How to get started with Quality Improvement - First steps for success

This is article two in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

It’s 1969 and the United States is planning to launch the Apollo 11 mission, to finally put a man on the moon. The press is there to cover the event and during a lull in the action, they see a janitor sweeping the hall, so they thought they would take the opportunity to capture some extra footage. A reporter approached the janitor and asked, “What is your job at NASA?” As the legend goes, the janitor leans on his broom and says, “My job is to get a man to the moon”. This person understood that he was part of the team and played a part in the overall mission of getting a person to the moon. (1) 

NASA had successfully created a culture where everyone had a strong connection between their work and an ultimate mission. The same goes for Quality Improvement. Quality Improvement (QI) is a way of thinking about your work and applying a systematic framework to improve the care you provide. The people who do the work must feel a part of this process, in order for it to succeed. But I am frequently asked, ‘Where do I start?’.  Here are some initial steps to take to get you started on your own improvement journey.

Educate yourself

Start with becoming fluent in Quality Improvement tools and methods, such as clinical audit, significant event audit, checklists and benchmarking, by utilising RCVS Knowledge resources. This will build your confidence when showing colleagues how these can be used to benefit the animals in your care and team wellbeing.

Then aim to build on that foundation by learning about the importance of fostering the right culture, how systems work and how to manage complexity, all of which will be discussed in future articles, so stay tuned. Education creates a common understanding to ensure that no one is left behind on the improvement journey.

Engage your team

Quality Improvement is a team activity. Therefore, an essential step in getting started is to engage in dialogue with your team. Make time to talk about what matters to people and involve them in solutions. No one person has the skills or knowledge to come up with a solution on their own. Identify the benefits to the team, clients and the animals that you care for, which will help with buy-in. If you don’t have buy-in from your team, you will likely fail, no matter how good your idea is (2, 3).

Leaders must actively support and make time for Quality Improvement processes, in order for it to take hold and flourish. Enable your team to openly share information and encourage people to take action where it’s needed. As a leader, you can create a culture where your team feels connected and empowered, just like the team at NASA.

Identify areas for improvement

With your team, identify a problem or a process that needs to be improved, and take some time to understand what may be causing it. This may be identified by national initiatives, clinical audits, significant event audits, complaints, evidence-based practice or benchmarking. The most important thing is that you start with what is possible and what matters to your team.  Small steps can add up to a big difference.

Monitoring and measuring change is a key aspect of QI and makes progress tangible. Benchmarking activities provides a starting point from which to measure progress and clinical audit will tell you when you’ve reached your goal, but also help the team reflect on how to get there. Enveloping these activities in a culture of excellent communication, compassion and an openness to learning will set you up for success. By using QI techniques and taking a systems analysis approach, the team will be able to identify all factors that will lead to positive change.

Get support

Ask for help when you need it. If you have a colleague that is experienced in Quality Improvement, ask if they will mentor you. Draw on the resources and advice from the team at RCVS Knowledge or see if your own organisation has resources for support.  In my experience, people want to help and see you succeed. 

It will take enthusiasm, optimism, curiosity, and perseverance to get you started and then help you to deal with the challenges you will inevitably face. The improvement journey takes time and not everyone will start in the same place as you. That’s ok. Start where you are, keep the dialogue going and encourage people to come with you.

Commit to change

Most importantly, you need to enjoy the experience. Quality Improvement makes change a real possibility, which is both empowering and satisfying for everyone. Finally, don’t worry about what you don’t know or it being perfect the first time. You will learn by doing and your skills will be developed as you go.  Celebrate your successes and your failures, as there is valuable learning in both.

Discussion point

Defining a meaningful mission can unite a team. It was NASA’s mission to enable human exploration of space. What is your team’s mission?

Checklist - what you can do next

• Listen to Shobhan Thakore about how, and why, to engage your team in QI. 
• Listen to RCVS Knowledge Champion, Lou Northway RVN, talk about How to be a QI Ambassador to Improve Clinical Standards. 
• Have you identified an area you would like to focus on? Use our Clinical Audit resources to guide you to find out how well you are performing as a team now, work together to implement change, and then measure whether the change has led to an improvement. Listen to Pam Mosedale and Charlotte Hartley talk about Getting Started with Clinical Audit. 
• Has something happened in your practice that you would like to avoid happening again, or perhaps something has gone so well you would like to make sure you continue to achieve the same outcomes? Use our Significant Event Audit resources for continuous learning and improvements and listen to Alice Bird talk about her experiences with Significant Event Audit.
• Is patient safety at your heart? Use our checklist resources to put a system in place. Listen to our RCVS Knowledge Clinical Lead, Pam Mosedale, talk about How and Why to Use Checklists. 
• Do you want to put evidence-based veterinary medicine into place at the point of care? Use our guideline resources to find out how. Listen to Tim Mair, our RCVS Knowledge trustee, talking us through the steps. Use our library and the Veterinary Evidence Journal to access the evidence.
• Share your data anonymously to help establish national benchmarks for Small Animal Neutering, and use the results to understand how you are performing compared to others.
• Take a strategic approach to supporting QI in your area of work.
• Passionate about QI? Why not submit an application to win our next Champion Award.

References:

1. Lloyd, R. Improvement tip: Quality is not a department. Improvement Stories. [Institute for Healthcare Improvement] [online]. Available at: http://www.ihi.org/resources/Pages/ImprovementStories/ImprovementTipQualityIsNotaDepartment.aspx [Accessed on 5 Sept 2020]

2.  Thakore, S. (2020) Getting your team on board to deliver quality improvement. RCVS Knowledge. [Podcast]  [online]. Available at: https://rcvsknowledge.podbean.com/e/getting-your-team-on-board-to-deliver-quality-improvement/ [Accessed on 5 Sept 2020]

3.  Jones, B., Vaux, E. and Olsson-Brown, A. (2019) How to get started in quality improvement. BMJ; 364 doi:https://doi.org/10.1136/bmj.k5437. Available at: https://www.bmj.com/content/364/bmj.k5437 [Accessed on 5 Sept 2020]

About the author

Angela Rayner BVM&S PgDipPSHCF MRCVS

Angela is Quality Improvement Advisor for RCVS Knowledge, Director of Quality Improvement for CVS, and is an RCVS Knowledge Champion for her role in improving CVS’ systems for controlled drugs auditing.

In 2018, Angela began an MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh. The programme supports healthcare professionals in using evidence-based tools and techniques to improve the reliability and safety of healthcare systems.

It includes how good teamwork influences patient outcomes, key concepts around learning from adverse events and teaching safety, understanding the speciality of clinical human factors, as well as the concept of implementing, observing and measuring change, monitoring for safety, and it focusses on quality improvement research and methodologies.