Quality Improvement Projects

I’m sure the QIP Paper is an utterly foreign idea to most of us who underwent training only in Malaysia. The 54-page description and example provided by MyCEP under FRCEM Resources. probably just makes it appear even more daunting. As far as I know, the Masters programme and other specialties do a thesis or dissertation, so it sounds like your bosses, colleagues and seniors are not going to be very helpful to advise on the subject.

But I assure you, the name is just fancy administrative jargon, and it is much easier to do than a dissertation. “How can I improve clinical practice in my department?” is the whole idea, which I’m sure you’ve pondered several times in your career in increasingly cynical tones.

Many are familiar with audits as that annoying data collection work that produces results which gets us screwed by the specialists, hospital directors, state department of health and/or Ministry of Health, then everything goes quiet for a while until another audit happens and we get screwed again. That screwing is essentially the QIP, and reporting that screwing in detail, including our performance after being screwed, is what we need to do for the QIP exam.

The steps to do a QIP are:

1. Identify area of weakness in department
   • Hand hygiene
2. Audit area of weakness
   • % of staff who adhere to 5 moments of handwashing over 1 week period
3. Implement change to improve
   • supply more handrub on every bed or cubicle
4. Re-audit
   • % of staff who adhere to 5 moments of handwashing over 1 week period
5. Analyse data and write QIP report/progress report
   • Are more people practicing good hand hygiene now?

If you are happy or procrastinated too much, you can stop here and submit it for the exam. If you are dedicated (read OCD), then you can keep re-cycling change, reaudit, change, reaudit, change, reaudit until you are happy, as below:

1. Can we make it even better?
   • During ward round/nursing handover, Registrar/Sister will remind everyone to adhere to hand hygiene
2. Re-audit and re-analyse (write report/progress report)
3. Can we make it EVEN better?
   • Posters in each zone reminding staff to handrub and encouraging patients to ask if handrub used
4. Re-audit and re-analyse, etc.

Then your QIP report can have a fancy title like “Hand hygiene QIP using a 3-phase implementation model” and probably score more points for the exam. How simple is that?

Many departments already assign a portfolio to each MO, who are responsible for their assigned area. At my previous hospital, I was involved in 2 areas – infection control (hence the Hand Hygiene example), and trauma database. Every one of my colleagues had their respective portfolios too, and most could be easily audited and made into a QIP. In fact, most people probably have made some kind of report and never realised that was a QIP. Otherwise, I’m sure your department has booklets on certain conditions (eg STEMI, sepsis, cardiac arrest, etc.) that the HoD will always nag MOs, who will then nag HOs to fill in. Those basically save you the effort of data collection yourself, so you can focus on introducing change.

Looking back, my very first involvement with a QIP was as a HO when my Medical specialist did a STEMI audit and I was one of the data collection monkeys. The audit showed that the hospital had poor door-to-ECG time, and when I rotated into ED, I showed the results to the HoD who then modified the department entrance to include an ECG room for all chest pains. If I had known about QIPs then, I would have re-audited the data myself, slapped it together with the Medical audit, and authored a QIP report titled “Emergency Department Renovation as A Cross-Specialty Collaborative QIP” crediting both departments’ bosses, thus polishing many many boots while boosting my CV for specialty applications.

Now before you start looking for some report you wrote donkey years ago to stamp a QIP on it, please keep in mind that the QIP exam requires the project to have been conducted under your capacity as an ST3/4 and above (ie Registrar level). Which means you should do it after you’ve passed MRCEM OSCE or FRCEM Int SJP and completed your rotations.

If your department does not have a culture of assigning portfolios or some form of clinical data collection, and you need some suggestions, you can look at the RCEM Audits page for ideas, which are mostly really simple yet important things like:

• Vital sign monitoring in the ED (a huge area for improvement at the cost of your friendship with nurses)
• Pain management in ED (we are terrible at door-to-analgesia time, reassessment of pain after analgesia, and following analgesic ladder. Seriously, stop spamming IV fentanyl; use IV morphine instead!)
• Fascia illiaca block for fractured NOF (easy to do with or without ultrasound and remarkable analgesia, just need bupivacaine in department)
• Procedural sedation and analgesia (adequate monitoring, depth of sedation achieved, airway safety, etc.)

If you have any friends working in the UK, audits are mandatory at HO level and QIPs at MO level, so they will likely have lots of suggestions, experience and advice to give.

Lastly, I have not attempted the QIP Paper, nor even really looked into their grading method, so please don’t expect much details from me about it yet. I am otherwise happy to discuss more about QIPs themselves. Projects I have attempted myself are:

• “Introducing an ED curriculum guide for HOs” (never took off because I left the hospital before it could be implemented although I did prepare the curriculum. Let’s face it, the HO logbook is the thickest among all specialties yet has too little detail, and their brutal shifts may not give them enough time to cram even Sarawak Handbook.)
• “Reducing unnecessary blood testing” (my own audit found a few unnecessary blood tests being done regularly ie coag for nonbleeding patients, uric acid, etc.)