{"id":4425,"date":"2017-10-06T13:23:34","date_gmt":"2017-10-06T12:23:34","guid":{"rendered":"http:\/\/www.thinkkidneys.nhs.uk\/kquip\/?p=4425"},"modified":"2017-10-11T12:04:44","modified_gmt":"2017-10-11T11:04:44","slug":"contextinqi","status":"publish","type":"post","link":"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/blog\/contextinqi\/","title":{"rendered":"The role of context in quality improvement"},"content":{"rendered":"

As someone who has tried to improve care for kidney patients via quality improvement methods, I was very happy to write a blog about the role of context. Basically, because boy do I wish I\u2019d understood it earlier! One of my first roles as a new consultant was to act as Director for a QI project to reduce infections from central lines in Salford Royal. For obvious reasons – I fought hard to have long term dialysis lines in the project although the organisational interest was in acute short term central lines following on from a now famous NEJM reported improvement project in ICUs in the States. Teams of clinical staff came together in a collaborative and worked hard for a year. I was proud we achieved success across ICU, Neonatal ICU, Medical HDU, and Surgical HDU and also on our own acute ward with temporary dialysis lines (see http:\/\/www.bjrm.co.uk\/journal_search_results.aspx?JournalID=2&sw=0&yrFrom=0&yrTo=0&sa=hegarty&ef=False&notw=0&alw=True<\/a><\/p>\n

However, sadly – despite my best efforts \u2013 we did not achieve success \u00a0in our main renal unit. This caused me much head scratching \u2013 and also when I reflect on it \u2013 extra work – as I responded in the main way I knew how back then, which was basically to work harder and not accept defeat.<\/p>\n

Well I could work as hard as I liked \u2013 it was still to no avail. The numbers stubbornly did not budge. We were still having significant numbers of line infections in long term dialysis catheters including complications such as endocarditis, discitis and death \u2013 and by then \u2013 looking at what had been demonstrated in other care areas – I truly believed much of this was avoidable harm.<\/p>\n

The intervention (a care bundle) was evidence based and worked in our Trust in multiple areas. So what was going on? The possibilities were broadly that something was inherently different with long term dialysis lines (eg technical differences in the line, or microorganisms in biofilm formation etc), with the case mix\/patient group (eg long term kidney patients with abnormal immune systems) or the area we were working in (our local renal unit\u2019s characteristics at the time).\u00a0 To get to the bottom of it and make effective change – I didn\u2019t need to work harder \u2013 I needed to work smarter\u2026<\/p>\n

Alongside the importance of what you do in change\/QI (usually what is called a multifaceted intervention ie many small changes \u2013 in this case a \u2018line bundle\u2019) and how you do it (implementation), the environment or context that you do it in also matters. It is the interaction between these three elements that makes for success. An analogy for those used to the joys (or vagaries!) of gardening is that if an intervention is a \u2018seed\u2019 then the context is the \u2018soil\u2019. Some types of intervention are fairly robust in all kinds of environments, while others are very sensitive to the type of local soil. They may need adapting (add lime or fertiliser?) \u2013 they may never work in that time and place \u2013 because the soil is just too hostile.<\/p>\n

Well another QI phrase is \u201cFailure is our friend\u2026\u201d \u2013 so after wounds were licked and soul searching done \u2013 we embarked on a further round of QI in our dialysis network \u2013 this time with a different approach. We invested in a new QI Fellow \u2013 Dr Azri Nache \u2013 and set him to work \u2013 that is spending a very significant amount of time on \u2018pre-work\u2019. We measured context on our dialysis units, PD and transplant teams and found a great deal of difference in safety and teamwork characteristics. There was indeed clear evidence of some more challenging conditions \u2013 for complex reasons including staffing issues such as vacancies and turnover, nursing leadership, physical environment, acuity\/case mix, and medical presence. We carefully designed a programme of QI that matched the difficulty of the target improvement with the characteristics of the clinical areas. Thanks to the dedication of frontline improvement teams \u00a0\u2013 \u00a0we showed some inspirational improvements (\u2013 for more detail see https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/28237984<\/a>)<\/p>\n

Some of how we went about things was against my natural instincts at the time; like many doctors \u2013 I inclined towards looking at the biggest beastliest problems and wanting to tackle them first. But research has shown that in QI you should go for the so-called \u2018low-hanging fruit\u2019 \u2013 demonstrate success and review how to spread best practice, once you\u2019ve shown you can achieve it. So what I have learned is that ignoring context risks wasting resources, money and effort.\u00a0 It is energy sapping and less likely to be successful. There is a long game in improving patient care in a way that can \u2018stick\u2019.<\/p>\n

For us at Salford Royal who now have had the good fortune to be in a forward thinking Trust that puts QI at the heart of how it tries to work for the last 10 years, we have now taken part or led on probably dozens of QI initiatives. Are we there yet? Like life, quality improvement is a journey not a destination and everywhere you look there remain opportunities to learn, evolve and do things better. But with a smart understanding of context \u2013 hopefully we now make our choices on what to tackle when, more wisely.<\/p>\n

How to measure context?<\/p>\n

This can be a very informal measure eg home grown survey assessing interest in the topic area, staffing levels, willingness to change, previous QI experience etc, or for larger or more challenging projects \u2013 using a validated or adapting a validated tool can be very useful. The measures should be formative ie they feed back into planning how to conduct the most successful QI project you can. If you are applying for funding for QI experienced funders will expect you to understand the importance of context and demonstrate how you will evaluate it and use the data to shape your project. Examples are given below<\/p>\n

https:\/\/www.researchgate.net\/publication\/51565829_The_Model_for_Understanding_Success_in_Quality_MUSIQ_Building_a_theory_of_context_in_healthcare_quality_improvement<\/a><\/p>\n

http:\/\/www.nccmt.ca\/resources\/search\/216<\/a><\/p>\n

http:\/\/www.nccmt.ca\/resources\/search\/187<\/a><\/p>\n

http:\/\/www.nccmt.ca\/resources\/search\/85<\/a><\/p>\n

http:\/\/www.ahrq.gov\/professionals\/quality-patient-safety\/patientsafetyculture\/index.html<\/a><\/p>\n

More Information:<\/p>\n

https:\/\/www.researchgate.net\/publication\/49691626_The_Influence_of_Context_on_Quality_Improvement_Success_in_Health_Care_A_Systematic_Review_of_the_Literature<\/a><\/p>\n

http:\/\/www.health.org.uk\/publication\/perspectives-context<\/a><\/p>\n

http:\/\/www.health.org.uk\/webinar-quality-improvement-role-context-and-how-manage-it<\/a><\/p>\n

This blog has been written by Janet Hegarty, Consultant in Kidney Medicine Salford Royal<\/p>\n

Email: janet.hegarty@srft.nhs.uk<\/p>\n","protected":false},"excerpt":{"rendered":"

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For…<\/p>\n","protected":false},"author":128,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"enabled":false},"version":2}},"categories":[1],"tags":[],"class_list":["post-4425","post","type-post","status-publish","format-standard","hentry","category-blog"],"acf":[],"yoast_head":"\nThe role of context in quality improvement - The Kidney Quality Improvement Partnership<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/blog\/contextinqi\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"The role of context in quality improvement - The Kidney Quality Improvement Partnership\" \/>\n<meta property=\"og:description\" content=\"As someone who has tried to improve care for kidney patients via quality improvement methods, I was very happy to write a blog about the role of context. 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