Speaker 1: Today we're going to start off by talking about who quality improvement is actually for, why you should be taking part in it, and what it really is. The first question is who quality improvement is for? Absolutely anyone who cares about the experience that patients have should be taking part in quality improvement work. If you think about a patient's journey from the beginning of being diagnosed with a condition by their GP, being sent to hospital for tests, being discharged from hospital and seeing specialists in the community such as physiotherapists, podiatrists, or going on to have education sessions about their new condition, absolutely every person that they meet along their journey could be a person who could improve their patient experience. The next question is what is quality improvement? In the past we used to do audits, which are simply pictures of what's going on at a particular moment in time, looking at an organisation's records and figures, and audits tended to be done year on year, and this is what was called an audit cycle. But now what we do is quality improvement work, where that point between your first audit and the second audit is where you do some very conscious work to improve the experience that patients have, or the system that you're working in, so that year on year you can show that you're doing something to change that. Sometimes quality improvement work doesn't actually make a difference, and that's also okay. What we want to do is share all that work so that people can learn from experiences whether they're good or bad around the world. One of the things we recommend you try doing is a plan, do, study, act cycle in your quality improvement work. This is known as the model for improvement. You plan an intervention, you implement it, and then you study it and see whether or not it worked and what could be improved. You act on what you find during that cycle, and you repeat it, and the best quality improvement work includes lots and lots of plan, do, study, act cycles, so that you hone that intervention and make it as good as you possibly can in the time that you have. So why should you get involved in quality improvement? Well, it's a way to make a difference to the experiences that your patients have, and that's the biggest reason to take part in quality improvement work. As people working on the ground, you're likely to see things that don't work properly all the time, and you may have an idea. Often you're just not brave enough to take that forward, and what we want to do is encourage you to take that step, engage other people that you work with, and be brave enough to go and make a difference to the patient care that you're giving. The other reason to do it is obviously it's great for your CV, it's good for continuing professional development, often for your appraisal you have to do an audit, and instead of doing an audit, you can take it a little bit further forward and do a quality improvement project. You can share your ideas by writing blogs about your improvement project, and you can publish your quality improvement work. One of the things I think is a great shame about the work that we do is that we often don't share it, and especially small quality improvement projects, such as the ones that you are doing, don't get shared. When I think about my previous experience as a medical student, and as a GP, and as a junior doctor, I can think of so many times when we have identified a problem and made a difference to it by changing referral pathways, changing the way we follow guidance, and changing the way we work with our colleagues, and all of that is quality improvement work. And by writing it down and publishing it, we can share that and allow other people around the world to do the same sorts of things. We should be trying our best to publish that work. A quality improvement project isn't a very high-level academic research paper. It's actually a specific type of paper which follows something called the SQUIRE guidelines, which is a checklist of a certain number of items which make up a quality improvement project. That includes things like writing an abstract, writing about a problem that you've identified, going through the model for improvement, going through your lessons and limitations, etc. So it's not like a very high-level piece of research. So don't be afraid if you're scared about statistics and P-levels and things like that. You can do quality improvement work. What you're doing is trying to share your story of how you changed the experience of patients and the experience of staff in your organisation. On average, it actually takes 17 years for a piece of research to get into clinical practice. But that's the difference between the kind of research I was just talking about and a quality improvement report. Let me take you to Lahore, to a hospital in Pakistan. Here, a group of junior doctors, led by a doctor called Matthew Clayton, did some very brilliant work to improve the experience of patients.

Speaker 2: A huge problem is that the outpatient clinics, patients come back to maybe six months, three months after they've been discharged from hospital, they have sometimes just not taken the drugs at all, sometimes they took them all in the first week, sometimes they've overdosed on them, and this is simply because they do not understand the handwritten discharge prescription they are given. We wanted to make an intervention. We designed a pictorial-based discharge prescription chart. So instead of handwriting the name of the drug with a lot of medical acronyms, we made it much simpler. We had a picture of a sun rising over the mountains to represent morning, a sun above the mountains to represent midday. We got the pharmacists to start writing number one, or number two, or number three, to correspond with our discharge medication sheet on each of the boxes of drugs they gave to the patients. The pharmacists understood this concept, they were very happy to engage with the whole project. And all of a sudden, illiterate patients had a box, they could read the number on it, and they could refer to the chart and they could see just where the Xs had been put to mark the time of day they should take it, and how many days they should be taking it for. And by the time we left, within nine days from start to finish, this discharge proforma was being used on the medical wards in this large teaching hospital in Pakistan, and since then I think it's been extended to the surgical wards and other wards since as well.

Speaker 1: This project was published in BMJ Quality Improvement Reports, and it showed that there was a 20% increase in patients' understanding of their prescriptions. This was a fantastic report, and what's really exciting about it is that later on, a hospital in Toronto did a very similar project after being inspired by reading this project. And that's what we want to try and encourage, people to very quickly publish their work and share it so that other people around the world can emulate the ideas that are generated from projects. So in the same way that that group in Toronto read a quality improvement report and were inspired, you could do the same thing. I know that getting an idea for a quality improvement project can be the most difficult part of doing this work, not quite knowing where to start. Well, I'd recommend you go along to the website where journal articles are published, qir.bmj.com, and read all the articles that are there. You can use the search toolbar to find out what projects are being done in particular areas, and you could also go onto Twitter and other social media and type in quality improvement. You'll find loads of other people who are really passionate about quality improvement online. You can contact them and ask them for help. You could also contact authors of previously published papers, and you can contact us at BMJ Quality. We're very, very happy to contact you back as soon as we can to give you that support. You can also go to the Health Foundation website, which has lots of guidance documents about how to do a quality improvement project, and there's lots of resources at BMJ Quality as well. When you log in at BMJ Quality, you'll find that there's access to webinars, blogs, and also we have a step-by-step toolkit, which tells you exactly how to write a quality improvement project. And along the way, you'll get access to lots of learning modules, which are very exclusive to BMJ Quality, which again go through all the steps of a quality improvement piece of work. One of the fantastic things about the BMJ Quality Improvement Reports journal is that when you submit a project, you will get your feedback about the project within four to eight weeks of submission. We aim to give you very robust feedback, which will help you to publish your work. And in fact, we publish 80% of articles which are received by us, because we really want to try and publish as much as possible and help to share that quality improvement story that you've written. If you still are struggling to get an idea, you could go to BMJ Quality Premium, where we have access to lots of pre-written workbooks, which are sort of recipes for quality improvement. At the moment, we have quality improvement projects focused on diabetes, dementia, COPD, as well as handover and improving clinical protocols. All of these projects are fantastic if you're not sure where to start and want to do a quality improvement project in a certain clinical area. If you have any questions, do contact us at support at bmj.com, or using hashtag BMJ Quality, or just explore the website at quality.bmj.com.