Audit & Quality Improvement
Summary
This online teaching session is relevant to medical professionals who want to excel in their roles by demonstrating their understanding of quality improvement and its application in healthcare. The session will discuss what quality is, how it fits into clinical practice, research, and leadership/management, and how to build a portfolio of evidence to show competence. Attendees will also learn the basics of clinical order and quality improvement, use of a spreadsheet to assess their experience, the 6-D model of quality, the PDSA cycle of continual improvement, and much more in this highly interactive and engaging session.
Learning objectives
- Identify the definition of quality in healthcare and the IHI Six Domains of Quality.
- Outline the key components of quality improvement and its role in clinical practice.
- Develop an understanding of how to apply various improvement models and methodologies.
- Describe the related techniques for assessing quality in healthcare.
- Apply the Plan-Do-Study-Act cycle to situations in their own practice and identify opportunities for improvement.
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polity Improvement Onda. Well, that I'm sorry. Here we go. I've got a declaration of interest. I've mentioned it at the start. Lots of this content is taken from the book that I wrote with Joe. As long as Joe was talking to you about a teaching, I think it was Yeah, teaching as I. As noted, in the corner, we wrote this book together and lots of it is taken from that. So it's a little bit of off feeding off what I've already written. Mawr eyes available course in the book. If you want to go ahead and get that. So I'm sure they slide at the start off the session last time as a surgical training is a journey, and it's a marathon can journey here. We've got the 109 year old turban and tornado world's oldest marathon runner on, you know, three months on from last talking to you, I think I must have aged another six on my months with all the things are gone in the interim on it doesn't feel like you're certainly in it for the long a long haul. But hopefully, um, you've been able to start taking on some of our recommendations. And the key message is that I really want to try to impart on is as you go on this gel throughout under graduate training throughout post graduate training that you document everything that you do that you record evidence on that You, um, you end up with this body off of evidence and justification when you go to apply for a specialty post or for your F y, or for other competitive based based positions, as always, if it's not on stronger. Did it even happen while if you haven't documented in your portfolio, was it even worth it on? And I showed you this slide last time as well. I just really want to come back to it. That quotation from a professor and mental of mine saying Your colleagues will be busying themselves quietly building little empires, and this is really just a call to arms for everybody who's here to start to construct that portfolio. If you haven't already assess it as you go through building your evidence, be systematic with it and be critical of it and think honestly on objectively, where are my strong? Where are my week? What's the low hanging fruit that I can go and achieve in order to take myself to the next role of the ladder, have one of my short and long term objectives. And one of the things that I am really find useful is this. This is a spreadsheet that I used. You can make your own, and it's basically lucking out the drops, specifications or person specifications off a specialty application program of interest to you, be it academic F y or course surgical training or run through orthopedics or wherever you're looking at applying. Look at what they want to see evidence in your portfolio and in your application, and then you rent it to you and stop pitching, holding your experience to date inside those and see why you're strong, see where your week and see where you need to be building. But today I'm going to talk specifically about clinical ordered and quality improvement on D. It's got the potential to be quite dry on. Actually, I thought that to be the case, and up until maybe three years ago, four years ago when I started to really branched into this topic, actually, it's it's ripe for exploration is low to stuff you can do. It's very closely aligned to clinical practice is very closely aligned to research, and it's very closely aligned to leadership in management. And really, if you're doing those things well, clinical order and quality improvement is what holds everything together. So I really hope this is going to be useful within this discussion, and I'm more than happy for it to be really conversational. If you want to shout out or interrupt her, ask questions fielded by the moderators. That's Grant, and we'll have a chat afterwards as well. So please feel free to engage. We're going to start considering what is quality on then? How do we go about improving it within the healthcare context, or is clinical order? It wasn't mean what types of all it's all there and what examples are available for you to evidence in your portfolio, and then we'll talk more practically on. How do I increase my own experience in clinical order? And Q. I ah, where can I find some opportunities? I'm at the end. We'll discuss a little bit. We can do a little clinic of what counts. What doesn't count on DTaP's on your own suggestions as well. So the golden rule is at the top of our chapter on clinical order and quality improvement. Is that quality improvement or Q. I D is more than just order it, and it's important to understand how it fits into clinical practice of an every day basis on also research in terms of chemical, academia and basic science. And it's important that we find opportunities in these areas. When you go to submit a nap occassion form or go to an interview, Thie examiners or assesses will want to know that you can demonstrate these skills. So this is what I think they're looking for when reading your application for Do you understand what you are? Is on what it's rollers within healthcare. Do you understand the basics that principles and practice of actually delivering quality improvement? And can you demonstrate that you've added value to some service or program or project through the application of your old Q. I methodology. Three key things that you need to demonstrate. So what is quality? That was, Ah, harder question minute. I thought it really needed to be when I writing this chapter, um, and I found that really nice US instituted medicine definition on. It's just the degree to which health services increase the likelihood off a desired healthy outcome. So you got service that delivers X as it's intended Goal. What is the likelihood? Or the degree to which that service delivers? X go and quality is categorized on a six time mentioned quality framework. The Institute for Health Improvement is in the US It's called I I I've got a six day I mentioned quality from work on a lot of Vienna. Just practice a lot of businesses on Behalf Time models are based on this. The principles are that we deliver safe care and by doing so, avoid harm to patients. We deliver an effective service that's evidence based care that delivers and demonstrably benefit to patients. It needs to put the patient at the center off the service. So you build that service around the patient's needs on around how their access and interact with the service. Rather than being something that's done to the patient as a passive recipient, the care that we give needs to be timely, so there shouldn't be any harmful delays, something that we're actually seeing an awful lot off, particularly the plan care sector of the moment. But we need to be developed there in timely care to patients as well. On the Cabinet, we give in the service that would give me to be efficient. So with as much avoidable waste as possible produced. And it needs to be equitable. We need to be delivering care that's fair to all patients on just on these often actually reflect those four medical, ethical biomedical pillars off off medicine. So we talk about safe, effective, patient centered care, delivered a timely, efficient and equitable minute on another way to explain that and something that's quite useful when your answering this question interviews, for instance, is the, um, the know needless model. So if you look to the right there, safe means no lead list deaths or know needless harm. Effective means know needless pain know needless suffering. Patient centered on person center care is no helplessness. Timely care is no one wanted waiting. Efficient care is no waste on equitable care. Is no one left out? That's quality, but what's quality improvement? Well, it's a process. It's a method of set of methods for increasing the degree to which health services increase the likelihood of design health outcomes. Let's go back to the quality there. We've got the degree to which health services increase the likelihood of desire, health outcomes and quality improvement is just a process for increasing that quality. It is vital. It's fundamental. It underpins all aspects of the healthcare systems. It's absolutely everywhere. Q. I methodology is everywhere on a local, on a regional national and on a super national level. That means it's really important to you guys sitting here listening to this because it is so popular with recruitment processes, with applications on with the the competitive process for getting jobs and things people want colonization, as you can deliver and understand you I methodology. And probably some of the reasons for this increase in interest is because we're dealing with an ever increasing resource pressure. Their course we need to improve efficiency would deliver. We're needing to deliver better services in an increasingly challenging context. Be a resource being the pressures of commercial interests, be the increasing agency off patients and advocates of patients. Eso of course, we need to increase the value of our service on this ever greater emphasis on safety on outcomes. This isn't the 19th early 20th century where people except unnecessary harm. Now people are held to account on. We need to demonstrate as clinicians and a service administrators that were delivering things safely on defectively on that the patient's outcomes are improving all over time. So what is Q. I then? Well, it's a set of techniques on underpinning this debt. This definition is that it requires systematic assessment of a service on intervention to improve it. The aim is to be sustained to provide this improvement process that lasts in perpetuity. And it's achieved through a multitude of approaches, many of which are taken from industry from Iota or General Motors or Dell, or these massive companies are delivering repeatedly. Reliable, high quality services with his little waist is possible, and that manufacturing line on the process for improving it is translated into the healthcare system. All of the approach is that you use as many products available. Many models available follow this basic process. You need to understand the process that you're dealing with, so whatever you're doing, you need to understand what are the aspect off this system and off this process from there, you could look at things that aren't great that aren't efficient, that are causing waste where they are source of potential harm. Identify which areas on there and write for improving and consider and then design an intervention that improved those What's the target of your improvement strategy and how you gonna go about doing it? And then you need to assess what you don't need to assess the impact of your interventions and then decide whether and how you're gonna employment your changes. This is the basic you I approach. Yeah, some of you may already have heard of this plan Do study act or PDS. A cycle has really interested to see the pole there of you saying that you don't get instruction on D checking about quality improvement in medical school. You don't feel that that services there because this is at the core of every Q. I project that we do and of every the morning day services with any clinical setting. So hopefully this style is gonna be useful to you and you will see a couple more times they want us. Well, this chain processes here the top here often mapped to what's called a PDS a cycle or otherwise known as an order it loop. Now these are terms that you'll start to see creeping up in application forms on interview questions, people might say, Tell me which how many closed loop audits have you done? And all that means is you have seen a quality improvement project progress from the planning stage, where you think what you're going to do through the doing stage where you trial and improvement or change through the study stage where you analyze the effects of your intervention on to acting where you actually look at what you don't previously and then implement something that is a sustainable change that would be one order loop cycle or one pds a cycle cycle. It's also known as closing the lip. That brings me nicely on to order it now order It is I'm so pleased we will talk to you about this because it is so broad on it means all manner of different things to all manner of different people. So I'm gonna try and touch on that now, and hopefully with this new phone knowledge, you're gonna be able to leverage it. You're gonna be able, Teo, tell people what it is and you're into your gonna be able to say, Oh, well, that looks like this time of ordered were really useful to improve that. Would you like me to go on, Deliver that as a student project? Hopefully, it's gonna be used. So multiple definitions exist, but ultimately ordered is a process by which to evaluate and assess and improve aspects of a service. I like this definition of clinical ordered here. I haven't cited it, referenced it. So I do apologize about that. It is in the book. I'm not sure where it's come from. Um, clinical order is a process that seeks to improve patient care on outcomes through systematic move you against explicit criteria on the implementation of changed healthcare services. That's nice and tight. And it's the sink. Um, but one of the key aspects of that is that order. It is underpinned by this phrase here systematic review against explicit criteria. You have something that is established at measurables objectively, it exists. You can perform an assessment to measure something to compare against that preexisting knowledge or pre existing data is that which separates chemical ordered from research. So I said this definition here, that process to evaluate assessing improve service eyes is a great definition. It reflects order it as a quality improvement or clinic governance process. But I really like this one because it's it's broader. Um, it really tells you what you need to know when you're delivering a project becomes a really interesting discussion about how you get permission to deliver certain projects clinical order to seen as something that is part and parcel of every day service delivery. And it's different from research on the discrepancy that is sufficient to require or not require ethical approval for a a project to be undertaken. And, as you know, in medical school, your your approach to things is time sensitive. You need to deliver things quickly on DSM times waiting The often months for ethical approval process is to, um, to play out just isn't practical in order to deliver things quickly and get into your CV and get it onto your portfolio. That's one of the main reasons why most of my research activity is actually in clinical ordered, because I don't particularly take much time over. The six approval process is so Where do we see examples off? Order it in half care but one of the areas that I worked the most in his standards based audit that's assessing performance against established standards. So that might be a national guidance on your measuring the performance against that national guidance Peer review is another type of order. It that's the routine or regular review off the performance of an individual or a product or a system on comparing the outcomes with others or monitoring that performance over time. I'll give examples of these in clinical practice in a moment. Adverse events screening is another type of all it. So that might be your more morbidity mortality meetings or might be incident reporting systems. Focus Groups of Focus group is a type of order it or can be a type of all it on. That might involve having service users or advocates for service users within the design or improvement process that you're delivering and then at the bottom here. We've got that plan do study act that, um, that classical cycle that when you go out into the wider world and people say, have you done an order it basically what they're asking is, Have you done a PDS A type model off project? So it's not with the standards based water first assessing performance against established standards. So in your interview questions, somebody might say, Give me an example of the standards based on it. I've had this question on this is what I prepared. I said, What the example is where I work the Scottish hip fracture or it the Scottish hip fracture order it collects Keep formance indicators measuring the performance off care delivered to all hip fracture patients in Scotland on what the order does is assess for every individual patient, how many off the standards of care is a dozen of thumb? How many of the 12 Scottish standards of care we're at here to for each patient, and it produces in for graphic Sinus looks year on year, what performances on we can start to identify where we might be doing well in the country and where we might not be doing well the country on these particular aspect, and we might drive to focus on one particular aspect to improve. Over the next year, you can develop run charts like you see on the right here showing performance martyrs percentage achieved off a certain standard over time. And then you can see you might see a certain event that precipitated a drop in performance or an increase in performance. And it starts to tell you how you can go about improving it. Serves the scholarship fracture also provides data like this. This is a funnel plot. S. So this is all of the 17 Scottish hospitals dealing with hip fracture on. It basically marks there achievement the percentage achievement off a certain standard. The standard is thea Timely surgery Standard plots that on a final plot on the green lines are the upper two standard and three standard deviations The red lines on the lower two or three standard deviations on where you want to be. His either above that clot meaning you're achieving better than expected or better than the standard deviations. But you don't want to be below it if you're below it. It means that you can see here the hospitals cross house and forth Valley Royal Infirmary were underneath the standard deviation lines, which means that outliars they're performing poorly on this particular standard and therefore we can go in and we can start to assess why that is an improvement. That's a standard space recorded. Perevi. Well, it might be a CP review. I've given the example here off the weekly arthroplasty meeting. Lots of mine talks are orthopedic team. Of course, I make no apology for that because it's the best specialty. Brilliant, but other specialties are available in the weekly after plastic meeting. A lot. The art of plastic surgeons get together the cases of presented for all of the arthroplasty activity done on the preceding week. Um, the indications are given patient details of given on the radiographs have shown, and it's a routine review off these track radiographs. And essentially, it's to ensure consistent practice is to identify issues early. And it's also a learning process for continued professional development, where you can share cases and say, This is what I learned from that saw somebody else might say. I've dealt with something similar. This is what I did the last time. That peer review processes is an order to swell adverse events screening. Uh, there's a few examples of this. I thought off. I put two here the Eminem meetings that you may have been part off are cases where the harm has occurred or might have occurred on the Eminem Eating is the name of it is to identify contributing factors, something like a process of root cause analysis or identify, and why things happened and then identified opportunities to improve. Another type is incident reporting systems. So date X you may have heard off is recording an event where mom occurred or might have occurred. And it's another process of analyzing contributing factors on identifying opportunities to improve on. Another example you seen down here is the n H R a, uh, the medicines to help care a regulator authority, which is that documents adverse effects off drugs that I used. So when you are considering these activities, go to M and M's. Go to arthroplasty meetings or trauma meetings are multi disciplinary meetings where there's peer of you going on. Asked to understand the date X process, document all of this and be able to show that you have engaged in these activities relevant to your particular specialty. Focus group is Ah, it's a slightly easier Terek example off Order it. No, um, an example of thought off here is is a patient advocacy group. Try to tie it in with the start about what his quality well when dealing with services and delivering ever increasing, patient centered care. We want to involve the stakeholders. So the patients are the patients out for cuts or cares or charities or public figures to identify what matters to the patients in the service users. That gives us a really great idea as to, um, how to assess the service that we deliver through the lens off the end user. What's the and uses experience? We might develop a fantastic idea, and then we go to a focus group and somebody said, Well, that's not gonna work because off ex wife said. And this creates feedback loops where we can say, Okay, that's great. Thanks very much. You go away and he decided to improve something a different way. You come back and you get feedback on it, and these are feedback loops all of the time, driving that continuous improvement. And then again, I said you'd see this again. The classical order you pop off PDS a cycle a little bit more detail on that following the plan Do Study act. It's an obviously a structured improvement process. It's a continuous process. It's definitely the most widespread off or it's that we see in clinical contacts and also in the context off. Tell me about in order that you've been involved in terms that have introduced, and then you need to be aware off about completing the Lupron about all it's cycles. Now I've said before, that's how many times you've been able to go around this lip on. If you're thinking now, I've got nothing on my application for my my portfolio about Q y and College Improvement. You're gonna need to look at this and think, Right, How can I take this simple methodology and put it into chemical contact somewhere? Which doctors or which service managers do I know, Or can I go and meet and find out and say, Look, I'm really keen on the specialty or this aspect of this particular service on. I'm keen on delivering a quality improvement project. Have read a little bit about it, and I went to a talk about it and some guy told me about PDS and I'd like to do or and then you're going in there with your eyes open you sound like, you know, we talked about and you're going to get an opportunity to be involved in something and finally on different types of order. This is something that I've published recently. It's drying, particularly take Call it and call it improvement, cause it's a subject close to my heart. Don't read all this it. This is a term that we've come up with some myself and under Doc, with Allison Collect Look, Pharaoh Tim White and that Clement was published in the Bone and Joint 3 60 on It's Where we Sea order going on. That's why we don't think or it is gonna be dropping off your CVS or dropping off your applications or interviews anytime soon because it's only going to grow and we've decided, described meta order it as a new type of ordered. That's a novel approach to health care improvement that integrates classical clinical it. You can see at the top here with aspects of medical informatics, linking multiple data sources together using increasingly complex ways to extract data pap natural language processing, creating large and diverse data sets rather than just you with a clipboard in a ward, and then integrates different health day to science techniques. Artificial intelligence. Continue data collection by computers all the time. Giving in life feedback on giving you the opportunity to apply machine learning or deep learning in order to develop prospective learning. So this order start teaching itself. So this is one I spent a metal it that were particularly excited about if you are interested in it, got read this editorial. It's hopefully quite a readable thing on, and it's also got some nice references. Two different types of all. It's a swell within the clinical setting, so some of my slides missing. That's a little bit about why all it's important. And it's a little bit about where all it might appear within the context of clinical practice or within about a clinical research and improvement. And this is how I think you can go about improving your CV improving application for and this is something that's taken from the book. I always think let's look at the opportunities that are available to improve my portfolio. Whatever. I definitely need what is just like the baseline good stuff to have. Then what starts toe push me up a little bit and turns that good stuff into really pretty good stuff makes me look impressive. And then what is, like gold standard stuff? What's brilliant stuff that's going to really elevate me, too. That's a cracking project that's gonna get you. Love marks that interview. So here's some just example evidence. So it will be expected that a good candidate will have demonstrated some involvement in a Q I project of souls on be able to demonstrate involvement in a closed loop ordered. That's an order that has gone through that full up of the PDS a cycle and note that within those two things that, um, the focus is very much on that PDS a cycle because even though quality improvement over the last probably say 10 years, 12 years has really grown to be pervasive in all different guises throughout medicine. Um, really, when you going to interview the things that people focus on? How many close the borders have you done? How many PTSA cycles have you done? I don't want to ignore the other stuff because it's important and the good skills toe have, and I'm absolutely certain that as you get into the time off applying for specialty training, so you might be what that might be. 3456 years down the line, the application forms. The interview questions will be widened. Teo, examine your wider experience in these processes, but everybody needs close liberal it evidence. But how do you take that? Good to be better? Well, first start, you can leave one of these projects, right? Rather than just going and saying kind of go and collect some data on a spreadsheet for a registrar study that's being done, you can go to somebody and say, Well, um, I don't know exactly what I need to do a project on, but I want to do a Q I project, and I'm interested in this that or the other. Are there any aspects of your service that you think would be amenable to a quality improvement project on? Could I tacked potentially take the lead on it, Onda. Within that sort of roll, you can lean on other people. You can get advice from people more experience in it, but you can take the bull by the horns and start to leave this project. Another excellent thing. To be able to demonstrate is sustained participation in a local improvement group. So I'll give you an example of we had some students when I was working a lot Infirmary on the Hip Fracture Improvement group. Locally, we had two or three students who've done lots of projects being involved in that set up. You just demonstrating rather than just going and doing a project and taking a box. You are demonstrating sustained participation within a specialty, specific or specialty relevant context. And you're that will report rewards because you'll get involved in X, Y Z and projects. You'll help how other people your multiply your gains, some sort of quality improvement course learning quality improvement methodology is great because if you come to an interview with out on say, Well, actually, I'm really interested in after I've taken it upon myself to go and learn this one. Of course, you can put this down your gold on this, but can you go online and look at it short free distance learning course looking at quality improvement thirds. These things usually take yeah, 20 minutes toe, three hours to complete and you get a nice certificate at the end and you probably learn something to Can you publish Accu. I work well. There's lots of rubbish. Q. I work I don't want you to go. Do and rescue I work on. We can potentially talk about what makes, uh, good cue. I worked good and what rubbish about rubbish. Q. I work later on in the session afterwards, but Q. I work is important because people can you can discover new things, and also you can discover on report new interventions that might be of use elsewhere. So it's definitely something that can be published, and I've got an example of that later on. So our very best things you could do well, he could make that argument case for these better, best and good to be, you know, mixed up in and in different ways of categorizing them. But if you can lead on a closely board it, that's more than just a local ordered. That's potentially over several different hospital sites, or it's even a national or it or it's got people involved for multi centers. Then you're really starting to elevate it to a a sort of stratospheric level. Can you take that? What I've told you about sustained participation in a local improvement group can you be part of? Demonstrates a stain participation in a regional or a national improvement organization? You know, you might look to the student representative body's now or the training representative body's later like a sit or boater and start getting involved in these set ups that try to continually improve things either in clinical practice or in training or whatever. So they will be. You go to there to try to seek out those opportunities. Um, I put here Quality improvement, Fellowship off Similar. This is because the book that this is from is for medical students, but it's also for Post Graduate our trainees. The training is in surgical training, already on D, reflecting the increased interest in Cuba. I methodology is the fact that you were actually going to doing fellowships, some sort of your long, six months long attachment on. But you can look at those in the future because if this really starts to float your boat, you might want to go and do one of those fellowships rather than a research fellowship or rather than a teaching fellowship. And these are things that can be done at any stage of your training and postgraduate sense. So it might be your inverted commas f y. Three year. Rather than going and doing the classical teaching job or go to Australia for year, maybe you can look at the Scottish Clinical Leadership Fellowship roll or the Scottish Clinical Improvement Leader course or or whatever or various other things that try to teach you to become a clinician who is an expert in Cuba. I we're really good at teaching. Clinicians are training conditions to be expert teachers or expert researchers on that same thing is being reflected in quality improvement. So one of the common pitfalls in clinical order and quality improvement again, it's something that we're having. The book, which is this is where students and trainees could get tripped up where they compile a load of energy into something. And really, the yields just isn't there. If you go about pursuing a project, if if you start a project on you haven't got a clear idea of a predetermined goal, Um, that's always a red flag on. It's something that if you're in one of those situations at the moment, I'd stop. Take stock on, speak to your supervisor or the person who is providing some sort of oversight. I just arrange a meeting to say, What's the point in this? You know, aggressively. But why we're doing this, What is the aims? What do you want to achieve? And having that predetermined goal will be absolutely invaluable and guide in the course to get in there Lots of you, by definition, because you're here tonight on absolutely crap. What was it Thursday today? Miserable night in winter means you're keen. You're likely to be about on the wars and with registrars with consultants who are active in this sort of field. Beware of picking up low quality work that perhaps it's something that somebody is just left hasn't been completed, and somebody says you could go and finish that off. Be cautious here because it might not be all that it's cracked up to be. It might have been left for a reason. It might be too difficult or two, and we'll see, uh, or not yield exactly what you want. On the other hand, if you're in these environments and people give you the opportunity to complete a high quality product project that might be low hanging fruit. So so don't write it off just because it's been started by somebody else. You could go in and say, Okay, well, somebody has done that work. It was great. Rather than reinvent the wheel, all the cycle are going. Complete the loop, and then you maximize your game to maximize your other person's gains on Duodenoscope to deliver something that's quite quick and efficient. This is something that I really quite passionate about here, which I've alluded to already on the third point. And that's a failure to recognize the breath of quality improvement as an entity on that really ties in with the last point, the fourth point off. I think you need to know ahead of time how que I or chemical or it or any of the other port for your application domains are assessed in your intended applications. Now you might all set here thinking, Well, I'm only in 30 years. I don't know what I'm gonna apply to, but that doesn't matter. You can go in luck. It's surgical application forms and job specifications. Luckett medical ones. If you're into that sort of thing and GP ones or whatever and you can say, Well, broadly speaking, How did the assesses, um, assess my evidence in Cuba or teaching or research or whatever and then start working towards those goals rather than just saying I really like this product project. I like this specialty. I'll do a big project on that. It might take you six months and a lot of work, and then you go to your application form in four years time. You think? Bloody hell, that's only worth one point. So be targeted and what you're looking at. So going back to that point again ordered cycle. That was my pitfalls for the way maximizing yield. Anybody who's been to one of my portfolio talks will know about maximizing your big found or saying, Well, I'm gonna be doing probably a shitload of work for this project. How can I make it work for me? How can I maximize my gains from it? So these are some of the ideas that I've come up with so seek projects, and you could replace Q I with research or teaching all medical leadership and management or whatever. But today for Q. I seek your projects that are focused, so you got one particular issue that you want to improve, find one that's useful. Don't just go and measure something for the sake of it, because you can measure it. Think what is a current thing? Relevant clinical question. That's why they're gonna guide or change clinical practice. There's an important note on that as well. Is that um if you could guide clinical practice, uh, you will be sighted. People will talk about you. They'll congratulate you. The tweet about you on Twitter, whatever. And if you can change practice, well, that's you hit the jackpot because some of you might have been at the school of surgery meeting. And one of the things that people ask whenever all it comes up is how is this man is to change practice. That's like the acid test of whether you've done a really big, decent project. Have you been able to change the practice in a local service? And all of that you can bear in mind when you design and what you're going to do with your supervisor, so you got focused project as useful. That's great, But is it deliverable? Think about the times that you've got. How much time can you spend delivering each certain aspect of it or each phase of it. How long have you got until your application forms? And, um you know, how long have you got until finals looming up and you're gonna have to focus on that. So I think one is deliverable with the time and resources that I've got on the final thing in maximizing Yield is trying to build this reputation, um, off being known to deliver good results, quick results, timely fashion minimal for us. That kid get stuff done. That's sort of reputation. Brilliant. It is, you know, stays true throughout your entire career. Until presumably your retirement. There are students. There are trainees who go about the place on we know X y and said, Get shit done and you can deliver good results within a certain time frame. And you can rely. You be relied upon. You start doing that, you're gonna see a snowball effect where people will say I I've got some work. You like to do it with the first one in the line to pick up all of this. Excellent opportunity. So what time is it is 20 past at the moment. Uh, what? I'm going to do here is take a little moment to have a little drink of what's in here on, and I'm going to go through some really portfolio examples off clinical ordered and Q I evidence that these are taken is just to take unformed. Um, work that after the past. So I don't need to ask anybody for any permission on Do a demonstrate way. You can take quality improvement or clinical order work where it can lead you to how it might look because the two projects I'm gonna do, we're gonna look very different. But they've used that high points out interviews in the past. They're with me one second because I'm very parched. You might guess that this isn't actually coffee. Um, so first portfolio sample of that to talk about is a local PDS, a style quality improvement project, and we'll leave plenty of time. So we're not gonna be going on for a hell of a long time with these talks because it could be just be very dry. I want to spend a lot of time either dissect in these projects or learning applying the lessons learned from these two other projects that you're currently doing well. We'll have a chat about what might work and future for you, or we'll just talk in general about about clinical order and quality improvement. But this is an example of a local project on it was something that I did as an F Y two in neurosurgery in Aberdeen. Andre. The question here was about improving quality of postoperative use in your surgery. So lots of audits and quality improvement projects arise from a situation where you're just being bugged by something now. It might not be this huge research question, you know, but the NIH is sending people, you know, tens and 50,000 lbs to do. Clinical trials are often these things are just little needles that would be noticed by you or have been noticed by the junior doctors on a ward or the nurses on award, or is something that you see in the conference on? An example of this was that I spent a year and a half working your surgery on. Um, what I saw was sick patients coming back from theater. Um, come on to the night shift. They'd be sent back up to the wars or two HD you on? Did I cover both the water and HD your up there? Because Aberdeen with wild time and these patients were coming back, and I was being bleeped just constantly about our ex patient is back and is really feeling sick That vomited the guts up. Haven't gotten the anti emetics written up or 11 o'clock at night on the night shift. You just set that down for a couple T and somebody says, Are somebody hasn't got analgesia really sore. They run out of what they've got. Probably the most important is let's go to the ward to review somebody who's on. Well, I've got no idea how they bean for the last 234 hours following their surgery. There's no documentation. So the objective here was to say, Let's assess on, hopefully improve the quality of postoperative of you of patient return into the ward because they're not being assessed currently, it should be easy to improve. But how do we go about doing it in a sustainable? So what I did was look at 50 patients consecutively who came back from theater on booked at the Post Operative reviews on But, uh, this is over a certain periods of June to October, when I was on shift, so defined my methods. My population of interest on bowel went going about delivering it. So how are you gonna measure that performance? I thought, Well, let's let's I need to measure against a certain existing standard on because that's the definition of all it. So what is the standard? What's required of a post operative review so that you have to go and look at the authority? So the wh show has a postoperative checklist. Authority sign guidelines gives advice about what's included post surgery on what needs to be documented. And so does the War College. Many sisters. Well, so I built a matrix based on these of saying, Well, was this done list on this toe missed? Um, and these things are recommended by these bodies, So that was my objective. And that was my established standard against which to measure. You don't need to be worried about the actual numbers here or anything. What, that reduced with these results, which basically the quality of postoperative use was put. We knew that already was terrible. Hardly anybody was getting anything but what we needed was Data data is absolutely key because data proves is a problem and data guides how you might go about improving it. So, for instance, I knew that the postoperative was crap, but I didn't know why. It's crap. Didn't know what wasn't being done. This tells me that the procedure, type and details were undocumented. Theus s mint of the patient coming back from the from theater wasn't documented or done. Postoperative information wasn't provided and things weren't prescribed on. Generally, it's crap cross the board. So that meant I could take this to the, um the surgeons who run the unit and to the to the management and said, Look, this is what I found. Will you back me to go and do something about it? So that's your first aspect of the plan. Uh, do study act cycle. So what's the do aspect of it? Well, I wouldn't presented these results and they were absolutely aghast as you imagine what 70% of people haven't got postoperatively reviews after newer surgery. Mad. No wonder people are getting sick. And then the intervention came, which is reaching a consensus about what is relevant for a neurosurgical postoperative. You we delivered education to people education. You'll find repeatedly his key as part of the colored quality improvement process. Because you need to bring people with you. You need to get people on board, and you need to get people pulling in the same direction. Otherwise, you just some nope, with clipboard trying to measure. How about the art? Their job? You can't do that. You need to bring them with you. And out of that came a newer surgery postop review performer that we made. It was bespoke it, hair on it, all of the tick boxes and the things that we wanted and none of the things that we didn't on because people were involved in making that they felt some sort of ownership over it as well. So we then went back on. We reordered it. This is what the thing look like, by the way, was basically printed on, uh, the sort of paper. How the time Most of you won't see this sort of thing because you got used to track notes on the electric patient record. Basically, the same sort of thing exists on track as a back slash short code now, So if you put back slash hip, for instance, you'll get a proof form that looks something like this for all hit fracture patients in their Clarkin's. So something's changed something. Stay the same to reassess, whether it was any good or not. We, this chart here shows. Before we saw that percentage of hearings to procedure information to assessment to instructions to the Acessa details on all of these different domains that we measured on, it was robust. As you can see down there was like, you know, 10% to about some of them, 50% for others when we put the perform in things or after we gave some education. Sorry, that's the sent the middle one There things improved. People realize they have to go about doing this, so it improved to run about 50 60%. But then when we put the poo performing in a swell, so we talked them about the importance of postop of you. We talked them why they need to to do it. And then we put this form in a swell Well, you can see the performance speaks for itself. It was like ceiling height the whole time. Everybody just did it, it became the norm. So our act was to look on that, to see what was good about it, which was most of it to see what was bad, but not very much. And we tweaked it. And then we implemented these interventions. And that was over 100 patients on 50 before 50 afterwards and actually went on again and did another 50 just to see if this improvement was sustained on it. Waas and this was published. So it's in the British Journal of Neurosurgery on It's the introduction of the neurosurgical postoperative checklist, improved quality of care and patient safety. I've got to improve it. Nothing is being written about this in neurosurgery before on. But it was decent methodology. It was just basic PDS a cycle. But it was for something that was useful. It was something that changed practice on. It made things safer. It was a tight, tight, e neat methodology. I was written up simply but effectively. So it was published, which goes to show that these basic things can sort of elevate you to being able to get your publications. And that's what to question to that. This is the second it's gonna be probably the second of two, so probably the last example, unless there's lots of time when we want to go and discuss another one because there's lows of different types of all, it's not a relevant to this. Um, this is a second type of order. So that first type of all of that I've demonstrated there, and I really hope it starts to to prompt examples in your mind, to make you think of opportunities because you must have been on a ward and thought, Why doing it like that? What? That could be better. Why don't we do it this way? Because you're all intelligent people. Um, just because your students undergraduates doesn't mean that you don't have that key, and I for why don't we make this more efficient? And only that's only gonna get more acute when you go and you start spending your time as F wise doing drops on a daily basis and think I could definitely make this better, So hopefully that starts to give you an opportunity to say, Let's do it this way. This is the second example. It's a multi center court study that uses clinical data and the reason for prisoners in here in italics is it's where clinical ordered me to research. Now this is an area off, um, a lot of interest in the moment because the boundaries between research and clinical it are very blood, and you'll know that they are the occupied different domains on your application form, so you can be quite can e and you can use Q I methodology in research for you to research within cure methodology. But it's time to get complicated. We'll talk about it later, uh, alluded to Before that worked this guy's hip fracture or it on. Basically, we wanted to know. Does the delivery off care for hip fracture patients calling to set of national guidance? So, following the guidelines does it make things better for patients? So do the Scottish downs of care for hip fracture improve patient outcomes. So a little bit of context here, uh, this isn't all slide. Over 6000 hip fracture patients now over 7000 hip fracture patients and Scotland did you huge bird and the Scottish stands of care. There's a dozen of thumb we developed within the last 10 years, and they keep evolving on, then nationally agreed. Every patient on every hospital ward who has a hip fracture should be dealt with in a way that is governed by these standards on D At the bottom. There it is conk, um, international level. So basically the care that is delivered to order these patients is is monitored is assessed on a continuous basis by the Scottish hip fracture or IT. So audit coordinators in every hospital looks at the care delivered in their unit feeds back centrally to the Scottish hip fracture or it and says yes. 90% of people were seen by a geriatrician within 72 hours, 45% got got their surgery within 36 hours, that sort of thing. So the object of that we had was to determine if adherence to these standards is associated with improved outcome. Now that's quite different to the previous study because it starts veering into the realms of research because it's not quite. I want to improve something by doing something. It kind of is one step removed from that. It's uh uh, that's happening. Let's assess the efficacy of that process. If that's not too abstract concept, so what do we go about doing well? We went to the Scottish hip fracture or it, which has data for it was then 21 hospitals and now 16 hospitals delivering hip fracture care on DWI. Got their data, every hip fracture patient between this time and this time in 2014. And then we assessed that was our data collection. Our assessment waas to look at the process of care and to say whether each of these patients had achieved each of the 12 standards. Our outcome measures were length of stay within the ward, 30 day mortality 120 days mortality on whether they were discharged back to their home setting or whether they had to go to somewhere in the interim like a rehab hospital or a nursing home because they had dropped. They're sort of performance status down data collection process, Measure out commission. Looking at the top left here on all of those outcome measures we looked to see was adherence to the standard of care associative better outcome measures Well, we can see going down that for each of these standards, prompt geriatric review prompt busy a review and prompt occupational therapy review was associated with the reduced 30 immortality and similar findings are true for 120 day mortality. Unsurprisingly, um, being able to complete all of the inpatient assessments was associated with a shorter length of stay on. Lots of these factors were so slightly with better or worse outcome in terms of the discharge destination as well. So what we were able to say it was yes, adherence to the's standards was associated with the better outcome on that. We should use the standards as a benchmark for the quality of care that we should deliver. So is this an order or is this research is blurred boundaries, isn't it? What were the implications of these findings on what actual intervention was supported? Well, what we said was that this is the best possible type of study that we could deliver because it's not ethical to deliver around the most control trial. You can't bring somebody in the hospital with a hip fracture and say, while you're randomized into good care, you're randomized into crap care, and we'll see who does better. So this clinical audit study is is the best way that we can really assess the association with outcomes and this was huge. This is published in the journal The Journal of Bone and Joint Surgery. So it's J B. J s in America, which at the time was the biggest orthopedic journal in the world's Now be JJ's is got a higher impact factor again. This is this is chemical it or this is research based on clinical it on. You can get these huge publications out of it. And it's very different methodology to what I've described earlier Is that simple? PDS A cycle. So I'm wrapping up now again. My declaration of interest is that lots of these lives have been taken from the content that I put into this book. So, uh, if you want it, go and get it. If you think that I plagiarized somewhere have plagiarize myself, eh? So don't worry about that. And thank you very much for be happy to, uh, to answer any questions, have any discussions about clinical order it or because we're in the final session off the Siris? More than happy to talk about any other aspect of the portfolio as well. Thanks very much. I'll, uh, start sharing my screen. I bring you back to the floor. Thank you so much. That is very, very school was always, um we are running slightly over time, and I'm aware of that. Things were bearing with us. I work very quickly wist through this sort of students perspective of things before handing the back to the sort of questions. Because I know that's what people really want to hear about, um So ah, I see you can even see about Yeah, can take this. Um, so just a quick note on sort of the student perspective on a mild It's good the way that we tried to structure things for this so presentation the series of presentations is to have a bit of a quick student perspective at the end of everything. And there are things that we wish we knew. And so it's this is a old imposed, the improvement. But it's also how to not be a this monkey, which I don't know the sitter everyone uses. But I thought that was something people said by doing those. It's But I sent these lights too, isn't she? Look over. And she didn't understand what addiction One closer. So I took what other people are on this cold. Get this bother? I have no way of knowing cause I'm just looking at about blank screen. Um, and I think the first thing to say is that there is a not a skills involved in being in order to and it's under, his said. You know, it's it's not just doing it for your point. Syria. It's learning how to ask the question. How to design data collection words, how to get order of people. If you're doing the biggest study getting called a cortical, you're uploading in to write cup or something, I thought. How to use TriCor churches difficult. The tunnel is the state of presentation and presenting skills in general. Um, on these are schools. They're useless to you. But also, if you're feeling a bit cynical, skills are interview talking points on If you're looking at something like a F P on, these are things that you would be asked to talk about ingenious, and these are things that you would be in the white space question. For example, it's something that you would be able to expand upon, so it's not just something that is useful for point, such as very useful three points, and that's why we're all here. Support to leave series. But and it's also very useful in terms of skills opportunities. In medical school, there are multiple, but just a brief of review. There is cooperative research, so things like star surgery non Sanger. I need multiple other collaborative running. I mean, I have a slight declaration. Interesting that I'm involved in Star Search. That's the example that I used, but you're you could be a day to conductor You could be a regional, leads you in both more in the running of the studies of cleaning approvals. And that's also something that's really valuable. You have your SS sees, and if you're in a gym, presses. See if I was quite a big one for jingle. That's what sometimes you can do the earlier and you also have longer placements where you're in the same department for quite a long time, and you can actually use that opportunity to see if there's anyone the scheme to have a student do an audit on. That's a room quite a good time to do things because you get to know people quite well. So just very quick. Note on collaborative research because I again I think it gets quite about drops sometimes on. But I feel like I just say something in terms of defending every talking about audits cause a lot of old. It's a relying a multi central that's a reliant on collaborative, and it's how you get really high impact start and stop like impact values. Discussing in the second example on it gives you a really good understanding of sound methodology. How old it should be one and how you design things will be well on. That's That's something that you can use to design your own things neutral. If you sort of get that grasp from people who have been doing it for a while, and it's also a gentle introduction to order, it's It's not very time intensive because, you know, if you're due to collect, you take on a couple of weeks, and that seemed. But you've got that introduction you. It's getting you into that departments getting you doing things in it. It'll currents on, even if it doesn't count for your rotation of a pea Applications. Of course, Surgical consultation on, and this is lifted from the ST to me our vacation. Sure, the pedic so on. But because they are basically to be one of the few people that try to collaboratively search currently. So it's something that comes later on. Hopefully, there's a big Christian recovery. People recognize it, so don't think it's not something that's not worth doing, because it very much on this is sort of one of my my last slides. And I have next Andrews favorite freeze, which is maximizing healed on. I think the most important things that you could do that and the vice. I got some terms of June projects and jingle that's in general if have very upfront discussions. I think a lot of people I know who need we have done all that's and things in go well, it's because they didn't have upfront discussions about what there would be and what they would get out of it. So have upfront discussions, and I think about post any project that you do and maybe approach someone who's like you were. Seniors are seeing your bedroom consultants or someone you wouldn't want to be doing the loss of that sort of who wouldn't be looking to do this for their own applications is well, perhaps, and plan enough time to heal that. Make sure that you're in the same place for for long enough to do that. Because if you're doing that and you know about to move across the country to start a fly, then you're not a great time to do that, Okay? And this is quite subjective thing. But in for a conference, maybe haven't think about something where it would be really good to apply on Bend this, and that would give you in two months and if to finish it. But it would also move that you have a place in London you're presenting, getting getting more out of it on. But I think the last thing was, don't forget the actual point. You know, it's it's about it improving quality, and it's very easy to get bogged down into sort of getting the points after that. But ask a good question and make it worthwhile. And if you're putting in the operating, might as well be Gene get something but actually useful and sometimes, you know, being addictive. Thinking. Doing small projects actually doesn't work out and, you know, be realistic. You won't be designing groundbreaking studies. When you're in medical school, sometimes it will take, you know, being in that person who collects a bit of data to start with, and there's nothing wrong with. But as long as you know that that's what you're doing in your pee with that and you're going to get skills. Um, so just have, uh, from discussions and know what you're getting into. So I'll stop there on the open the fluid questions. I sure hope money on going to persist. The link to the feedback for him. A swell eso. If you guys can fill that in, you will get a certificate for model immediate in ball. So we're looking at people who have come to, um, sort of old seven of them, and they're going to get uncertified from our CIA, said Andrea For the membership. Is there any questions? Any questions? Very good of us. Also, I have suicide running over and clearly always hours about clinical order it because it's, you know, you feel off of research. You know it's very is bringing the world together. We've just published about two publish AM, a kind of gold of 112 hospitals of 7000 patients. You know, it's something that you've heard me 10 times, so it's a little can be anything you want it to be. Is that a question? There There is a costume where they would have in quite a big idea for two. I projected some pretty new research. Done. How'd you get team together and a good place to make contact support to get the ball rolling on hard. You gain trust that you're capable of a project. Okay. Um, interested one. So, uh, quite a big idea for Q. I push in for them to research. Done. Ah, presume that means that there were certain time. Maybe it's electro literature of you or you want to see what exists already. Essentially, I would go to somebody. If you know somebody in that department you trust don't go to them. Failing that, I would look at going to the service, leave the clinical lead, that particular service, given example, I had somebody come to me saying I've got a really good idea for Major for an order it or major trauma. Eso I said Yep. That sounds great. I can't particularly help you. My self different setting. But Tim White is a clinical, you know, trauma or the incurs lake is the major trauma lead. Eso go to them with the understanding that there are very busy and they're not necessarily doing this sort of data work or supervision themselves, but that they will know who is good to go to. They might have acute. I lied. Who's a consultant or registrar? Go to them and say that I have this proposition. What I would do is and I've done it before, is is go prepared, go prepared with with a document already kind of invest the time ti while them It's kind of a blitzkrieg approach. So if I A is the clinical lead off general surgery or something else I would go to and I say I've got this great idea. I would like to do this project on this on. Then she says, Great. Well, have you thought about how to do it? That's not as good as if I go to I and I say got this idea. Look at this word document, please. Can I take three minutes of your time? What I'd like to do This is the title of working title. This is my objective. This is how I'm going to go about collecting data. This is what I want to collect on. This is what I do with that data. And then this is where I see this going on.