Mandatory requirements
By the time you reach the end of training you need a minimum of 1 QIP and 2 QIAs. The QIP should evidenced in your portfolio (the section for the QIP is different from the QIA learning log) and your supervisor will assess, grade, and discuss this with you.
GPs in training are required to demonstrate their ability to engage with quality improvement in primary care, and to ensure that the subject of the QIP is relevant to primary care. As such, the QIP should be done in a primary care setting. If this is not possible, then the QIP can be done in a non-primary care setting, providing you discuss this in advance with your Supervisor.
Once you have undertaken the QIP, you should then complete the QIP template:
You should then upload the completed template as well as the Quality Improvement Project itself to the Trainee Portfolio. Your supervisor then assesses the QIP on the Portfolio and feedback is given to you by them, which should encourage further discussion. This example QIP shows a completed form and the GP supervisor comments:
Feedback
Your Supervisor will mark you against the following feedback levels: below expectation, meeting expectation or above expectations for each domain, compared to the expected level of a GP in training working in the clinical post. The supervisor also rates you on your overall competence.
This document sets out examples of what each feedback level might look like against each area of the QIP:
Unsatisfactory QIPs
The assessment is not a pass/fail exercise. If you are consistently below expectations when assessed by your supervisor, it is likely that you will be recommended to repeat the exercise, or a component of it and write a follow-up learning log entry. It is mandatory to complete the assessment and action any recommended follow up. Common indicators of an unsatisfactory QIP include:
- No team engagement
- No engagement of stakeholders (people affected by the change, including patients)
- Minimal measurement
- No real attempt at implementing change, just a discussion that change should happen.
This example QIP shows the sort of feedback and explanation that might accompany an unsatisfactory QIP:
How to undertake a QIP
As a GP in training you are well placed to identify areas for improvement to maximise the quality of care for patients. QIPs focus on improving service delivery and patient outcomes to achieve specific goals, by designing and implementing a change followed by measured evaluation. Measurement should be holistic, considering patient and population outcomes as well as the financial, environmental, and social impacts of an improvement.
It may be appropriate to work with a colleague to complete a larger QIP in the practice, or across multiple sites. It must be clear what work you completed and the QIP must be adjusted to work well in your practice. The write-up should describe your personal involvement in the activity and identify what was done collaboratively and your personal reflections. You can compare your data, or the practice’s as a whole depending on the project. It might be appropriate for a colleague to run a computer search to gather data, however it would be encouraged for you to learn how to undertake an appropriate computer search. You are encouraged to lead the project to gain full experience of completing a QIP whilst being supported by your supervisor/colleagues.
The QIP contributes to evidence in the following capabilities: Fitness to practise; maintaining performance learning and teaching; data gathering and interpretation; working with colleagues and in teams; organisation management and leadership.
The following is a step-by-step guide to undertaking a QIP. The example that has been used is a QIP with the aim of trying to improve the 6-8w baby check.
Choosing the subject of your QIP
When you write up your QIP you need to include the reason you chose it, which should be an identified need in your training practice. You could choose your QIP after an event in the practice, be driven by external pressures such as reducing environmental or financial costs, be a prior interest or through inspiration from colleagues or from the QIP Ideas (ensuring that the project is relevant to the practice). You will also need to include a brief summary of the current evidence/guidance supporting good practice in this area and how your QIP will improve patient care.
E.g. “A patient saw me and was complaining that her son hadn’t had his 6-8w check until she made the appointment herself at 14w old. This made me wonder how our system works and how we could offer a better process for mothers and their babies.”
Engaging the team, patients, and other stakeholders
Consider who you need to involve in the project to achieve your aim.
Ask:
- Who will be affected by any change proposed?
- Who will be involved in the implementation of the change?
- Who will be responsible for ensuring that any changes will be sustained when you leave?
- Who may you need for advice?
Possible stakeholders include other doctors, administrative staff, the practice manager, pharmacists, health visitors, nursing team and patients and carers. You need to plan how to engage them and communicate the impact of changes with the rest of the team. It is often useful to contact other primary health care teams asking to share their policies. Talking with the patients who have personal experiences of the area you are trying to improve makes sure that you have a full perspective. This might be talking to the mothers of babies if you were doing a QIP on baby checks.
Using the Model for Improvement
This is a recommended approach to conduct QIPs within healthcare. The model asks three questions:
- Aim - What are we trying to accomplish?
- Measure - How will we know if a change is an improvement?
- Change - What changes can we make that will result in improvement?
Let's look at each of these in more detail.
Developing clear aims
The first step of a QIP is to outline the aim of your project. The QIP needs to be tailored to your practice and the way it operates. The aim of the project may need refocusing during the QIP process as you learn more about the system you are working in.
The ‘SMART’ acronym is helpful to set the criteria for effective setting of the aim.
- Specific - Be specific about what you are improving, who will be impacted, by when you expect to see improvement, in what way you expect it to improve and how much by.
- Measurable - It is important to be able to evaluate an improvement with measures, so ensure this can be done easily either quantitatively (numerical data) or qualitatively (descriptive data).
- Achievable - It should be feasible for you to complete the project within the time frame set, so ensure the data is easily collectable and keep the aims simple.
- Relevant - QIP should be focus on quality of care for patients and should result in meaningful change aligned with the goals of your organisation.
- Time defined - Choose a reasonable timescale in which to conduct your QIP – you should aim to complete at least two sets of data measurement and evaluation of improvement.
For our example 6-8 week baby check QIP:
- Overall aim: Improve timeliness of 6 week baby checks
- SMART goal: ‘To increase the percentage of 6 week baby checks performed between start of week 6 and end of week 8 by at least 10%’.
Measure
The next stage of the model for improvement is to consider how you will know your change is an improvement. It is important to evaluate measures, as not all change leads to improvement.
Data for measurement can be quantitative (numerical)or qualitative (descriptive). To know if you have generated an improvement, you must collect and compare measures at baseline and after improvement implementation.
For our example 6-8 week baby check QIP this might be:
Qualitative: Questionnaire of patient experience at baseline, included a mother commenting ‘it was difficult to change appointment as I did not want to bring my other two children with me’. Another asked why it was not at the same time as her own postnatal examination.
Quantitative: A baseline audit of six-week baby checks over the last month demonstrated 57% of babies were aged 6-8 weeks at the time of examination.
It is important to evaluate an improvement holistically, i.e. not just looking at patient outcomes or at financial savings. It is appropriate to expand your measures to include the impact on the wider population, addition of social value and environmental impact. This approach is called sustainable value, and is a family of measures that should be considered in QIPs.
For our example 6-8 week baby check QIP these impacts might be:
- Outcomes for patients: Timely identification of potential clinical complications.
- Outcomes for wider populations: earlier engagement with services for postnatal depression is possible with prompt checks and this can be expected to bring to the extended family and their networks.
- Environmental impact: the new system could result in fewer trips to the surgery by car and so less pollution.
- Social impact: Less stress for new mothers, a more streamlined process could help administrative staff.
- Financial impact: An improved booking system could save on Did Not Attend appointments.
Change
The final question in the Model for Improvement considers what changes can we make that will result in improvement?
Quality Improvement tools and techniques
There are several quality improvement tools that you could use to help generate change ideas including process maps and driver diagrams.
Process maps are a useful tool to study a system to understand what is currently happening and identify problems to address with change ideas. It is important to include all relevant stakeholders to ensure your process map is accurate (see section on how are you going to engage the team). You can identify resources used (environmental, social, financial) to each step of the process to identify low-value steps, bottlenecks, or hotspots of disproportionate resource use.
For our example 6-8 week baby check QIP, the process map below outlines how eligible patients are invited for a six-week baby check at the practice. The circles demonstrate resource allocation at each step.
Driver diagrams can be used to design improvements. This should be done with the team familiar with different aspects of the problem you are trying to improve. It is good practice to engage and involve patients in the process. You can consider potential improvements and then decide on one or two to pursue and measure.
When thinking about potential solutions, consider the principles of sustainable healthcare to design a holistic and sustainable improvement.
PDSA
Another quality improvement tool is the PDSA cycle. THis is similar to the audit cycle, but involves making a small change, studying (i.e. measuring) the effect (including any unintended consequences) and then planning the next change. The changes in a QIP can be small and there should be at least two PDSA cycles in a QIP project.
- Plan - document the objective, the initial plan, identify who will be doing the test, how will it be done, and when the change will be made.
- Do - undertake the change, gather the data and document any problems.
- Study - analyse the data and summarise learning.
- Act - what changes will you make based on the outcome of the first change and develop a plan for the next cycle to make it better.
The PDSA cycles illustrated below demonstrated two changes made in the process of 6 week baby checks in the practice.
Improve percentage of 6 week baby checks done by end of week 8: Cycle 1
Act
- Develop system to follow up did-not-attends
Plan
- Discussed at practice meeting
- System set up to text reminder to mother about appointment day before
Do
- Record weekly change in percentage done
- Ask 2 patients about their experience
Study
- Small increase in percentage checks done
- Patient mentions difficulty of rearranging appointment
Improve percentage of 6 week baby checks done by end of week 8: Cycle 2
Act
- Review timing for premature babies
Plan
- Set up system to follow-up patients who do not attend for check up
Do
- Record weekly percentage of checks done
- Ask patient about being followed up
Study
- Further improvement in percentage of baby checks done
- Confusion about when check should be done for premature babies
Describe the data or information gathered to demonstrate the impact of the change used
There are many ways to present your measurements. One of the best ways is to plot measurements each time they are taken on a run chart - a line graph of data plotted over time. Run charts measure data frequently and demonstrate if changes are leading to an improvement.
Further details about run charts
Using the 6-week baby check example again, the run chart below illustrates the impact of changes introduced.
Summarise and Sustainability
At the end of your project, you should summarise the changes made as a result of your project. This could include exploring why the change has been effective or possibly ineffective. You should present your findings in the practice and reflect on the process and any feedback you receive. An important part of any quality improvement, especially if the changes have improved quality, is ensuring that the process is embedded into the practice and will continue beyond completing the QIP.
Reflection
The final process involves reflecting on the process of undertaking a QIP – what have you learnt, what worked well, how did you work with others and what would you do differently in the future.
Resources
QIP Ideas
The following ideas are taken from Quality Improvement Projects carried out by trainees in various parts of the country. They are intended as a trigger for possible ideas, their inclusion is not intended to suggest that they are promoting up to date or best practice necessarily, or that these projects are better than others. There is deliberately little detail, the list should generate possibilities and is not a template!
Most of the suggestions are from projects done in GP, though some secondary care suggestions are made lower down the list of ideas.
For those who want further inspiration based on what their peers have done the website for Health Education Wessex Projects may be useful.
Primary care based QIP suggestions
Green Impact
The NHS has committed to reducing its carbon footprint. The RCGP has collaborated to produce a wide range of achievable changes which practices may want to adopt to reduce their carbon footprint (while also positively impacting patient care).
Asthma care
Metered dose inhalers are a particularly important source of greenhouse gases. This guide - High Quality and Low Carbon Asthma Care – Greener Practice - though not written as a QIP source is full of ways to improve asthma care and improve sustainability.
The following suggestions are taken from Quality Improvement Projects carried out by GPs in training.
Improving assessment of chest infections in Primary Care
Introduction of a particular template to ensure recording of heart rate, BP, RR oxygen saturation levels, temperature etc.
Improving referrals of children with bronchiolitis
Construction of a knowledge questionnaire for primary care (and ED) specialists which identified some gaps in knowledge which were addressed through teaching sessions before repeating the questionnaire.
Improving Antibiotic Prescribing for Sore Throats
Review of patients with relevant Read coded diagnoses and treatment packages against the CENTOR criteria, education of the team and repeat of the data collection.
Introducing Record keeping- "Test Results To Patients By Phone"
Identification of a safe process to record which patients have contacted the practice to be given their results on EMIS (minimal clicks!), training staff and demonstrating that the system is being used having ascertained that there was no system in place initially which has patient safety implications and lacked efficiency.
Improving follow up for pre-diabetics in general practice
Review of patients with HbA1c of 48+ who had not had DM confirmed on re-test to see if they had or would develop DM and developing an IT process to ensure regular follow up is automatically requested.
PSA monitoring in primary care
Setting up systems for those who were on GP only follow up of Prostate cancer to have dairy dates, and appropriate tasks to team members to enable testing and then demonstrating that there has been a change in follow-up achievement.
Metformin Monitoring
Identification of the group of patients who needed monitoring; trial of letter reminder, phone reminder, and team updates to the practice template were all used.
Investigation and Management of Vitamin B12 deficiency
To analyse patients with vitamin B12 deficiency at the practice and determine how often patients get tested for intrinsic factor/parietal cell antibody; design a protocol to adhere to recognised guidelines and present to the practice and re-audit at a later date to determine the changes in practice.
Compliance in prescribing antibiotics for sinusitis in line with local guidelines aiming to reduce antibiotic prescribing
Retrospective data collection of antibiotic prescribing for sinusitis; presentation of results to team and updated on guidelines and re-measurement of data. Use of PDSA cycles and reflection on team involvement.
Review of diagnostic approach and management of patients with symptoms suggestive of Urinary Tract Infection in women under 65 according to recently updated local guidelines
Retrospective data collection; results and updated guidance presented to the team; change introduced (the development of a template) and data re-measured.
To review patients with gastric band to ensure compliance with BOMSS guidelines (vitamin and mineral supplements and annual blood tests)
Initial data collection suggested no patients were being managed in line with the guideline. Changes suggested included raising awareness among team; pop up reminders and contacting patients. Run charts were used to demonstrate impact of changes.
Ensure that carers register remains up to date
Project undertaken following significant event when bereaved patient invited for carer’s review. QIP tools used included process map. Measurements included numbers on carers register and details of person cared for before and after changes made. Changes made included greater awareness of health implications of being a carer, change in carers registration form and template and annual review letter.
Case Finding of patients with fragility and arranging comprehensive assessment.
Patients were identified using electronic fragility index (eFI) and invited for comprehensive assessment using a newly developed template. Measurement included admission rates in over 85s three months before and after introduction of case finding and measurements of changes made after assessment.
Assess if patients prescribed Mirabegron are having six monthly blood pressure checks as recommended by NICE
Data collected and results presented to team. Changes include setting up a recall system and letter to inform patients of need for BP check. Data re-measured.
Improve use of care plans in residential and nursing homes to reduce unnecessary hospital admissions
Review of admission data identified patients who would not have been admitted if the care plan had been consulted. Questionnaire used to ask staff in homes about usefulness of current care plans and identify the most useful information. Changes made included development of two-page summary. Questionnaire repeated after introduction of summary.
Review of measurement of pulse rate in patients prescribed Donepezil
Retrospective data collection undertaken. Changes made included annual recall system using template incorporating assessment of pulse rate and education session for practice staff. Data collection repeated.
Secondary care based QIP suggestions
Improving consideration of bone protection in patients with a fragility fracture
Review of patients on a ward who had been admitted following fragility fractures and then used this to teach the team about the issues and then reviewed the prescribing of bisphosphonates after the intervention.
Improving admission documentation
Aiming to improve the documentation of drug history, PMH, and allergies for those admitted from eye casualty to inpatients, and to provide a tool for handovers.
Do Oncology patients with DNACPR forms have a clear escalation plan?
Project looking at appropriate documentation of inpatients with a DNACPR – whether they had a clear “ceiling of care” plan defined and agreed in advance of changes in their condition, work was undertaken with the SHOs on skills in enabling consultants to define these and continued the process over a few rounds. An additional sticker reminder created for the notes.
Improving Individualised Paediatric Patient Stethoscope Use
The policy to reduce cross infection is that there should be one stethoscope per patient on the paediatric ward. The project used spot checks, purchasing unusual colour stethoscopes, and an adaptation to the standard checklist.
Loss of hearing aids on mental health unit for older adults.
Project included review of literature on effect of hearing loss and mental health. Undertaken following significant event when patient lost private funded hearing aids. Measurements included number of patients admitted with hearing aids using them and numbers referred for hearing aids on admission using them when provided. Changes included education of staff; dedicated hearing aid storage; labelling hearing aids and facilities for battery change. QIP tools used were process maps and run charts.