A Guide to Resident Quality Improvement Projects

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What is a Quality Improvement (QI) Project?

• A quality improvement project is a focused and structured effort to achieve better outcomes of a given process. Some of the earliest formal quality improvement initiatives originated in the manufacturing industry with the goal of avoiding production defects and improving efficency1. Similar quality improvement efforts have since been adopted by the healthcare industry.
• The goals of healthcare related quality improvement projects are often to increase patient safety and to avoid the waste of limited resources.
• A famous example within the realm of surgery would be the SAGES Safe Cholecystectomy Program (https://www.sages.org/safe-cholecystectomy-program/) which has the specific focus of reducing common bile duct injuries.

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Why Should Our Residents Engage in QI Projects?

As leaders of the healthcare community, it is essential that we play an active role in the never-ending effort to improve the care of our patients. One way to do this in a fashion that may help a large number of patients is to take part in quality improvement projects.

By encouraging residents to become involved in quality improvement during their training, we can endow them with the motivation and skills needed to carry out such efforts in their future practice.²

Furthermore, involvement in quality improvement efforts is mandated by the ACGME Common Program Requirements (https://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements)

Listed below are numerous citations from the current ACGME Common Program Requirements pertaining to quality improvement:

II.B.2. Faculty members must:

• II.B.2.g) pursue faculty development designed to enhance their skills at least annually: (Core)
• II.B.2.g) (2) in quality improvement and patient safety: (Core)

IV.B.1.d) (1) Residents must demonstrate competence in:

• IV.B.1.d) (1) (d) systematically analyzing practice using quality improvement methods, and implementing changes with the goal of practice improvement (Core)

IV.D.2.a) Among their scholarly activity, programs must demonstrate accomplishments in at least three of the following domains: (Core)

• Research in basic science, education, translational science, patient care, or population health. Peer-reviewed grants. Quality improvement and/or patient safety initiatives. Systematic reviews, meta-analyses, review articles, chapters in medical textbooks, or case reports. Creation of curricula, evaluation tools, didactic educational activities, or electronic educational materials. Contribution to professional committees, educational organizations, or editorial boards. Innovations in education
• IV.D.2.b) The program must demonstrate dissemination of scholarly activity within and external to the program by the following methods:
• IV.D.2.b) (1) faculty participation in grand rounds, posters, workshops, quality improvement presentations, podium presentations, grant leadership, non-peer-reviewed print/electronic resources

V.C.1.c) The Program Evaluation Committee should consider the following elements in its assessment of the program:

• V.C.1.c) (5) (d) engagement in quality improvement and patient safety (Core)

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability

• VI.A.1. Patient Safety and Quality Improvement: All physicians share responsibility for promoting patient safety and enhancing quality of patient care … Graduating residents will apply these skills to critique their future unsupervised practice and effect quality improvement measures.
• VI.A.1.b) Quality Improvement
• VI.A.1.b) (1) Education in Quality Improvement
• A cohesive model of health care includes quality-related goals, tools, and techniques that are necessary in order for health care professionals to achieve quality improvement goals.
• VI.A.1.b) (1) (a) Residents must receive training and experience in quality improvement processes, including an understanding of health care disparities. (Core)
• VI.A.1.b) (3) Engagement in Quality Improvement Activities Experiential learning is essential to developing the ability to identify and institute sustainable systems-based changes to improve patient care.
• VI.A.1.b) (3) (a) Residents must have the opportunity to participate in interprofessional quality improvement activities. (Core)

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How Do We Start a QI Project?

The first step in starting a quality improvement project is to identify the problem to be addressed.

These problems may be revealed by external audits, internal reporting systems, or personal observation. ³

Your institution’s safety officers (infection control etc.) can be of great value in this stage of your project as they are likely aware of specific problems and may have access to the data you will need to justify your QI efforts.

Given the amount of time and effort required to properly carry out the QI process, it is important to pick a project that will have a meaningful impact (e.g. preventing aspiration events may be a better objective than increasing patient satisfaction with respect to coffee quality).

While a QI project should have as meaningful an impact as possible, one should also consider their institution’s resources and avoid choosing a goal that is too lofty and ultimately unachievable (While you may be able to create an order set or two, but it could be a stretch to re-write a national EMR’s programming to promote discharge efficiency)

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What are the Steps of a QI Project?

State the problem to be addressed:

• After identifying a problem of interest, draft a formal statement describing the problem and the overall aim of the project.
• For example: “After reviewing patient records, we have found that the incidence of post-operative aspiration events at our institution is higher than that described in contemporary literature. It is our aim to decrease the incidence of post-operative aspiration at our institution”

Assemble a QI team:

• With the quality improvement goals clearly laid out, the next step is to put together a multidisciplinary team to help carry out your project. ⁴ Team members may include:
• Project Leader: This should be the resident who identified the QI issue to be addressed. They must be a motivated and well organized individual capable of carrying the project out to its end.
• Project Assistants: The project leader may need help planning and executing their QI project. It is reasonable to involve additional residents to share some of those responsibilities.
• Project Sponsor / Principal Investigator:  This should be a faculty member who can offer guidance through-out the QI process. Ideally, this is someone well connected at the institution who can help overcome administrative hurdles and assist in acquiring necessary resources.
• Safety Officer / QI officer: As previously stated, your institutions quality improvement officers such as those involved in infection control or patient safety are invaluable in this process. They may shed insight into what issues are present and the resources available to address them.
• Patient Care Providers: The project leader should reach out to those directly involved in patient care including physicians and nurses. Leaders from this community such as nurse managers can lend extra insight into the problem at hand and what those directly caring for patients might be able to do to address it. These individuals can also help to institute the changes proposed by the project’s plan.

Develop a project plan:

• With a team in place, you must develop an organized plan for how you are going to achieve your desired improvement outcome. Several models for quality improvement projects have been developed including the following:
• Plan Do Study Act (PDSA) Model: Originally conceived by statistician Walter Shewhart in the early 20^th century and now used frequently in healthcare, the PDSA model is a cyclic method of quality improvement that entails enacting changes and then fine tuning those changes based on the observed impact that they have.⁵
  • As the name suggests, this model involves four stages
    • Plan: Identify the change that may achieve the goal outcome and determine how to implement it.
    • Do: Implement the change
    • Study: Analyze the impact of the change on your goal outcome.
    • Act: Decide if you need to modify your plan to better achieve your goal outcome
  • It is important to realize that the PDSA model entails a continuous cycle of learning and updated changes and that it is not designed to be a onetime effort. The cycle should be repeated numerous times until the maximum benefit is achieved.⁶
• Lean Model: Derived from Toyota’s 1930 operating model, Lean is a QI methodology that is designed to improve efficiency in the production or delivery of goods and services. The core model consists of five key principles: Define value, map the value stream, create flow, establish pull, and pursue perfection.⁷
  • The Lean process involves carrying out those five Lean principles to achieve continuous improvement.
    • In healthcare, this entails establishing the value of an intervention or medication, identifying ways to deliver it more rapidly, and determining what waste can be removed from the process to reduce costs and conserve resources
    • Like the PDSA model, the Lean process is not a single intervention and requires persistent efforts to improve efficiency.
  • In addition to the Lean process, Lean also involves specific Lean assessment and Lean improvement activities.
    • Lean assessment activities work as analytic tools to identify waste and areas of possible improvement. Lean assessment activities include:⁸
      • Root cause analyses
      • Value stream mapping
      • Rapid Process Improvement Workshops
      • Spaghetti diagrams
      • Gemba walks
    • Lean improvement activities strive to reduce waste and improve the workplace. Lean improvement activities include:⁸
      • Application of 5S principals
      • Institution of stop-the-line measures
      • Production leveling
      • Standard work enforcement
• Six Sigma Model: Originally developed by Motorola in the 1980s, Six Sigma was a QI methodology designed to eliminate defects in the manufacturing process. It has more recently been applied in the field of healthcare to help eliminate medical errors and waste.⁹
• The name “Six Sigma” comes from the goal of achieving a fraction of defect free outcomes that is six standard deviations above the mean. It does not mean that there are six steps. The DMAIC framework, which is central to the Six Sigma model, instead involves five distinct steps:
  • DMAIC (Define, Measure, Analyze, Improve, Control) is a structured approach to quality improvement that places a strong emphasis on identifying sources of error.¹⁰
    • Define: In this first phase, the specific problem to be addressed if declared and the final goals of the project are determined.
    • Measure: Next, measurements of various metrics related to the quality of the process in question are carried out.
    • Analyze: The measurements are then analyzed to identify the root cause of any errors in inefficiencies.
    • Improve: After root causes of error are identified, changes to eliminate them are developed and implemented. The efficacy of the change is evaluated.
    • Control: If changes are found to be effective in eliminating waste and error, efforts are made to make sure that those changes can be maintained. The cycle is then repeated to further improve the process.
  • In addition to DMAIC, Six Sigma involves several other quality control measures such as 5S which work synergistically to reduce errors (further information regarding all aspects of the Six Sigma method can be found in the tutorials listed in the additional resources section below)

Obtain project approval:

• After a quality improvement model has been chosen and a detailed plan has been developed, the project should be presented to the project sponsor for approval.
• Depending on the scope of the suggested changes, the project may also need approval from your institution’s IRB. The need for approval should be discussed with your IRB officer. If it is determined that IRB approval is needed, the plan must be submitted and approved before instituting any changes.

Carry out the project plan:

• After receiving approval, the QI project must then be physically carried out.
• Quality improvement is a team effort and will require the resident to work closely with patient care providers. It is important that the team leader be gracious towards and appreciative of those providers as they will strongly rely on them to implement the desired changes.
• While carrying out the project, administrative hurdles and resource limitations will almost certainly be encountered. The resident must not give up when this happens and should instead seek guidance from their project sponsor or institutional safety officers.

Evaluate the results of the project:

• In addition to the frequent self-appraisal suggested by most quality improvement models, a final evaluation of the results of the QI project should be carried out.
• Evaluation of patient outcomes may entail a query of medical records. Your medical records office can help with this process (Depending of the information to be gathered, this may require IRB approval).
• In the end, the resident should determine if their project had a meaningful impact, if further improvements could be made, and what they or their peers could do better in future QI efforts.

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What Should We Do at the Conclusion of a QI project?

Thank all involved parties: QI projects generally require a considerable effort from numerous members of the healthcare team at your institution. Showing gratitude is not only in good manners, it may also increase the willingness of those who helped to assist with future projects.

Publish your results: This is not mandatory, but if the project was well designed, had a meaningful impact, and could be reproduced at other institutions, it may be worth sharing with the medical community (also, it will benefit your residents’ CV).

Assure sustainability: Achieving the goal of a QI project has little value if the improvement that was instituted cannot be maintained. Efforts should be made to assure that the training and resources utilized during the project remain available after its completion.

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Additional Resources

Overview of QI projects:
Large Overview of QI projects by the department of health and human resources:
https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf

Plan Do Study Act tutorial:
Detailed tutorial of the PDSA method with worksheets:
https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool2b.html

Lean tutorial:
Succinct tutorial on the Lean method in healthcare
https://legacy-uploads.ul.com/wp-content/uploads/sites/40/2015/02/UL_WP_Final_Applying-Lean-Principles-to-Improve-Healthcare-Quality-and-Safety_v11_HR.pdf

Six Sigma tutorials:
Tutorials and courses on the Six Sigma method:
https://www.sixsigma-institute.org/What_Is_Six_Sigma.php

5S

A Look at Six Sigma’s Increasing Role in Improving Healthcare

Lean Six Sigma tutorial:
Concise Lean Six Sigma tutorial focusing of the DMAIC steps.

Lean Six Sigma: Step by Step (DMAIC Infographic)

ACGME Common Program Requirements:
The complete current ACGME program requirements including those pertaining to QI
https://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements

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Works cited

1. Girdler, S. J., Glezos, C. D., Link, T. M., & Sharan, A. (2016). The Science of Quality Improvement. JBJS Reviews, 4(8), 1. doi:10.2106/jbjs.rvw.15.00094

2. Allwood, D., Fisher, R., Warburton, W., & Dixon, J. (2018). Creating space for quality improvement. BMJ, k1924. doi:10.1136/bmj.k1924

3. Katakam, L., & Suresh, G. K. (2017). Identifying a quality improvement project. Journal of Perinatology, 37(10), 1161–1165. doi:10.1038/jp.2017.95

4. NC State University Industrial Extension Service and the Institute for Healthcare Improvement. (Accessed 2020). A Step by Step Guide to Quality Improvement. http://www.amchp.org/Transformation-Station/Documents/QI%20Step%20by%20Step%20Guide.pdf.

5. Berwick, D. M. (1998). Developing and Testing Changes in Delivery of Care. Annals of Internal Medicine, 128(8), 651. doi:10.7326/0003-4819-128-8-199804150-00009

6. Leis, J. A., & Shojania, K. G. (2016). A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name. BMJ Quality & Safety, 26(7), 572–577. doi:10.1136/bmjqs-2016-006245

7. Flynn, R., Newton, A. S., Rotter, T., Hartfield, D., Walton, S., Fiander, M., & Scott, S. D. (2018). The sustainability of Lean in pediatric healthcare: a realist review. Systematic reviews, 7(1), 137. https://doi.org/10.1186/s13643-018-0800-z

8. Rotter T, Plishka C, Lawal A, et al. What Is Lean Management in Health Care? Development of an Operational Definition for a Cochrane Systematic Review. Eval Health Prof. 2019;42(3):366–390. doi:10.1177/0163278718756992

9. Al-Qatawneh L, Abdallah AAA, Zalloum SSZ. (2019) Six Sigma Application in Healthcare Logistics: A Framework and A Case Study. J Healthc Eng. 2019:9691568. doi:10.1155/2019/9691568

10. Prajapati, D., & Suman, G. (2019). Six sigma approach for neonatal jaundice patients in an Indian rural hospital – a case study. International Journal of Health Care Quality Assurance, 33(1), 36–51. doi:10.1108/ijhcqa-07-2019-0135