The BMJ Guide: Quality Improvement Project (QIP)

The Quality Improvement Project (QIP) is a constituent of Workplace Based Assessment (WPBA), one of the three parts of the MRCGP examination. It comprises identifying a deficit in quality of care and aiming to improve, by making small cumulative changes and measuring their effects. 

It differs from clinical audits in that audits test practice against more formal standards and there is a longer interval between the two data collection points. The QIP is completed during a primary care placement in ST1 or ST2. 

When conducting quality improvement in healthcare, a useful framework is the Model for Improvement. This considers what the QIP is trying to achieve, how it will be known if a change resulted in an improvement, and what changes are necessary to satisfy the objective.

How to start a QIP 

To choose a topic for the QIP, trainees may consider an area of practice that impacts patient safety that they feel strongly about. Alternatively, inspiration can be taken from a patient complaint or significant event. Trainees should be able to give reasons for their choice of QIP.

Next, a project goal – that is specific, measurable, achievable, relevant and time defined (SMART) – must be constructed. This means that the data, qualitative or quantitative, must be easy to measure and collect and the project should be sufficiently straightforward as to be completed during the primary care placement.

The aim should be to make a difference to patient experience in the local primary care setting. Some examples of QIPs that have previously been conducted are provided in Box 1.3

Box 1 – QIP ideas

• Introducing a form to ensure that, for example, heart rate, blood pressure, respiratory rate, oxygen saturation and temperature are noted in the assessment of chest infections in primary care

• Reviewing pre-diabetic patients for development of diabetes mellitus and designing an IT procedure for routine follow-up  

• Introducing a short summary in care plans to improve their usefulness for nursing home staff, to minimise unnecessary hospital admissions

• Developing a biannual blood pressure recall system for patients prescribed Mirabegron 

• Identifying knowledge gaps using a questionnaire and organising teaching to improve referrals for bronchiolitis in children 

A literature search should be conducted to generate an overview of the guidance and evidence relating to the topic, for inclusion in the writeup. 

Planning and doing the QIP

Trainees must consider who else – for example, other doctors, administrative staff, nurses, and patients – must be involved in the QIP. This should include everyone who will execute, and be affected by, the changes. A plan for communicating with the rest of the team, including raising awareness of the need for change and managing resistance, should be developed.

Subsequently, it is necessary to consider how trainees will know whether a change resulted in an improvement. This means that baseline data must be collected. This may be done retrospectively.

The next stage is to generate ideas for changes that will result in improvement, using quality improvement tools. It is beneficial to involve other team members in these activities. 

Process maps are diagrams that set out each step of what is presently happening to detect problems in the system. Solutions to the problem can be identified using driver diagrams.

These comprise an aim, primary drivers of change and secondary drivers of change. Primary drivers of change are all the areas of the system that must be addressed to achieve the aim; these are subdivided into secondary drivers of change.

Driver diagrams are used to generate as many potential solutions as possible. One or two of these, termed change projects, are chosen to be implemented as part of the QIP.

Another quality improvement tool is the plan, do, study, act (PDSA) cycle. This allows the introduction of small changes with quick results – for example, weekly – which is beneficial for engendering enthusiasm. In the planning stage, a record is made of who will make the change, and how and when it will be made.

The change is then implemented, and data is collected. Next, the data, including any unintended effects, is studied and the results are summarised. Finally, the results of the first change are used to inform a plan for further improvement and the cycle is repeated, gradually moving towards the aim. There should be a minimum of two PDSA cycles in the QIP.

At the end of the QIP, trainees should present their findings to the team at a practice meeting. This may include an evaluation of why a change has not resulted in improvement. They should also attempt to make effective changes permanent. Additionally, trainees are required to reflect on their learning and identify points for improvement. 

Trainees should have detailed discussions with their GP supervisors before and during the QIP.

Assessment

Trainees must complete a QIP form and upload it to their portfolio. The form is available on the RCGP website. A checklist of what is included in the writeup is provided in Box 2.4

Box 2 – QIP writeup checklist

• Title and reasons for choice

• Aim

• Method of baseline data collection

• Method of data collection after change implemented

• Method of planning and implementing changes

• Stakeholder engagement

• Evaluation of results and plan for maintaining changes

• Reflection on learning

Although the QIP is compulsory, it is not assessed as a pass or fail. Instead, QIPs are marked by GP supervisors against the level expected of GP trainees holding the post. The feedback is classified as below expectation, meeting expectation or above expectation. 

Absent team or stakeholder engagement, nominal data collection or no attempt at implementing the change may result in a QIP that is below expectation.Trainees may be advised to redo all, or a part, of the project if they repeatedly fail to meet expectations.  

References

1. How to do a Quality Improvement Project [Internet]. Royal College of General Practitioners. [cited 17 May 2021]. Available from: https://www.rcgp.org.uk/-/media/Files/GP-training-and-exams/WPBA/QIP/RCGP_How_to_do_a_QI_project.ashx?la=en 

2. Quality Improvement Project (QIP) [Internet]. Royal College of General Practitioners. 2021 [cited 17 May 2021]. Available from: https://www.rcgp.org.uk/training-exams/training/new-wpba/qip.aspx 

3. QIP ideas [Internet]. Royal College of General Practitioners. [cited 17 May 2021]. Available from: https://www.rcgp.org.uk/training-exams/training/new-wpba/qip.aspx

4. Quality Improvement Project (QIP): blank template [Internet]. Royal College of General Practitioners. [cited 17 May 2021]. Available from: https://www.rcgp.org.uk/training-exams/training/new-wpba/qip.aspx