Step 2 - Finding a Project
Sources for Project Ideas
So what would you like to improve? What frustrates you that you would like to fix?
There are near-infinite possibilities and what you end up working on will undoubtedly by influenced by your interests, personal values and past experiences. Ultimately, a successful project will be one which you are motivated to undertake; there is no equal substitute for true passion. Even still, with an entire healthcare system in front of you it can be tricky to focus in on a viable project idea. So here are some common sources for project ideas:
A Personal Interest – At the beginning of an improvement project much of the progress will be determined by how well you are able to rally people behind what you are trying to accomplish. If you are truly enthusiastic about your work, this will shine through and others will follow. Trainees therefore often do projects in a speciality they have a personal interest in e.g. a budding surgeon might do a project on improving an aspect of theatre safety, or post-operative recovery. In addition both positive and negative past experiences can influence how motivated someone is about improving a particular area. A doctor on an oncology placement might have built a great relationship with a patient and learned what made the biggest difference to them in their last days of life, inspiring them to improve end of life care for others. Conversely a doctor who had made a previous error resulting in serious harm may be motivated to do a project to prevent a similar situation happening again in the future.
A Recurring Problem – There are lots of ‘minor’ annoyances that we encounter every day in clinical life and these are ripe for improvement. ‘It annoys me’ is enough to do something about it! Often the annoyance is because it involves wasted time (having a knock-on effect on almost everything else from timeliness of drug administration to time spent exploring a patient’s ideas, concerns and expectations). These problems will require you to persuade others they actually exist and that something can be done about them. We come from an academic training background, where improvements in morbidity and mortality are seen as most desirable. Not for QI. If it impedes your daily work in any way, it is a candidate for a project no matter how ‘small’ a problem it may seem (in fact small is actually better, but we will discuss this below and in future sections). For example it may be that it takes a long time to find equipment in the clean room – a project to reduce how long it takes on average would be perfect.
New Guidelines – New guidelines about something are published almost weekly, such as from NICE or the Royal Colleges. National guidelines make great sources for project ideas. Select one recommendation from one piece of guidance and try to increase the percentage of valid patients receiving that aspect of care. New guidance is often not known about and QI work based around them are a great way to spread awareness and implementation. Like the first point, guidance from a clinical speciality you are interested in will make a better project as you will be more personally invested in it. For example, in March 2018 NICE Guideline 88 (NG88) – Heavy menstrual bleeding (HMB): assessment and management, was published. Recommendation 1.2.7 states: “Testing for coagulation disorders (for example, von Willebrand’s disease) should be considered for women who: have had HMB since their periods started OR have a personal or family history suggesting a coagulation disorder”. A QI project could easily seek to increase the percentage of patients presenting to a GP practice with HMB who meet the criteria, who are investigated
Scope and Scale
How ‘big’ to make your project is something worth addressing early on in the QI process. Let us answer this question straightforwardly – make it small (at least to begin with). This is true with both scope and scale:
Scope – How many individual aspects of care you are looking to improve (this should only really be 1)
Scale – How many patients or different clinical areas you are looking to make the improvement in
We all want to make as big a difference to patient care as possible and it’s OK to aim high, however it is a key part of the QI approach to start small, as this allows us to learn what works or not work BEFORE scaling up. There are many benefits to this approach:
– If an idea ends up not working, little resource is lost
– Colleagues will more likely initially co-operate with small changes to practice than large ones
– Many improvement ideas can be tried in rapid succession
We see the opposite all the time in the NHS – huge amount of resource is invested into a new system or process, only for it to flop when actually implemented. This can be avoided by starting small, and making adaptations as you build up. Picture planting a seed and working on the conditions to encourage it to grow over time rather than trying to plant an adult tree straight away in foreign soil. The other problem with the scale being too wide is that the work increases massively, and most importantly you have many more people you have to work with to rally behind your idea.
In practice this will mean starting with one ward, one day, one outpatient clinic, one theatre list, even one patient. Once more, learn what works on a small scale before building up. This is a central theme to the guide and we will return to it again many times but most notably when discussing SMART aims (step 5c), data (steps 6a, 6b) and PDSA cycles (step 7b).