This page provides guidance on building your case for improvement: identifying the problem you aim to improve (not solution), backing up with local data and gaining health service support to establish your quality improvement team.
It is important to determine a realistic timeline prior to starting the improvement project. As a guide, it can take 6 to 18 months to initiate, test, implement and sustain an improvement.
Note: This timeline may be shorter if previous improvement efforts have been made and may be longer if the change is complex and/or involves different services and departments.
What is the end of life problem you want to solve?
Start by identifying the problem you aim to improve. You can do so by gathering local data and conducting a literature review. It is important to focus on the problem not the solution at this phase.
Each year nearly 50% of people who die in NSW die in NSW acute care facilities. A common concern highlighted in many incident reports is the failure of treating teams to identify patients at risk of dying, and then develop and document appropriate treatment plans and communicate appropriately with patients and carers.
To undertake an improvement project, there must be an issue or problem that you aim to improve, for example:
- Patients end of life goals of care are not routinely discussed especially for patients with chronic conditions and have had at least 2 acute admissions in the last 6 months
- There is no standardised approach to identifying patients at risk of dying during an admission or within the next 3-6 months
- There are increasing number of patients dying in our unit/ward that have no end of life plans in place
- Family complaints around their loved one’s care and management at the end of life have increased.
At this stage of the project, it is about identifying the problem you aim to improve NOT brainstorming solutions.
When determining the focus of an improvement project, some common errors include:
- Selecting a problem no one is interested in
- Implementing a solution rather than investigating a problem
- Focusing on a process that is currently in transition or unstable, for example, manual to electronic process
- Selecting a problem that is beyond your capability to change or outside your sphere of influence.
All improvement requires change. However, change is not always welcomed or accepted by individuals or teams, even when it is improvement focused. Improvement projects can often struggle to gain momentum if there is considerable resistance from those who will be impacted most by changes.
Assessment of the current unit/ward context is essential to clearly establish the readiness for change. The assessment should investigate the existing culture, communication and team practices, and safety and quality concerns. If there is an overall lack of enthusiasm and a resistance to change, it is vital this is addressed before proceeding further with the improvement project. For more information see the CEC Safety Culture webpage.
Data will assist in identifying the problem and build the evidence base about why this is an important problem to focus on. Seek guidance from your Clinical Governance Unit or the CEC to identify appropriate sampling numbers and data sources.
Existing data: Examine your health service's:
- Rapid Response data
- Death review database
- Incident data including RCA's
Baseline: Completing a baseline audit is an effective way to identify the problem.
Staff and patient stories: gaining information about the experience of the change can provide different insights into program processes, show impact, identify unintended consequences, demonstrate innovation and support the quantitative data.
Literature search: Further information can be gathered by searching the literature.
Resources available to support data collection
The improvement project brief is essentially a document that outlines your improvement project. It should include what the problem is, why is it important (to patients, their families, staff and the broader community), how long it will take to do and the approach you will use to achieve an improvement.
A strong improvement project brief should be founded on the supporting data you have collected, should take into consideration how the improvement will be sustained and align with your health service's priorities. You can use the improvement project brief to help with gaining support for your improvement project.
It is strongly recommended that you engage with your Clinical Governance Unit to seek support for and during your improvement project. Your Clinical Governance Unit will be able to link you with local quality improvement experts.
You may also choose to reach out to colleagues in other health services to find out how they approached their improvement work, including their successes and learnings.
How do you gain leadership support for your improvement project?
It is essential to gain leadership support from within your health service as all improvement projects require an investment of time, resources and commitment at every stage of the project.
Use your Improvement Project Brief to gain a project sponsor. The project sponsor is someone who can provide support and guidance to you during the improvement project. They can help with ensuring appropriate resources are provided and help remove barriers when needed. Ideally, your project sponsor is someone who does not work directly on the improvement project but is in a senior position.
The level of seniority of the project sponsor will depend on the scope of your improvement project (for example, Nurse Unit Manager versus an Executive Director). Ideally you should communicate closely with the project sponsor and provide regular updates.
Your project sponsor will be able to provide guidance on where the governance for your improvement project will sit within your health service. This will ensure there is operational responsibility for the improvement project and a channel to report back on how the improvement project is progressing. For example:
- At unit/ward level: Integrate project reporting with existing M&M/clinical review meetings
- At Facility: Integrate review of outcomes with existing Health Care Quality & Safety Committee reporting.
- At Local Health District: Oversight of outcomes through committees such as the End of Life committee or peak Healthcare Quality & Safety Committee.
Who should be in your improvement project team?
The improvement project team should be interdisciplinary and include the right people, with the right experiences, expertise, and interest in contributing, for example:
- Team leader
- Quality improvement advisor/expert
- People from all areas of the process the improvement project will target, including junior and senior staff
- Consumer representative (or interview / survey consumers).
The team leader role is essential, and they will organise and lead the team meetings, ensure delegation of responsibilities and be the 'voice' for the improvement project.
As the team leader, it is essential to assemble a dedicated team who are also committed to actively supporting the improvement project. Improvement projects often fall down when team members are unable to sustain interest or participation in the improvement project, leaving the team leader to carry the improvement project.
The role of the project team includes:
- Evaluating current care of the dying patient processes
- Identifying and enlisting clinical champions
- Establishing general goals
- Developing, implementing and evaluating improvement strategies
- Disseminating results and findings.
Once the project team has been established, it is important to make sure everyone is on the same page regarding the problem the improvement project is targeting and what is IN and OUT of SCOPE. Without a well-defined scope, improvement projects tend to grow beyond what is achievable, lose focus of the problem, and fail.