Editorial: Setting the case for a series of educational articles on quality improvement and related concepts and methods

A few years ago, The Journal of Clinical Urology commissioned a successful series of short articles on Research to help educate clinicians on the breath of research opportunities and their methods. In this series, the journal is repeating the process by commissioning eight educational articles on Quality Improvement (QI), and its related concepts, methods and disciplines.

QI is the practice of using systematic change methods to make measurable improvements to the configuration and delivery of healthcare services. This forms part of a broader quest for making the practice of continuous improvement an integral feature of multi-disciplinary healthcare teams. The modern vision for healthcare is that training in QI methods should be embedded into medical education curricula early on, in training and be reinforced throughout an individual’s professional career.

The three articles in this series aim to offer a digestible and practical overview of QI methods in an accessible form, including specific urological case studies, and how they can be practically harnessed to improve urological care. This is increasingly important as the expectations on clinicians have changed. It is no longer thought enough for a clinician to be proficient in clinical knowledge and practical skills. To provide the best care, modern urologists must also have additional capabilities, such as professional values and behaviours, good team-working skills, leadership and communication, the ability to deal with uncertainty while maintaining safe practice and safeguarding vulnerable groups, promotion of health and illness prevention and capabilities in research, training and QI. ¹

Importantly, QI skills differ from the earlier expectation of doctors to audit themselves against defined standards. Instead, the emphasis is now on constantly striving to improve the care provided, while assessing whether changes put in place actually lead to any real improvement or not. ²

In 2017, the General Medical Council (GMC) in the United Kingdom (UK) published their General Professional Capabilities Framework, which translated the principles and professional responsibilities of all doctors into educational outcomes that should be incorporated into curricula by 2020 (the full set of required QI capabilities are set out in Box 1). ¹ However, at the time the framework was produced, there was sparse guidance given concerning what specifically should be included in the surgical curriculum regarding QI, or how to go about embedding it in surgical training. This was primarily because there was no evidence regarding the best way to go about training surgeons in QI. ³ Sporadic programmes existed but none on a national scale and none dealing with a whole surgical subspeciality like urology, nor encompassing a wide variety of methods.

Box 1.

Domain 6 of the General Medical Council General Professional Capabilities Framework: Required skills and capabilities in Quality Improvement.

Doctors in training must demonstrate that they can design and implement quality improvement projects or interventions that improve clinical effectiveness, patient safety and patient experience by: • Using data to identify areas for improvement • Critically appraising information from audit, inquiries, critical incidents or complaints and implementing appropriate changes • Deploying quality improvement methods (e.g. plan, do, study, act or action research) and repeat quality improvement cycles to refine practice • Involving patients and public in decision-making at group or community level • Engaging with stakeholders, including patients, doctors and managers, to plan and implement service change • Effectively evaluating the impact of quality improvement interventions

This gap was addressed scientifically by the Education in Quality Improvement Programme (EQUIP), which was set up as a research project (2017-2021) to identify what QI training methods and strategy would work best to embed QI training into urology and how to scale such methods nationally across UK urology training programmes in the first instance.^4,5 To date, the EQUIP team has produced a systematic review of how QI skills can be taught to surgeons and surgical trainees; has developed a feasible and effective short QI methods module taught to urology specialist trainees at the annual National Bootcamp in Leeds (since 2017); has helped Specialist Advisory Committee members define the QI component of the new Urology Training Syllabus; has incorporated QI skills training into an early-phase consultant bootcamp for early career urologist consultants in the United Kingdom and produced a consensual implementation strategy for embedding QI training more widely in UK Urology. ⁶

One key outcome of the systematic review produced by EQUIP on how to best teach QI skills is the importance of support offered to trainees when they undertake QI projects. Successful QI is a team effort. It is not enough just to teach trainees and expect them to deliver a successful QI project without wider support, as that is likely to lead to change which is unsustainable, has minimal impacts or poor-quality outcomes. Instead the whole multi-disciplinary team in urology needs to skill up in QI, to support QI projects and make a real difference to patient care – and in doing so, support should be offered to trainees undertaking QI projects within urology departments and services.

This series of QI articles has been proposed by the EQUIP Steering Group (which includes patients, nurses, managers, improvement scientists, urologists and trainees) to provide a solid basis in the fundamentals of QI principles and methods and related disciplines, such as implementation science and patient safety. As with most of surgery, the honing of practical QI skills often comes from repeated application in real-life situations; however, a good understanding of the supporting concepts and available methodologies is a necessary starting point. The series aims to empower frontline staff in urology departments to become active in QI by providing a firm theoretical grounding in these disciplines and how they relate to each other conceptually, alongside very practical guidance on ‘how to do QI’ and where to find helpful tools and resources. The articles will cover the following topics:

1. An introduction to QI: We introduce the concept of ‘quality’ in healthcare and summarise the origins and principles of QI. We discuss the broader context of QI including how it relates to other approaches to improvement, such as audit and research, and the infrastructure for supporting QI practice at a departmental and national level.

2. QI Approaches and Methodologies: We present core approaches to QI, including the Model for Improvement, Plan Do Study Act cycles, Lean and Six Sigma. We introduce common QI tools and methods, such as process mapping, and signpost a suite of additional resources for planning and running QI projects on the ground.

3. Measurement for QI: We discuss the importance and nature of measurement for QI, including measurement principles, types of measure and common approaches to presenting and analysing improvement data. We also outline the importance of using data to drive engagement and to provide stakeholder feedback.

4. An introduction to patient safety: This article will outline the background and aims of patient safety science and its links with QI, including important shared concepts, such as the ‘systems approach’ to surgical safety and root cause analysis.

5. An introduction to implementation science: We introduce the field of implementation science and outline its application to QI, in particular for understanding how to adapt improvements to different contexts and maximise their sustainability and impact. We discuss implementation strategies and the importance of including implementation outcomes in the evaluation of change.

6. Stakeholder engagement in QI: This article focuses on who key QI stakeholders are likely to be and what stakeholder engagement really means. We review stakeholder analysis and mapping and discuss the concept and stages of co-designing QI interventions.

7. Leading QI: We discuss the importance of leadership alignment and engagement with improvement strategy and practice. We define leadership in the context of improvement and discuss the attributes of strong leaders at both the organisational and individual level, while acknowledging where the limits of leadership may reside.

8. Embedding QI in urology practice: We conclude the series with a discussion of the importance of embedding QI into urological care and discuss the priorities for making this a reality moving forward. We pay close attention to organisational culture as the driving force for change and improvement.

The articles are aimed at the entire Urology team, who may all champion or become involved in QI projects, including nurses, trainees, consultants, managers, public partners and allied health professionals. We hope that the articles will also be a useful resource for clinical audit or effectiveness leads who can themselves support multi-disciplinary teams in all aspects of QI work, thereby embedding processes for continuous improvement into the day-to-day working practice of their departments.

We believe that the growing appreciation of how QI can bring tangible improvements in care delivery and make the experience of care easier for patients, carers and staff alike, alongside a wider QI knowledge base, will persuade and empower clinicians to embrace QI as an integral part of their clinical armoury. QI will become part of a skill set that is useful throughout their whole career in urology, from their days as trainees until they reach the level of senior consultants and undertake clinical management and leadership roles in their hospitals. Ultimately, we hope that departments will value individuals with skills in QI in a similar way they currently support colleagues with skills in research, education, audit and management.