Making Your Quality Improvement Project Achievable During a Clinical Rotation

Why This Topic Matters

Quality Improvement is fundamental to safe, effective, and patient-centred care within the NHS. It involves a systematic approach to making changes that lead to better patient outcomes, system efficiency, and staff experience. For junior doctors, engaging in QI demonstrates leadership, problem-solving skills, and a commitment to improving healthcare delivery.

However, the perceived burden of 'another project' can lead to superficial efforts or, worse, brilliant ideas never seeing the light of day. This is particularly true for those on short rotations (e.g., four to six months), where establishing a project, collecting data, implementing changes, and re-auditing can feel like an impossible task. National reports, such as those from NCEPOD, frequently highlight areas where systemic improvements are needed, and trainees are uniquely placed to identify and address these issues from the frontline. Making QI achievable during a rotation isn't just about ticking a box; it's about fostering a culture of continuous improvement that truly benefits patients and staff.

Practical Explanation: Embracing Achievability

Achievability in the context of a rotational QI project largely comes down to sensible scoping and leveraging existing resources. It's about designing a project that can realistically move through its core phases (identify, plan, do, study, act – PDSA) within your allocated time, ideally allowing for at least one full PDSA cycle. This often means focusing on small, iterative changes rather than large-scale, departmental overhauls.

Key considerations for achievability include:

• Scope: Is the problem clearly defined and narrow enough? Avoid projects that require changes across multiple departments or significant infrastructure investment.
• Data Collection: Can you gather the necessary data efficiently? Are existing datasets available, or can you collect new data with minimal effort?
• Stakeholder Engagement: Who needs to be involved, and will they be readily available to support your efforts? Early engagement with a supportive supervisor and key team members is crucial.
• Change Intervention: Are the proposed changes simple, locally actionable, and likely to be adopted?
• Measurement: Can the impact of your intervention be measured quickly and clearly?

Common Pitfalls

Many well-intentioned QI projects falter due to common pitfalls, especially for those on rotations:

• Over-scoping: Trying to solve a 'hospital-wide' problem within a single placement. This often leads to projects that are too complex, resource-intensive, and time-consuming.
• Lack of clear aim: A vague project aim leads to unfocused efforts and difficulty measuring success. Your aim should be SMART (Specific, Measurable, Achievable, Relevant, Time-bound).
• Insufficient stakeholder engagement: Failing to involve key staff (nurses, pharmacists, allied health professionals, consultants, managers) from the outset. Their buy-in is critical for successful implementation and sustainability.
• Data collection burden: Designing a project that requires prohibitively time-consuming manual data collection, leading to project abandonment.
• Poor communication: Not regularly updating your supervisor or wider team on progress, leading to a lack of support and missed opportunities for problem-solving.
• Neglecting the 'Study' phase: Implementing a change but failing to measure its impact properly, making the project incomplete and lessons unlearned.
• No plan for sustainment: Even small changes require thought about how they will be embedded after you leave. Neglecting this makes your efforts transient.

Step-by-Step Approach to Achievable QI

Here’s a structured approach to planning and executing a QI project that fits within a rotation:

Step 1: Identify a High-Leverage, Small-Scale Problem

• Look for frustrations: What are the common 'grumbles' in your department? What takes up excessive time or causes patient safety concerns that feel manageable?
• Review local data: Are there local audit results, incident reports, or patient feedback that highlight a specific, addressable issue within your immediate area?
• Think 'micro': Instead of 'improve patient flow', consider 'reduce the time from medical ward referral to physiotherapy assessment for hip fracture patients on Ward X'.
• Consult your supervisor: Discuss potential ideas with your educational or clinical supervisor early on. They may have suggestions or be aware of existing departmental priorities where your project could fit.

Step 2: Define a SMART Aim and Clear Measures

• Specific: What exactly do you want to achieve?
• Measurable: How will you know if the change is an improvement? Identify 1-2 key outcome measures and 1-2 key process measures.
• Achievable: Can this realistically be done within your rotation?
• Relevant: Does it align with departmental goals or patient safety priorities?
• Time-bound: Set a realistic end date for your measurement periods.
• Example Aim: "To reduce the average time from consultant ward round decision to prescription charting for new medications by junior doctors on Medical Ward 3 from 120 minutes to 60 minutes, improving 80% of cases by the end of my 4-month rotation, as measured by review of drug charts."

Step 3: Understand the Current Process (Process Mapping)

• Walk the process: Spend time observing how things are currently done. Talk to staff involved at each step.
• Identify bottlenecks: Where are the delays or inefficiencies?
• Fishbone diagram (Ishikawa): A simple tool to brainstorm potential causes for the problem under categories such as People, Process, Equipment, Environment, Materials, Management.

Step 4: Design a Simple Intervention

• Focus on 'low-hanging fruit': What small, simple changes could have a noticeable impact? Avoid major policy changes or expensive solutions.
• Leverage existing resources: Can you use existing meetings, communication channels, or templates?
• Examples: A new checklist, a dedicated 'huddle' at a specific time, a clearly labelled whiteboard, a reminder poster, a short teaching session, a designated role for a specific task.
• Predict consequences: What might go wrong? How can you mitigate this?

Step 5: Plan Your Data Collection Strategically

• Keep it simple: Use existing data sources where possible (e.g., electronic patient records, patient flow software, previous audit data).
• Minimal new data collection: If collecting new data, design a simple proforma or use a digital tool that requires minimal time per data point.
• Baseline and Post-Intervention: Collect a small baseline dataset (e.g., 20-30 data points) before your intervention, and then a similar dataset after your intervention. Run charts can be highly effective for showing change over time with limited data points.
• Involve others: Can a ward clerk, student, or colleague help with data collection (with appropriate governance)?

Step 6: Implement and Study (PDSA Cycle)

• P (Plan): Plan your intervention and data collection.
• D (Do): Carry out the intervention on a small scale if possible (e.g., on one ward, for one week).
• S (Study): Analyse your data. Did it work? What did you learn? Compare to your baseline.
• A (Act): Based on the results, adapt the change, abandon it, or implement it more widely. Then, plan the next PDSA cycle.
• Be agile: Be prepared to adjust your intervention based on early feedback and data.

Step 7: Document and Share Your Learning

• Keep a project log: Note decisions, interactions, and results.
• Present your findings: Share your results with the team, department, or at a local QI meeting. This is crucial for embedding change and for your portfolio.
• Consider a re-audit: If successful, plan for a subsequent re-audit by the department to check sustainment. This might occur after your rotation.
• Write it up: A concise write-up for your portfolio is essential. Highlight your contribution, the method, results, and lessons learned.

Example in Clinical Practice: Reducing Delays in Discharge Summaries

Dr. Anya Sharma is a Foundation Year 2 doctor on a 4-month General Medical rotation. She often notes delays in discharge summaries being completed, leading to patients returning home without clear care plans for their GP. This causes frustration for patients, GPs, and nursing staff.

Step 1: Identify Problem: Delays in discharge summary completion for patients discharged from Ward E.

Step 2: Define SMART Aim: 'To reduce the proportion of discharge summaries completed more than 24 hours post-discharge from Ward E from 40% to 15% within my 4-month rotation, as measured by daily audit of discharged patients.'

Step 3: Understand Current Process: Dr. Sharma observes the discharge process. She identifies that summaries are often left until the end of the day or the next day, particularly when junior doctors are busy with admissions or ward rounds. Missing medication information from TTOs is also a common delay.

Step 4: Design Simple Intervention: After discussing with her supervisor and ward manager, Dr. Sharma proposes two small changes: 1. Dedicated 'Discharge Huddle': A 5-minute huddle at 13:00 daily with the junior doctor and ward pharmacist to review patients planned for discharge, ensuring TTOs are accurate and discussions about summary completion occur. 2. 'Discharge Summary First' Prompt: A prominently displayed poster at the ward computer stations reminding doctors to prioritise discharge summaries for patients discharged that morning.

Step 5: Plan Data Collection: Dr. Sharma designs a simple spreadsheet to track: patient name, date of discharge, and time of discharge summary completion (from EPR). She collects data for 20 patients over two weeks as a baseline.

Step 6: Implement and Study (PDSA Cycle):

• P: Implements the huddle and poster for one month.
• D: Dr. Sharma leads the huddles and encourages use of the prompt. She continues to collect data for 20 discharged patients post-intervention.
• S: Analysis shows the proportion of delayed summaries reduced to 25%, a good improvement but not quite at 15%. Ward staff report the huddles are useful but sometimes overrun due to consultant ward rounds extending.
• A: Dr. Sharma decides to adjust the huddle time to 14:00 to avoid ward round clashes and reiterates the 'discharge summary first' message. She plans to run another PDSA cycle over the next month.

By the end of her rotation, Dr. Sharma demonstrates a sustained reduction in delayed summaries to 18%, close to her target, and has established a new huddle process with clear benefits, which the ward manager plans to continue.

How Lazomis Can Help

Lazomis offers several tools designed to streamline your QI journey and make it more manageable within a busy clinical schedule:

• QI Project Setup Wizard: Guides you through defining your project aim, measures, and data collection plan, ensuring you cover all the essentials for an achievable project.
• Data Collection Templates: Provides structured templates that can be customised for your specific data needs, reducing the effort of designing one from scratch.
• Run Chart Generator: Easily visualise your data over time to demonstrate the impact of your interventions without complex statistical software.
• Reporting & Portfolio Template: Helps structure your findings into a clear, concise report suitable for your portfolio or local presentation, ensuring all key elements are included.

These tools help you focus on the QI work itself, rather than getting bogged down in administrative tasks, making your project significantly more achievable.

Key Takeaways

• Choose a small, clearly defined problem directly relevant to your current practice.
• Develop a SMART aim with simple, measurable outcomes that can be tracked in your rotation.
• Engage your supervisor and key team members early and regularly.
• Focus on simple, actionable interventions ('low-hanging fruit') that don't require major resources.
• Design a data collection strategy that is efficient and minimises your workload.
• Use PDSA cycles to test small changes iteratively and learn quickly.
• Document your progress and share your findings to embed changes and build your portfolio.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.