Patient safety and good care is reliant upon continuous quality improvement.
"Constant change can be exhausting, but constant improvement can be invigorating. We need to cultivate a culture of always doing things a little bit better." – Person Centred Medical Home Handbook
Key requirements for quality improvement:
- The improvement is informed by data, so the impact of changes can be measured. Data can be drawn from a variety of sources, including feedback from patients, team members in the practice, and clinical data analysis.
- All members of the team are involved on a routine basis.
Why is data so important?
If we can't count, we can't see as much and we can't compare before and after. It's a tool to generate insight, raise questions, experiment, and help make decisions. It should be stimulating a lot of conversation. The pioneer of data-informed improvement in healthcare was Florence Nightingale. "Before Nightingale, we were in the dark" (from a detailed article about her life and work) . She's famous for being a nurse, but she was also a brilliant statistician. This quick video is a good overview of Nightingale's work and impact: What would Florence Nightingale make of big data?
Continuing on from Nightingale's legacy, we now have data analysis tools for healthcare providers, such as POLAR. They do a lot of the heavy lifting of the data extraction, transformation, mapping, and analysis. They make it easy for clinical and adminstration staff to visualise data for analysis and spotting patterns. So you don't have to be a statistician like Florence, but you can still benefit from the data.
POLAR isn't the only tool you can use. A little bit of familiarity with Excel can go a long way. It doesn't take much to get going. This 20 minute YouTube tutorial for Excel is well worth watching.
Model for Improvement
The Model for Improvement, from the Institute for Healthcare Improvement, is a good framework. There are two key components to the framework: 3 fundamental questions and PDSA (see below). There are a range of downloadable resources for the Model from the Australian Primary Care Collaboratives webpage.
3 fundamental questions
Before undertaking any improvement activity, you must first answer these questions:
- What are we trying to accomplish? (In other words, what's a problem you're trying to solve?)
- How will we know that change is an improvement? (In other words, what could you count that would tell you how you're going with addressing that problem?)
- What changes can we make that will lead to an improvement?
At first, it may seem hard to answer these questions. But once you start talking about these amongst yourselves you may be surprised at the amount of ideas that start flowing. Pick the best ideas, the ones that make the most sense, that are the most practical, easy to do, and meangingful to all in the team (see the Quadruple Aim below).
PDSA (Plan Do Study Act) cycle
The PDSA cycle is a useful tool. It helps your documentation, but more important, it helps you structure your improvement approach. Each PDSA represents a test, something you're trying to do to achieve a goal. You're most likely to have multiple PDSAs before you reach your goal. The PDSAs don't need to be long, indeed they're probably going to work better if they're very short. The cycle’s steps are: develop a plan of the test (Plan), carry out the test (Do), observe and learn from the consequences (Study), and determine what modifications should be made to the change (Act).
For more information about the PDSA cycle, see the RACGP QI & CPD Handbook (pg 23).
The Quadruple Aim is the 4 domains to consider when improving something:
- Patients' experience of care
- Clinicians' experience of work
- Improved health outcomes for patients
- Sustainable cost
If you're struggling to decide what to do, narrow your options down to those that fit within all four of these dimensions, because anything that fits in all four is more likely to get everyone engaged and motivated. The activity should turn out to be interesting.
Outputs vs outcomes
You could be measuring outputs (e.g. the number of Type 2 Diabetes patients who have had a recent HbA1C).
Or you could be measuring outcomes (e.g. more Type 2 Diabetes patients who are controlled, which could be measured by counting, over time, those with a recent HbA1C in target range).
We recommend you choose an outcome measure. It's more meaningful to everyone, and it's more important because it's measuring what you're actually trying to achieve.
Here is an example of some outcome measures you might want to track:
- % patients with Type 2 Diabetes who are controlled (HbA1c < n)
- % patients with IHD/CHD who are on anti-platelets
- % [at-risk patient cohort] who have had a flu vaccine
- trend in eGFR of patients with CKD (i.e. how many maintained renal function)
“If we apply the knowledge that we have in a systematic way for the benefit of all the lives we touch, we will be successful in the myriad ways that this can be measured. Start with the patient. Finish with the patient. Everything else is really a proxy measure.” – Dr Ralph Audehm
When data is reused, it inevitably improves. It's a consequence of people seeing the data in different ways. Flaws in the data become apparent that were previously hidden. If you have a meaningful outcome measure that the whole team is working on, you'll find that your data will start to improve with minimal conscious effort. In other words, you needn't devote energy to activities solely dedicated on data quality improvement.
SEMPHN's QI resources
- PDSA template
- PDSAs and walkthroughs on our POLAR webpage
- Practice Coaching website
- Excel template for line chart with clinician names - to use this template, make sure you Enable Macros (it will prompt you when you open it)
Once you've picked an important outcome measure, how do you track it? SEMPHN knows that practices are very busy places, so we've developed a way for you to easily create a chart without having to use Excel.
You could update the chart each month and print it out for your team, or you could even publish it on your practice's website. Below is an example of what the chart looks like.
External QI Resources
- All Are Welcome is a locally developed QI resource by enliven to help you in being a more inclusive practice for the LGBTQI+ community.
Practice Incentive Payment Quality Improvement (PIP QI)
The Practice Incentive Payment Quality Improvement (or PIP QI) is for general practices that participate in quality improvement activities to improve patient outcomes and deliver best practice care.
How to register
Registration is available from 1 August 2019. Register via HPOS (using PRODA). The steps in HPOS are:
- Log on to HPOS
- Click My Programs
- Go to the PIP tile
- Click the Update button
- The Program and PIP information screen will appear
- Click the Exit button at the bottom of the information
- Look for the Main menu (red header at top-left of screen), and click Incentive summary
- In the Quality Stream section > Quality Improvement Incentive, click the Apply link
- Read the terms.
- Tick the Participation Payment option
- Click Submit
Important note: once you've registered, you must contact SEMPHN to tell us that you've registered and what your PIP Practice ID is.
There are two requirements that practices must comply with in order to receive payment:
- Participate in continuous quality improvement each quarter (such as PDSA activities), in partnership with their local PHN. The measure for the activity must be from clinical data.
- Submit the PIP Eligible Data Set on a quarterly basis to their local PHN.
The Eligible Data Set comprises fields required to calculate 10 metrics and analyse them according to the PIP QI Data Governance Framework.
The 10 metrics are:
- Proportion of patients with diabetes with a current HbA1c result
- Proportion of patients with a smoking status
- Proportion of patients with a weight classification
- Proportion of patients aged 65 and over who were immunised against influenza
- Proportion of patients with diabetes who were immunised against influenza
- Proportion of patients with COPD who were immunised against influenza
- Proportion of patients with an alcohol consumption status
- Proportion of patients with the necessary risk factors assessed to enable CVD assessment
- Proportion of female patients with an up-to-date cervical screening
- Proportion of patients with diabetes with a blood pressure result
More information and the Guidelines for PIP QI are on the Department of Health webpage for PIP QI Incentive guidance.
South Eastern Melbourne PHN acknowledges the traditional custodians of the land our catchment covers, the Boon Wurrung and Wurundjeri people. We pay respect to them, their culture and their Elders past, present and future, and uphold their relationship to this land.
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