Quality improvement projects

Quality improvement projects can be effectively used to improve individual performance. Here is a structure and example of a simple quality improvement project which uses some of the quality improvement techniques described in this e-learning programme.

Title: Improving individual referral letter accuracy, timeliness and completion

Date completed: 1 May 2010

Description: A quality improvement project focusing on improving the accuracy, timeliness and completion of specialist referral letters.

Reason for the choice of topic and statement of the problem: The project was triggered by a significant event involving a delayed referral letter for a patient. Fortunately, the patient did not come to any harm but it became apparent to me that my processes for completing referral letters needed to be safe, effective and efficient and there was no room for error or delay.

Process under consideration (process mapping): Current processes for referral letters were reviewed. This involved producing a list of referrals when they were indicated; dictating the letter on a tape after each surgery or dictating the letter directly to a secretary if the doctor was available and particularly for urgent letters; leaving the tape for the secretary to type and initiating an electronic booking with the specialist unit; and then signing the letter when next in the surgery or sometimes on the same day if an urgent referral was required. There were delays and potential for waste or error in this process, many of which had previously been experienced. For example, dictation machines and tapes or secretaries were not always available, batteries were sometimes missing from machines and tapes were sometimes damaged. Secretaries were not always able to understand what he had said on a tape, either, because it was damaged or because technical language was used that they did not understand. If a secretary was on leave or unwell there was a delay in the letter being typed. Inaccuracies in letters had to be corrected, necessitating retyping and leading to further delays.

Priorities for improvement and the measurements adopted: The aim of this quality improvement project was to improve the timeliness, accuracy and completion of referral letters. The steps required in the process and the potential for waste or error in the process were measured.

Baseline data collection, analysis and presentation: The baseline analysis was the process map of the steps involved in producing a referral letter and any risks or threats to a letter being sent described earlier.

Quality improvement objectives: The objective was to reduce the steps required to generate a referral letter and to minimise the potential for waste or error in the process.

Techniques used to improve the process: A process map and two plan-do-study-act (PDSA) cycles were used to improve the process of generating and sending referral letters. This was discussed with the secretaries and administrators. In the first PDSA, referral letters were typed directly onto the computer system after a surgery and the typed letter sent to the secretary as a computerised task (similar to an internal email on the clinical computer system). Letters were retyped on headed notepaper and a referral booking actioned by the secretary. In the second PDSA, letters were typed while the patient was in the room or just after he or she had left. This reduced the number of steps further and meant there was less to remember when generating a letter – sometimes the patient could be asked for salient information to include, prompted by the process of writing the letter.

Intervention and the maintenance of successful changes: The new process of typing referral letters with the patient present or just after he or she had left the room and sending them directly to the secretary as a computer task was implemented. This system has been maintained with benefits for the patient primarily but also for the doctor, secretaries and administrative staff.

Quality improvement achieved and reflections on the process in terms of knowledge, skills and performance; safety and quality; communication, partnership and teamwork; maintaining trust: This quality improvement project enabled the doctor to refine the process of generating referral letters. Letters are now generated with the patient present or just after the consultation. Patients are pleased that referral letters are sent immediately and when they have an opportunity to be involved in the content of the letter. Secretaries have fewer difficulties interpreting damaged tapes or difficult jargon and are more confident with the new process. The new process saves time, reduces errors and minimises waste or rework (having to do things twice or several times).