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QI stage 1: Analysing the problem

Introducing tools that can be used to analyse and identify quality improvement problems
Healthcare professionals, patients and their families and health administrators have overlapping views on what is the best quality in healthcare. Healthcare professionals want to provide a timely healthcare service which makes our patients healthier without being harmed by the drugs we prescribe or procedures we follow. Patients and families want to be listened to, their views taken into account, and to be included in decision-making about their health care. And of course, our administrators want all this to be done at the lowest possible cost. Across all health systems and settings, there is always scope to improve the quality of healthcare for each of these viewpoints.
Administrators and quality officers are responsible for managing quality of care improvement at the hospital, organisation or programme level.
They are responsible for providing: Adequate staffing, such as doctors, nurses, appropriate resources, like drugs or diagnostic services, agreed protocols, guidelines or standards of practice for teams to follow for different health conditions, audits, by undertaking monitoring outcomes such as mortality rates, complication rates or adverse events. Frontline healthcare providers are equally involved in managing the quality of healthcare. To consider what a team of front-line health care providers, or a doctor or nurse, can do to improve quality of care we need to understand three important terms - inputs, process and outcome.
In a healthcare facility, inputs are all the resources needed to provide health care. Inputs include the patients, drugs and supplies, equipment, diagnostic tools and healthcare providers.
Process is all the activities health professionals carry out to provide care, for example, inserting an intravenous line, providing oxygen therapy, assigning responsibility for collecting data on ROP screening, or communicating with parents about the screening. Outcome is the results of the health care intervention provided to patients.
For example, did the NICU team: Provide all preterm babies with timely ROP screening? Or, counsel all parents whose babies needed ROP treatment and follow up? Or, report the numbers of preterm infants who developed functional blindness due to ROP in their unit? Outcomes depend on both the inputs and process of care. Frontline health care professionals often have little control over inputs but they may be able to make changes in how they carry out activities (the process) and improve the quality of the care provided.
Quality improvement (or QI) is an iterative step-by-step process.
Step 1. A QI leadership group is established from the health care team. Step 2. This group then carries out a situation analysis to find and recognise problems in health care delivery. Step 3. Prioritises the problems which need to be addressed first. Analyses the reasons behind these problems and lists possible QI interventions. And in Step 4. Identifies the QI intervention to test and brings together a team to carry out the testing. In step 5. This team plans how to carry out the selected QI intervention. Step 6. Does the intervention. Step 7. Studies what changes as a result, by measuring indicators and evaluating whether the intervention has addressed the identified problem. In step 8.
The QI leadership group then acts on the evaluation
and makes a decision to: Adapt the intervention by refining the implementation strategies, adopt the intervention and move to sustain the successful change, or abandon this intervention and identify another one to implement Health care teams use the QI process to improve outcomes in the care they provide. Lets look at step 2 in the framework from the perspective of the QI leadership group. How do we find and frame problems with the care we are providing to preterm babies to prevent visual impairment? A good way to start is looking at different information
sources: Departmental monthly or quarterly statistics, for example, what proportion of preterm babies develop ROP? Feedback from patients or families, for example, waiting time in the outpatient clinic. Discussion in the ROP team about what needs to be improved. This is valuable, as to begin with, there may not be data about what team members feel is wrong with the care provided. For example, a nurse may point out that babies appear to be in pain after their eye examination. This can be confirmed, and quantified, by quickly collecting data, such as average pain score or cry duration, in the next 10 babies examined. If too many problems are identified, the team lists and prioritises which to tackle first.
To do this, they rate: How important a problem is for the target group, for example preterm babies, parents or nurses. How feasible it is to address the problem. Is it within the control of the team?
Problems that do not need extra resources should score highly.
The next step is to analyse the reasons behind each prioritised problem. It is important to do this as a team because only a team can carry out a quality improvement process, not individuals. To maintain objectivity, the team should use an analysis tool to guide discussion of the reasons behind the identified problems. To start with, team members share reasons leading to the problem at hand. For example, the way equipment is set up or the lack of a particular hospital policy. The team then categorises all these reasons in defined boxes in the analysis tool and uses the results to come up with ideas for change.
There are several commonly used analysis tools, two of which are used by almost all quality improvement projects, fishbone and process-flow charts.
The fishbone tool is useful to help teams look objectively at different possible underlying reasons behind a problem, rather than blaming each other. To begin a fishbone chart, the problem is stated in the head of the fish. For example, not all eligible babies get first screening eye examination by four weeks of postnatal age. Next the skeleton of the fish is made with four main bones - people, place, procedure and policy. The team brainstorms all the underlying reasons for the missed screenings in each of these 4 main categories. For example, under policy, one reason might be the protocol of not disturbing babies currently on respiratory support.
Under place might be difficulty in identifying babies which need screening across different sections of intensive and step down units in the hospital.
A process flow chart is another useful tool for identifying underlying reasons for a problem. The team uses it to identify each step in the care they provide. It is important to depict how care is currently provided not what should ideally happen. Following on from our fishbone example, here is a process flow chart for the steps taken by an ROP team to carry out eye screening examinations in the NICU.
Start: Babies who need screening have been identified. The neonatal nurse assesses whether the baby is stable enough to go for screening. If yes, the baby is sent to the retinal imaging room with a neonatal nurse. If no, the nurse sends information on the decision to the ophthalmologist to reschedule screening.
Then, for babies who are screened: The nurse dilates the baby’s pupils with the recommended eye drops hour before examination. Arranges a speculum for the examination, and waits for the ophthalmologist. The ophthalmologist arrives and assesses dilation. If the baby’s eyes are dilated, the ophthalmologist performs the screening examination. If not, the examination is rescheduled and dilating instructions for the next day are given to the nurse.
The fishbone and process flow chart look at a problem from two different viewpoints. The process flow charts maps each step
in a care pathway to identify: bottlenecks, redundant or missed steps, and the personnel involved. The fishbone chart assesses the possible reasons behind the identified issues. The QI leadership group use the results of these analyses to list and prioritise change ideas (or QI interventions) to address the identified problem. Finally they identify which QI intervention to test.
In summary, you should now understand: What quality improvement is. The role of frontline health care professionals in contributing to quality improvement. How to identify health care problems.How to define inputs, processes and outcomes in health care, and how to analyse the reasons behind identified quality problems.

Quality improvement (QI) is a process which first recognises the present outcomes from health care provision and then reflects on possible actions to provide a better outcomes. QI is a cyclical, ongoing process. To illustrate this, let’s consider quality improvement for a simple activity, such as baking a cake.

Quality improvement for baking a cake

Imagine you are baking a new type of cake from a recipe you have found in a magazine. You mix all the recommended ingredients and follow the recipe instructions. After baking, the cake looks perfect but when you and your children taste it, it is not very good.
You reflect on what could have gone wrong and perhaps even discuss it with other bakers who have made a similar cake. Several suggestions and questions come up:
  • Add more baking powder.
  • Was the type of flour appropriate?
  • Did you mix the ingredients in the correct order?
  • Change the temperature at which you baked the cake.
Based on your reflection and analysis, you bake the cake again and make two key changes. You follow the exact order when mixing the ingredients and you adjust the baking temperature. This results in some improvement and the family agrees that the cake tastes better. To get to the exact taste you want takes a few more adjustments and cakes. Quality improvement is attained through testing, reflecting, retesting and then implementing the practice.

Health care is much more complex than baking of course, with many people and resources involved. Implementing QI in health care needs a scientific approach to provide a framework for reflecting, developing, testing and implementing sustainable change in practice. This approach also reduces inefficiencies from random changes implemented as an impulse or immediate action.

The PDSA approach to quality improvement

In this course, we introduce Plan-Do-Study-Act (PDSA) as a method for implementing quality improvement in ROP prevention and management. We explore the key steps of the PDSA cycles and provide opportunities to read and critically appraise case studies of PDSA being applied. The aim is to familiarise you with the PDSA approach and enable you to undertake quality improvement in your own setting.

Throughout the PDSA cycles frame your questions around:

  • What are we trying to achieve?
  • How will we know if the change is an improvement? What measures of success will we use?
  • What changes can we make that will result in improvement? The ‘change concepts’ to be tested.

Watch the video on this step to learn more about the processes used to answer the first question above and who needs to be involved. As you watch, consider:

  • How is quality of care provision assessment and managed in your setting?
  • Is there an active process taken to guide the team on what is essential and feasible to improve care of the preterm baby to prevent retinopathy of prematurity?

Next week, we will explore how a QI team undertakes PDSA cycles to test a selected intervention for the identified problem.

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Retinopathy of Prematurity: Practical Approaches to Prevent Blindness

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