Quality Improvement/Practice Improvement (QI/PI) Projects involve identifying an opportunity for improvement in your practice, implementing a change to address that opportunity, and measuring the impact of your change. These projects are a form of scholarship and are integral activities in fellowship and medical practice, performed with the direct goal of improving patient care locally, using known or published best practices. All fellows must complete at least one QI/PI project during their fellowship and present a final report to the department prior to graduation. Institutional policies for faculty and resident engagement in quality improvement can be found in the GME SharePoint under Policies and Procedures.

How To Start a QI/PI Project:

The first step in starting a quality improvement project is to identify the problem to be addressed. These problems may be identified through external audits, internal reporting systems, or personal observation. The quality and safety officer, Linda Coleman, can provide valuable assistance at this stage of your project, as they are likely aware of specific problems and may have access to the data you need to justify your QI efforts. Given the amount of time and effort required to properly carry out the QI process, it is important to pick a project that will have a meaningful impact. While a QI project should have as meaningful an impact as possible, one should also consider the institution’s resources and avoid choosing a goal that is too lofty and ultimately unachievable. Please note that while participating in a Root Cause Analysis (RCA) or simulated activity is a requirement of fellowship training, this alone does not constitute a PI/QI Project, although it may serve as the impetus for a project.

Steps of a QI Project:

1. State the problem to be addressed: After identifying a problem of interest, draft a formal statement describing the problem and the overall aim of the project. For example: “After reviewing patient records, we have found that the incidence of CLABSI events at our institution is higher than that described in contemporary literature. It is our aim to decrease the incidence of CLABSI at our Naval Medical Center San Diego.”

• Assemble a QI team with the quality improvement goals clearly laid out, the next step is to put together a multidisciplinary team to help carry out your project. Team members may include:
• Project Leader: This should be the fellow who identified the QI issue to be addressed.
• Project Assistants: The project leader may need assistance in planning and executing their QI project. It is reasonable to involve additional fellows and residents to share some of these responsibilities.
• Project Sponsor/Principal Investigator: This should be a faculty member who can offer guidance throughout the QI process.
• Safety Officer/QI officer: As previously stated, quality improvement officers, such as those involved in infection control or patient safety, are invaluable in this process. They can provide insight into existing issues and the resources available to address them.
• Patient Care Providers: The project leader should reach out to those directly involved in patient care, including physicians and nurses. Leaders from this community, such as nurse managers, can provide extra insight into the problem at hand and what those directly caring for patients might be able to do to address it. These individuals can also help institute the changes proposed by the project’s plan.
•  Developing a Project Plan: Once your team is assembled, it is crucial to formulate a comprehensive plan for achieving the desired improvement outcome. There are several established models for quality improvement projects, including the following:
• Plan Do Study Act (PDSA) Model: Created by statistician Walter Shewhart in the early 20th century and widely employed in healthcare today, the PDSA model is a cyclical approach to quality improvement involving the implementation of changes and subsequent adjustments based on the observed impacts. This model comprises four stages.
  • Plan: Identify and plan the implementation of a change that could lead to the desired outcome.
  • Do: Carry out the planned change.
  • Study: Analyze the effect of the change on the desired outcome.
  • Act: Determine whether modifications to the plan are necessary to better achieve the outcome.
  • It is crucial to understand that the PDSA model promotes continuous learning and iterative adjustments. It is not a one-time effort, and the cycle should repeat until maximum benefit is realized.
• Lean Model: Originating from Toyota’s 1930 operational model, the Lean methodology aims to enhance efficiency in production or service delivery. Its core principles are defining value, mapping the value stream, creating flow, establishing pull, and pursuing perfection. Implementing these five Lean principles fosters continuous improvement. In healthcare, this includes defining the value of a treatment or medication, devising more efficient delivery methods, and identifying and eliminating waste to conserve resources and reduce costs. Besides the Lean process, Lean also incorporates specific Lean assessment and improvement activities. Lean assessment activities function as analytical tools for identifying waste and potential improvements. These activities include root cause analyses, value stream mapping, Rapid Process Improvement Workshops, spaghetti diagrams, and Gemba walks. Lean improvement activities aim to minimize waste and enhance the work environment. These activities range from implementing the 5S principles and stop-the-line measures to production leveling and enforcing standard work procedures.

• Six Sigma Model: Conceived by Motorola in the 1980s, the Six Sigma methodology was initially intended to reduce defects in the manufacturing process. More recently, it has been applied in healthcare to reduce medical errors and waste. The term “Six Sigma” refers to the aspiration for achieving an exceptionally low defect rate, six standard deviations above the mean. It does not refer to the number of steps. The DMAIC framework is a structured technique for quality improvement that emphasizes identifying sources of errors. It is an integral part of the Six Sigma model and consists of five distinct stages: DMAIC (Define, Measure, Analyze, Improve, Control).
  • Define: In the first phase, the specific problem is identified, and the project’s final goals are set.
  • Measure: This involves gauging various metrics related to the quality of the process under scrutiny.
  • Analyze: The measurements are examined to identify the root causes of errors or inefficiencies.
  • Improve: After identifying the root causes of errors, changes are developed and applied to address them. The effectiveness of these changes is then evaluated.
  • Control: If the changes are deemed effective in minimizing waste and error, measures are put in place to ensure their continuity. The cycle then begins again to further refine the process.
• Obtain project approval: After a quality improvement model has been chosen and a detailed plan has been developed, the project should be presented to the program director for approval. Depending on the scope of the suggested changes, the project may also need approval from the IRB. If it is determined that IRB approval is needed, the plan must be submitted and approved before instituting any changes.
• Carry out the project plan: After receiving approval, the QI project must then be physically carried out. Quality improvement is a team effort and will require the fellow to work closely with patient care providers. While carrying out the project, administrative hurdles and resource limitations will almost certainly be encountered. The resident must not give up when this happens and should instead seek guidance from their project sponsor or institutional safety officers.
• Evaluate the results of the project: In addition to the frequent self-appraisal suggested by most quality improvement models, a final evaluation of the results of the QI project should be carried out. In the end, the fellow should determine if their project had a meaningful impact, if further improvements could be made, and what they or their peers could do better in future QI efforts.

Requirements for Completion of Project:

1. Present completed project: A final project and its implementation must be presented to the PCCM department prior to graduation. While projects are not always successful due to external factors outside of the fellow’s control, an honest effort to complete the project is required. If a project is unsuccessful, a discussion of the reasons as well as “lessons learned” must be part of the final presentation. “I got too busy” is not an acceptable reason!
2. Publish your results: This is not mandatory, but if the project was well designed, had a meaningful impact, and could be reproduced at other institutions, it may be worth sharing with the medical community.
3. Assure sustainability: Achieving the goal of a QI project has little value if the improvement that was instituted cannot be maintained. Efforts should be made to ensure that the training and resources utilized during the project remain available after its completion.