Health and social care professionals, NHS managers, patients and members of the public want straightforward yet effective ways to make demonstrable improvements to the quality of services. Lucy Goulding, programme manager at King’s Improvement Science (KIS), reflects on using experience gained while working on quality improvement projects to develop a suite of resources.
When I joined the King’s Improvement Science team in 2014, I was faced with a number of deliberations that may be familiar to others: What exactly is quality improvement? Which quality improvement method is ‘best’ and why? Which quality improvement project ideas have the most chance of being successful? How do we strike a balance between pragmatism (getting things done) and rigour (having detailed information about whether and how an improvement has been made)?
Researching the different quality improvement methods and getting started
Being a trained researcher with a PhD in patient safety, but new to quality improvement, I turned to the academic literature to look for answers. I found that there were a number of different ‘brands’ or approaches to quality improvement to choose from, for example, Plan, Do Study, Act cycles and the Model for Improvement, Lean thinking and Six Sigma. Research papers suggested that when properly applied, these methods could be effective in changing processes (the way things are done). However, a carefully compiled review of the evidence concluded that none of the commonly used approaches was better than any other. Rather, what appeared to be important was selecting an approach that would be a good fit for the local context and applying this chosen approach in a methodical way.
With this in mind, and with the support of my senior King’s Improvement Science colleagues who had years of experience of improving services, I jumped in at the deep end and began learning about quality improvement by doing. We were incredibly lucky to work alongside fantastically motivated healthcare professionals who had identified an aspect of their service that they wanted to improve. In some cases, our projects were greatly strengthened by involving patients, service users and members of the public. You can read more about our projects on the King’s Improvement Science website.
Our approach to assessing the potential impact of a change
Our starting point was always the same: review the existing literature and speak to a range of people who would be interested in or affected by the project to see what we could learn about the specific changes that we hoped to introduce and the best ways of implementing them. So, for example, in our project aimed at improving the lung health of people attending an addictions service in Brixton, south London, our team reviewed the literature, spent time with staff who worked in the service, and worked closely with a group of people with lived experience of addictions services throughout the project.
Selecting the methods and tools that suited each project
Knowing that there was no one best method, we used the quality improvement methods and tools that made sense for each project. In our work with critical care teams at King’s College Hospital, we drew on the Model for Improvement to introduce regular audits and behaviour change interventions in a systematic fashion. We supplemented this with additional quality improvement tools such as process mapping and patient story-telling. You can read more about one of our critical care projects at: http://bmjopenquality.bmj.com/content/4/1/u203938.w3268
Collecting numerical and narrative data
We focussed on the collection of both numerical and narrative data that would help us to evaluate the success of our projects (though this was often much more challenging than anticipated – a subject for another blog post perhaps…). In our project to introduce a care pathway for people with atrial fibrillation or atrial flutter within a cardiac device clinic at Guy’s and St Thomas’ NHS Foundation Trust, we designed an electronic assessment form to capture quantitative data and we interviewed patients and staff about their perceptions of the new care pathway.
Keeping multidisciplinary project teams on track
We found that fairly basic project management was essential to keep our multidisciplinary project teams on track: we created a project planning document summarising the background to the project, our aims and objectives and the methods we would use; we constructed Gantt charts in an attempt to plan our time (when timelines slipped these remained a useful to-do list!); and we held regular project team meetings and took detailed minutes.
Capturing our learning and sharing our insights: developing the KIS resources
By the end of 2016, we had worked on five collaborative quality improvement projects and had learned loads. From my perspective, ‘doing’ quality improvement was not as simple as some of the conference speakers, websites and other literature had implied – I think we experienced all of the challenges listed in a useful guide by the Health Foundation (their suggestions for overcoming these challenges were helpful). We were therefore keen to capture our insights and share these with others. One way of doing this was through the development of a suite of resources made freely available on the King’s Improvement Science website.
Following much group reflection, we decided that our resources for quality improvement should take the form of three sequential steps that mirrored our own journey towards developing expertise: first, learning about quality improvement; second, identifying feasible quality improvement projects; and third, planning and evaluating a project. This seemed logical for the following reasons:
- At the start of 2017, my fab colleague Barbora Krausova joined the King’s Improvement Science team. Barbora was new to quality improvement (just as I had been three years earlier). Barbora began documenting her own learning and this morphed into the ‘Step 1 KIS introduction to quality improvement’. This resource explains what quality improvement is, signposts recommended reading and useful websites, and provides recommendations from the King’s Improvement Science team for people who are thinking of setting up a quality improvement project.
- Over the years, a number of health and social care teams expressed interest in collaborating with us on quality improvement projects (unfortunately more than we had the capacity to support), which meant that we needed to create criteria to appraise and select potential projects. Furthermore, we discovered that people often had a long list of ideas for things that could be changed and improved and wanted to know how this list should be prioritised and which project ideas were most likely to be successful. That’s why we spent a number of months consolidating our learning and adapting our criteria to develop the ‘Step 2 KIS guidance for deciding what to improve and assessing the feasibility of a quality improvement project’.
- We then worked to further develop the project planning document that we had used for our five collaborative quality improvement projects. We incorporated links to resources from other organisations that we’d drawn upon when conducting our own projects. This became the ‘Step 3 KIS template for planning and evaluating a quality improvement project’.
Our resources don’t advocate any particular quality improvement method above any other. Back to my earlier point about the existing evidence: what seems to be important is taking a systematic approach to designing and conducting a project that best suits the needs of the people and the organisation affected by the change. Our aim was not to add to the plethora of existing quality improvement methodologies, but to provide resources that will help people to approach quality improvement in a considered way. We’re looking forward to testing this out and getting feedback.
The three KIS guides to quality improvement are just one part of a family of resources that have been developed by the team. Members of KIS have also developed advice about patient and public involvement, resources for designing high-quality implementation science research, and a guide that signposts resources and gives tips for evaluating health and social care initiatives. During 2018 we will be working on the production of the ‘KIS glossary’ – a document that will help to explain the (confusing!) terminology used in quality improvement, improvement science and implementation science.
Join us for the launch of the new KIS resources
Our resources will be launched at an event on Wednesday 18 April – please join us to find out more! See our Eventbrite page for further details and to register.
Looking for further help and advice?
If you are looking for further help with your quality improvement or implementation science project, our advice clinic may be just the ticket.
Finally, a big thank you to everyone who has helped to shape the KIS resources.
 A systematic, narrative review of quality improvement models in healthcare. Powell, Rushmer and Davis. NHS Quality Improvement Scotland, 2009.