quality assurance and quality improvement’.4 To reflect this, the UK Medical Royal Colleges are starting to move from having ‘Audit’ as a compulsory activity for yearly assessments to having ‘Quality Improvement or Audit’ which comes as a very welcome change. This is also reflected in recent changes to UK medical Consultant NHS revalidation (The Medical Appraisal Guide (MAG) model).

There is certainly great enthusiasm from DrPGTs. Last year’s edition of the Network Casebook, an on-line publication of QI projects from DrPGTs and other junior healthcare professionals, had over 150 submissions. Clearly where the support exists, front-line healthcare professionals are keen to make changes, and there is an infectious energy for QI growing from DrPGTs, who have demonstrated how empowering and rewarding QI projects can be for both their personal development and for improving care for their patients.

Educational approaches to supporting QI

Recent years have seen the development of new initiatives to train and support clinicians to undertake QI. These schemes are useful both to the participants and to other clinicians developing new programmes in their own workplace. The improvement community strongly supports collaboration and sharing good practice and we recommend that readers make use of the resources and experience that schemes like this can offer.

Structured educational programmes

Our experience suggests that many child health professionals are not familiar with the concepts of quality in healthcare and QI methodologies. A structured programme within an organisation can address this gap in knowledge through taught sessions on QI methodology. However, this training is only the first step and may not result in change. Workshops and seminars can help identify QI opportunities and provide practical support such as progress feedback and project surgeries. There is no widely accepted QI curriculum, but the US Institute for Healthcare Improvement (IHI) provides a helpful framework to help set content for such a programme. Ideas for teaching topics can be found in box 1 (adapted from Royal College of Paediatrics and Child Health (RCPCH) QI education programme). Consideration needs to be given to evaluation of the programme (see below) and in releasing clinicians from clinical work in order to attend teaching. It may help to link such a programme to Continuing Professional Development and professional training/appraisal requirements.

Box 1

Ideas for quality improvement (QI) teaching topics

  • What is Quality in Healthcare? Defining quality and safety in paediatric care

  • The Model for Improvement21 and PDSA (Plan, Do, Study, Act)

  • Common QI tools: Process mapping, Lean, Six Sigma, writing SMART (Specific, Measurable, Achievable, Relevant, Time-specific) aims

  • Using data for improvement: understanding run charts

  • Stakeholder engagement

  • Patient engagement and involvement

  • Change theory (the psychology of change)

  • QI and clinical governance

  • Spread and sustainability

  • Local QI activities and resources

If your programme sits in a wider leadership programme, sessions on understanding the structure of the National Health Service (NHS) and finance in the NHS can be helpful. A local ‘Who's Who’ in management can also be beneficial.

Experiential learning

It is important to provide support and mentoring for participants undertaking QI projects. This can help them learn from their experiences and help promote successful and sustained improvement. Regular meetings, action learning sets and project surgeries can help to discuss barriers and stalled projects. A multi-professional approach here can help open doors and bring a wider perspective; it also broadens the potential faculty available to deliver such support. On-line support through email and web conferencing can be provided for clinicians in isolated settings or where QI faculty is not available on site. This has been successful in the Royal College of Physician's QI programme ‘Learning to Make a Difference’ (https://www.rcplondon.ac.uk/projects/learning-make-difference-ltmd).

A combined approach

A combination of structured teaching and experiential learning is often the most effective to promote QI learning5 as it provides practical experience with a solid foundation of improvement science. Local and regional programmes in the UK, such as Enabling Doctors in Quality Improvement and Patient Safety (EQuIP)6 (see box 2) and Doctors Advancing Patient Safety (http://www.daps.org.uk), have demonstrated successful projects and learning outcomes from this approach. International examples include Cincinatti Children’s Hospital Intermediate Improvement Science Series (I2S2) for developing QI leaders, including clinicians,7 and QI Programmes at University of California Davis School of Medicine (USA),8 Beth Israel Deaconess Medical Center (USA)9 and Jonkoping University, Sweden.10

Box 2 An example of a local QI education programme

Enabling Doctors in Quality Improvement and Patient Safety (EQuIP) has been designed for doctors in postgraduate training (DrPGTs) at Great Ormond Street Hospital (GOSH) to develop them as future leaders for quality and safety. The aim is to support DrPGTs through a quality improvement (QI) project within their department aligned to the organisation’s objectives of ‘No waste, No waits and Zero harm’. Crucially, the programme was peer-designed with a three-level approach to engage and inspire DrPGTs in a 1 h workshop (level 1), educate and support them through a project in a 6-month rolling programme of workshops and project surgeries with managers (level 2), and to spread and sustain the QI projects with senior QI champions (level 3).8 Pre-programme and post-programme evaluations demonstrated an improvement in DrPGT knowledge, skills and behaviour, and participants perceived the programme to be a valuable learning experience. They reported that they feel valued and empowered to make changes within their department to improve patient care. There were also significant results for the organisation, which recognised and valued their contribution and agreed to fund a replacement ‘Darzi’ leadership fellow to continue the programme.

Box 2 describes the EQuIP programme that has been developed at Great Ormond Street Hospital NHS Trust, London, UK.6

Multi-professional QI learning

There is enormous value to a multi-professional approach to QI. Recent years have seen ‘paired learning’ initiatives that link managers and clinicians to undertake QI work and to gain a different perspective on their daily work.11 Many QI projects benefit from linking medical, nursing and allied health professionals in a team approach. Pairing primary and secondary care clinicians would also be an option.

Benefits of such programmes include increased preparedness for leadership roles, developing collaboration to improve care and real service improvements.11 Successful programmes require leadership and organisational support—from both medical and management hierarchies. Participants need to be given time and some mentoring support. As with experiential learning, it can be helpful to run a structured education programme alongside such an initiative. Even without such a programme, just facilitating conversations across traditional boundaries and promoting QI collaboration can be of benefit.

Examples of programmes that promote this include:

  • Paired Learning, a flexible approach which encourages UK doctors in training to work more closely with NHS managers on a QI project to learn from each other's experiences and expertise. A toolkit is now available for spread to other organisations.11

  • Learning Together, Leading Together, a UK-based initiative to pair foundation year 2 doctors with NHS graduate management training scheme trainees and undertake a QI project together. This encourages collaborative learning at an early stage of their career.

Factors for success of a QI education programme

Many well-intentioned new schemes are developed in isolation, failing to learn from the experiences of others and thus destined to make the same mistakes. We recognise that clinicians taking time and effort to develop training opportunities deserve recognition for this work and we hope that collaborating with existing schemes is not seen as a less rewarding option.

The EQuIP programme identified important lessons for learning for other organisations, mirrored in a report by The Health Foundation:12

  • Experiential learning on a project alongside a structured educational programme on QI methodology (focused on the model for improvement) must be supported by senior clinicians and managers within a department.

  • Clear project aims that are achievable and measurable, with projects integral to daily clinical work, are important to ensure completion of projects.6

  • Multi-professional collaboration on projects should be encouraged, although the educational programme may need to be tailored specifically to the needs of the participants. Engagement of patients in projects is recommended and is also very rewarding.

  • Mentoring, accessible expert advice through open project surgeries and monthly rapid-cycle feedback on projects (brief presentations on project progress with peer discussion) are essential components.

Evaluating interventions

There are a growing number of educational programmes to teach QI, but they are rarely formally evaluated. Their impact needs to be robustly examined before they are spread. A systematic review of teaching QI to clinicians recommends that curricula are evaluated based on whether learner’s attitudes, knowledge and skills improve.12 This is especially important when improvements are ‘associated with intermediate clinical gains’.13

Kirkpatrick’s 4-level model14 has been proposed for evaluating training programmes:

  1. Reactions of the participants

  2. Learning (increase in knowledge or capacity)

  3. Behaviour change (or capability improvement and application)

  4. Results for the organisation.

The South-West Junior Doctor Quality Improvement Programme15 and EQuIP6 have used pre-programme and post-programme surveys to subjectively assess trainee’s reactions (level 1) and improvements in knowledge, skills and behaviours (levels 2 and 3). EQuIP participants were asked to rate their knowledge of QI methodology, such as Plan–Do–Study–Act (PDSA) cycles and process mapping, pre-programme and post-programme. The Cinicinatti I2S2 evaluation used a similar approach, subjectively assessing improvement in knowledge, but also used peer feedback and course director’s rating of the use of QI tools in their final project report.7 All three programme evaluations showed improvements in knowledge and skills (level 2), interest in continuing QI work in future (level 3) and demonstrated project results (level 4). Although the Cincinnati programme followed up participants later with a survey regarding ongoing participation in QI (level 3), further work needs to explore the long-term impact of such programmes not only on the individual but also on the organisation and patient care.

Further education

Other approaches to QI learning include taking time out of work/training to focus specifically on leadership development. This could be to undertake a further qualification such as a Master’s degree or a Leadership Development/QI Fellowships. UK examples include fellowships offered by the NHS Leadership Academy and the Faculty of Medical Leadership and Management (FMLM). There are also schemes that run alongside clinical work (eg, Leading Improvement in Patient Safety programme, run by the former NHS Institute for Innovation and Improvement).

Self-directed learning

There is a wealth of information and support available for individual clinicians who wish to undertake QI:

  • The best established of these is the IHI Open School. Members can access learning modules and resources about a breadth of QI topics with a strong focus on practical application. There is free access for those who register as a resident (equivalent to a UK DrPGT).

  • The NHS Institute for Innovation and Improvement developed toolkits and information packs relevant to clinicians. The Institute closed in April 2013, but resources are currently still accessible through the archived website (now being administered by NHS Improving Quality).

  • BMJ Quality has developed an on-line platform to support individuals and organisations through QI projects, with access to learning modules and project mentors (quality.bmj.com accessed on 27 Oct 2014).

Other useful resources/websites

Health Foundation: http://www.health.org.uk/ (last accessed 19 Oct 2014)

Scottish Patient Safety Programme: http://www.scottishpatientsafetyprogramme.scot.nhs.uk/programme (last accessed 19 Oct 2014)

Paediatric International Patient Safety and Quality Community (PIPSQC): http://www.pipsqc.org/ (last accessed 19 Oct 2014)

Running Horse Group: http://www.runninghorsegroup.com (last accessed 19 Oct 2014)

Sharing learning

QI is underpinned by the principle of sharing good practice and learning from others’ experience. The dissemination of findings from QI is important for advancing the field as well as improving patient care by increasing the likelihood of success of future interventions. Few QI projects reach publication, however, partly because the design, types of intervention, data collection and analysis related to QI do not fit traditional publication guidelines. Van Cleave et al16 identified other barriers to publishing, including small-scale local initiatives, and strategies to overcome these, including working in networks and creating incentives.

The Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines were developed by stakeholders from various disciplines in response to this challenge.17 This is a checklist of 19 items for authors and forms an explicit framework for sharing the learning and knowledge from improvement work (see http://www.squire-statement.org accessed 27 Oct 2014). Just as CONSORT (Consolidated Standards of Reporting Trials) provides guidance for reporting of randomised controlled trials, SQUIRE provides a structured guideline to form a bridge from the completion of a QI project to the sharing of the conclusions with others.

QI projects can be presented as posters and short oral presentations at international conferences such as the IHI/BMJ International Forum for Quality and Safety in Healthcare, ISQUA (International Society for Quality in Healthcare) and The Patient Safety Congress. Further opportunities can be found at regional conferences, such as those in the UK hosted by London Deanery, South-West Strategic Health Authority, the FMLM and the BMJ (Agents for Change). Reports of larger improvement initiatives may be published in journals, such as BMJ Quality and Safety, The Joint Commission Journal on Quality and Patient Safety and The International Journal for Quality in Health Care but, in the authors’ experience, there are few peer-reviewed journals that will accept smaller projects for publication. To meet this need and allow sharing of innovative junior clinician-led projects, an on-line collaborative of DrPGTs in the UK established ‘The Network’ and developed a ‘casebook’ series of QI projects selected for prizes, presentations and publication. The British Medical Journal is also developing a database of projects through their QI reports website, http://qir.bmj.com/ (accessed 24 Oct 2014).

Overcoming barriers to supporting clinicians in QI

The Health Foundation review on engaging clinicians demonstrates that ‘improving quality is part of clinicians’ professional identity and that tapping into this can be a powerful motivator for change’.18 They give recommendations on delivering, supporting and evaluating QI to amplify the impact of physician engagement in QI on improving patient outcomes. These recommendations are presented in the table below as a way of overcoming barriers to supporting clinicians in QI:

Training the trainers

Within organisations, there are a growing number of individuals with QI skills who should be supported and encouraged to educate and engage other clinicians in QI. This in-house resource is key to providing QI education programmes and ensuring that clinicians are supported to actually put change into practice in their own work environment. In order to recognise and develop their skills, it can help to include these individuals in a faculty development programme. This may involve giving them the educational context relevant for participants (eg, postgraduate curricula, assessment requirements) and developing their teaching and facilitating skills. Equally it may involve giving QI skills and knowledge to clinicians in an educational supervision role who may feel ill-equipped to support their trainees in undertaking QI.

In the UK, The RCPCH has developed a QI Education Programme for child health professionals across the country. QI methodology is taught through introductory courses, but the overall programme has a particular focus on providing teaching resources and developing a QI education faculty. The vision for the programme is to develop a network of Child Health QI Champions across the UK who can deliver structured education programmes locally. We encourage UK readers to visit the RCPCH QI website to make contact with others in their region, and to find QI education days relevant to their needs as a novice (introduction to QI) or as new faculty to lead and support QI activities. Child health professionals in an education role should consider how they are supporting QI activity and education. This may involve workshops at professional meetings and conferences, providing on-line resources for the education community and developing QI training programmes.

Conclusion

The 2013 Keogh Review into the failing English NHS Trusts identified in the Francis Report is clear about the importance of junior clinicians in improving healthcare.19 DrPGT ‘must not just be seen as the clinical leaders of tomorrow, but clinical leaders of today’. The report goes on to state that these clinicians are ‘potentially our most powerful agents for change’. This report has relevance to healthcare systems worldwide.

There are many examples of junior clinicians being effectively supported to make real change within healthcare. Interestingly, many of these initiatives, such as ‘NHS Change Day’,20 are led and coordinated by junior clinicians themselves who can engage and inspire their peers. They may also understand best how to design a programme that meets the needs of their colleagues. Despite this, exposure to QI educational approaches is inconsistent, and awareness of QI is variable. Junior clinicians are not all fortunate enough to have the opportunity to participate in supported QI education programmes.

It is our hope that senior clinicians, healthcare managers and those involved in healthcare education can see the benefit of investing in their workforce, both for their present and future roles. Developing multi-professional QI programmes has the potential to inspire and enable front-line staff to make meaningful change and thus can be a powerful tool for driving change and improvement. We believe that sharing learning and celebrating success will help to spread the innovations and improvement such that all clinicians feel empowered to play an active role in improving the care for their patients.

References

Footnotes

  • Contributors JR and AR both contributed to the conception and drafting of this article.

  • Competing interests The authors, JR and AR jointly lead the RCPCH QI education programme.

  • Provenance and peer review Commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.