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Start of my Quality Improvement Journey 

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Start of my Quality Improvement Journey 

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1st cycle
In my first block of FY1 I became quickly aware of an area I was keen to improve: escalation planning.

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October 2019 Escalation Planning Out of Hours  

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October 2019 Escalation Planning Out of Hours  

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Working on a Respiratory ward as an FY1 - COPD deteriorations overnight, with unclear escalation plans. Failure in patient care, and recognising that we can do better.

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"Continual Improvement is Better Than Perfection "

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November 2019 Recognising Room for Improvement 

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November 2019 Recognising Room for Improvement 

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Plan - The Tayside Respiratory Lunchtime Meeting provided a platform to present a topic I had become passionate about, as well as allowing me to research other health boards escalation planning policies and undertake a literature review.

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Do - I developed and piloted this TEP form.
Drawing on similar forms from around Scotland and working with members of the Palliative Care Team. It was printed in colour and given to senior decision makers to complete for patients they felt would benefit or require an escalation plan to be in place.

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Study - The uptake was positive, and barriers were discussed. The main talking point was time. Senior decision makers on the ward round felt they had little time to undertake a conversation. MDT discussions with medical and nursing staff queried whether other members of the team could undertake these conversations, not just senior decision makers.

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Act - My next step was to undertake educational sessions with the ward staff to boast understanding and uptake. However, the covid pandemic started and the respiratory team were under too much pressure and stress.

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"Being prepared to get things wrong, learn and get it right"

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Having worked through the covid pandemic it became even more apparent how crucial escalation planning was. I was keen to seek out any projects related to escalation planning and try again.

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Plan - I contacted numerous clinicians to get involved in escalation planning, and joined a national team involved in launching the ReSPECT form in NHS Tayside. My role was providing frontline, clinical feedback. Alongside the team we discussed exactly what retrospective data was required

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Do - I liaised with consultants, improvement advisors and information governance to gain approval to audit medical notes. I was part of a team leading a group of 5th year medical students through data collection. Pre covid medical notes from ward 3 were reviewed and points relating to escalation planning were recorded.

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Study - the 5th year students presented the data as part of their SSC. With clear conclusions that escalation discussions and plans rarely took place. They also undertook conversations with the ward and documented a positive response to escalation planning and ReSPECT forms.

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March 2021 SSC Project - Test of change 

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March 2021 SSC Project - Test of change 

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Act - I then liaised with the ward staff and qulality improvement staff to implement a test of change.
The medical staff on ward 3 trialled the ReSPECT form with the inpatients at the time. And provided feed back.
We recorded that overall it was a successful tool, however it was not appropriate for all patients and a trigger tool needed to be considered.

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Plan - Following on from the previous cycle we appreciated the need for a trigger tool. I was again involved in educating and leading a group of 5th year SSC medical students through the cycle and data collection. We were provided with a trigger tool that should trigger an escalation conversation, and aimed to review the notes in relation to the trigger tool.

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Do - We reviewed medical notes for current inpatients in ward 2 NW, and completed a trigger tool from the information provided in the notes. Ultimately documenting whether the patient’s situation would trigger an escalation conversation. We then reviewed and discussed the outcome for each patient with the ward 2 consultant. Recording whether he agreed or disagreed with the triggering tool outcome.

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April 2021 - Developing the Trigger tool 

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April 2021 - Developing the Trigger tool 

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Study - We then reviewed the tool and identified areas that could be improved. Removing areas of ambiguity and making it more concise.
We also reviewed other NHS health board's trigger tools, appreciating that they had identified the most important components such as a NEWS score, care home resident, recurrent admissions and life limiting conditions.

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Act - the team then developed a new trigger tool.
That was clear and concise, and very easy to use. This has been presented to the larger ReSPECT team and will hopefully be developed and involved in the ultimate implementation of the ReSPECT forms.

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Importance of QI methodology
- Understanding a system & attitudes prior to implementing change
- Predicting the barriers/outcomes
- Effectiveness of working as a team, awareness of different roles/strengths
- Realistic aims that are recordable and achievable