Updated: Feb 28
You are in the middle of a busy night shift and you see a 73-year-old female with diffuse abdominal pain who is hemodynamically stable. You have a wide differential and order a CT scan to aid in the diagnosis as you begin empiric management. Three hours pass by and the CT has not been performed. This is the third time this week that this has happened. In light of this, you feel strongly that this could be improved as prolonged waits for urgent imaging may be detrimental to your patients. You want to undertake a quality improvement (QI) project to improve this situation.
There are several considerations in preparation for a QI project in the ED. In our last post we discussed general frameworks for thinking about QI in the ED, including key QI terminology, the Donabedian model of quality measures, data collection, and examples of consensus-based quality measures.(1) As you start to think of your potential QI project, you wonder if you have identified an appropriate QI initiative. While there are a plethora of QI issues to tackle, the following questions may help guide which practical areas to target:(2)
Is the initiative important with implications for patient care?
Does the initiative occur frequently enough to measure and intervene?
Does the initiative have evidence supporting an optimal benchmark or accepted practice?
Is the initiative within the scope of the QI team?
Quality Improvement Team
Before you start working, you need to put a team together. Healthcare is a complex endeavour with many moving parts reliant on different systems, people, and technologies. It is essential that you put a complementary and relevant team together to tackle QI problems. There are several elements you may consider in a team. The following is a list of questions you may ask yourself as you put a team together.(2,3) One person may encompass more that one role and not all may be filled in a single team. However, these questions are meant to guide the diversity of opinions.
Have we included a representative from each discipline that touches the work?
Have we included a representative who will provide systems expertise or management support?
Have we considered including non-registered staff who also support the work?
Have we identified a team leader?
Are there local champions on the team?
Should we include a constructive skeptic on our team? (i.e. someone who will question the status quo and enable a deeper dive into our change ideas).
Do we have someone with QI skills to facilitate our progress?
Should we consider a patient or patient representative?
Should we consider an external stakeholder?
A strong team will have balanced perspectives of people involved in the process, have a designated leader, and a representative with decision-making authority. Local champions, as well as front-line workers, should also be included among the groups that will be affected by thechange to diversify perspectives and increase buy-in of groups. Patients are also increasingly being involved in QI initiatives through patient advisory councils across the healthcare continuum.(4) A good place to start is your hospital’s patient relations office or equivalent. As an example, for this project, you could consider having a physician from the ED and radiology, a CT technician, porter, nurse, clerk, resident, administrator and patient.
Building an AIM statement
You reflect on your project with delays to obtaining urgent CT scans in the ED, and ponder the following questions: What are the specific aims of your initiative? How will you present it to stakeholders in a meaningful way? You wonder: is it the time spent at the CT per patient? Is it the number of CTs per shift? What will you measure? And how long do you have to complete this task?
A simple way to organize and focus the approach is creating a SMART aim statement:(5)
Specific – focused and well-delineated aims, such as ordering to test completion improvement from 120 minutes to 90 minutes.
Measurable – has aspects that are amenable to measurement before and after improvement interventions such as timestamps, number of patients, etc.
Actionable – within your core team’s scope of influence.
Realistic – achievable, which may exclude ideas like purchasing three more ED CTs or hiring more techs!
Time-defined – with a specific timeline in mind for the completion of the project.
A poor example for your project aim statement may be:
Improving the CT scan process
A good example for your project aim statement may be:
Decreasing the time from CT order to CT completion for CTAS 1-3 patients in the ED by 25% in 6 months (i.e. date XYZ).
Building a strong team and a well-defined aim statement is essential to starting any project. Other things to consider are outlining the responsibilities of team members, potential time investments, and the aim statement in a transparent and accountable manner as part of a project charter. Project charters may facilitate a shared understanding and streamlined communication during the project. Project charters come in many different forms and may include other information such as measures, key stakeholders, and future actions.(6) Here are two examples of current project charter templates:
As you begin to coordinate with the team to move forward on your QI project, you may want to consider the following in order to maximize the effectiveness of your team:
To facilitate the ED QI team working together, consider using online scheduling such as Doodle© to set up meetings, shared documents on Google Drive© with important documents uploaded to it, and enable teleconference or videoconference for those unable to attend the meetings.
Consider having a designated note taker and timekeeper for meetings.
Consider having a standard approach to your meetings such as the Nominal Group technique to maximize meeting efficiency and ensure all points of view are considered.(7)
Now that you have formed a team, and have a project charter ready with a SMART aim statement. You are ready to start thinking about the different stakeholders involved in the project. You also think about how hard it has been to get people to change their behaviour with previous projects you have seen in your ED. Stay tuned for our next post which will be discussing these important areas of consideration!
Senior Editor: Ahmed Taher
Taher A, Trivedi S. HiQuiPs: Quality of Care and the ED – HiQuiPs [Internet]. 2018 Aug 1 [cited 2018 aug 14]. Available from: https://www.hiquips.com/post/hiquips-quality-of-care-and-the-ed
Chartier LB, Cheng AHY, Stang AS, Vaillancourt S. Quality improvement primer part 1: Preparing for a quality improvement project in the emergency department. C. 2017;20(01):104-111.
Quality Improvement Guide [Internet]. Health Quality Ontario; 2012. [cited 2018 Aug 15]. Available from: http://www.hqontario.ca/portals/0/Documents/qi/qi-quality-improve-guide-2012-en.pdf
Armstrong N, Herbert G, Aveling E-L, Dixon-Woods M, Martin G. Optimizing patient involvement in quality improvement. H. 2013;16(3):e36-e47. doi:10.1111/hex.12039
Doran G. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manage Rev. 1981;70(11):35-36.
Project Charter [Internet]. Institute for healthcare Improvement; 2016. [cited 2018 Aug 15]. Available from: http://www.ihi.org/education/IHIOpenSchool/resources/Assets/QIProjectCharter_Worksheet.pdf
Delp P, Thesen A, Motiwalla J, Seshardi N. Nominal group technique. Syst Tools Proj Plan. 1977;1:14-18.