Completing the QIA
The QIA must be recorded in the Trainee Portfolio as a Quality Improvement Activity reflective learning log entry.
QIA Examples
The following examples of QIAs are taken from actual QIAs by GP registrars, who have agreed to share them with the training community.
Example 1
- Title
IM B12 audit
- Brief description:
B12 deficiency can be a significant clinical condition resulting in neurological symptoms such as peripheral neuropathies, autonomic symptoms, gait issues, anosmia, confusion, and infertility, with most severe sequalae including subacute combined degeneration of the cord. In some patients B12 deficiency is detected due to megaloblastic anaemia on blood tests, often asymptomatically.
Treatment for B12 deficiency can be either oral or IM, with urgent neurological symptoms requiring urgent treatment with IM loading of B12, using IM Hydroxocobalamin 3x a week for 2 weeks, with then quarterly IM top-ups. The IM injections can be painful and pose a risk for infection.
This initial loading period takes 6 nursing team appointments – 10mins a piece – with 4 appointments a year thereafter, resulting in 1 hour of nursing time in 2 weeks, plus then 40 minutes every year, for life.
The cost of a box of hydroxocobalamin is between £9.50 - £20.90 (5 ampoules) and the NHS Drug Tariff price is £10.74, representing a loss when prescribing B12 through our dispensary.
None of these points factor in the time required to administrate the PGDs for the prescription, both initially and annually thereafter.
Oral treatment is available over the counter. This represents significant targets for improvements in the care we provide; reducing the more invasive treatments for our patients if they are not required as well as reducing the financial and capacity costs of lifelong injections.
- What were you trying to accomplish?
Understanding the scale of B12 use in our practice and trying to reduce the number of people using IM B12 who don’t need to.
- How have you engaged with others?
I discussed my aims with fellow GPs prior to starting the project. Once completed, I discussed my findings at a practice meeting and agreed an action plan with pharmacy, nursing and doctor team.
- What changes have taken place?
Those on IM B12 appropriately were labelled as such.
Those who were not adequately investigated at initiation were then switched (when their PSD was due) to oral and follow up bloods (B12 and IF) at 6 months with safety netting for symptoms.
- Reflection: what will I maintain, improve or stop?
I held a discussion with colleagues, where we emphasized a collaborative approach and the importance of clear labelling of notes. Prior to the change I had not considered that there may be a placebo effect from an injection and will be more mindful of this in the future. Conversely, one patient I switched from injections to oral supplements was particularly pleased, as they found it challenging to visit the surgery. Again, I had not considered this potential benefit prior to the change. This change highlights significant benefits for the practice, including reduced nursing hours and lower prescription costs.
Example 2
- Title
Hospice Discharge Process
- Brief description:
Arranging a discharge from the hospice requires a lot of leadership from the doctors to ensure all parts of the process are complete properly. As there are multiple factors to consider there is a lot of room for error. We were finding that there was often at least one part of a discharge that did not go to plan which may delay discharge or make managing them in the community more difficult. My role was to make a discharge checklist to help us to check that we had considered the main important things
- What were you trying to accomplish?
The goal was to achieve a well organised discharge, that meant patients leaving the hospice had the maximum chance of being well managed within the community, whether this be as a preferred place of death or a place for ongoing long-term care. This is important as our aim as a team is to ensure patients have the best possible quality of life for whatever time they have remaining.
- How have you engaged with others?
I attended a discharge party meeting that included doctors, nurses and social workers to help share any issues we were having with the discharge process and discuss potential solutions shared that I was making a discharge checklist which would help to guide us doctors in preparing a discharge and welcomed any feedback on this.
- What changes have taken place?
We now have a discharge checklist which we are using to help us facilitate a discharge. We have needed to add other things as time has gone on, especially around TTOs e.g. whether a patient needs a NOMAD as this needs extra time for pharmacy to prepare and whether their local pharmacy is able to continue with dispensing these medications. Since starting to use the discharge checklist, there have been fewer issues with discharges - as noted at the most recent discharge party meeting.
- Reflection: what will I maintain, improve or stop?
I am glad that I was able to participate in a quality improvement activity based on a need that I had noticed during my time working at the hospice. This helped me to be genuinely interested in the work I was doing towards it, as I could easily foresee how it would help our team and patients. It was also nice to see how positive the team was about this work also. This has motivated me to make constructive suggestions for projects in the future. In the future, I could improve this by more objectively assessing the effectiveness of any changes.