QIP Final Report (template)

How to finalize the written documentation for a quality improvement project

EBM-QIP Initiative

Evidence-based

The aim of Evidence-based medicine (EBM) is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The principles of evidence-based guidelines and population-level policies explicitly describe the available evidence that pertains to a policy and ties the policy to evidence instead of standard-of-care practices (SOP) or the beliefs of experts.
A rationale must be written.

Documentation

If you are a health care professional, the phrase, if it wasn’t documented, it wasn’t done, is something you have likely heard.
It means that if there is not a record of the care you delivered in the patient’s chart, the activity was not done. If something happens at work, or you provide first aid or provide a statement of a near miss or anything else, its critical you make a record.
While this makes sense at face value, when placed in the context of patient care delivery, this statement has more extensive legal implications. For this COULD be the ONLY notes you are allowed in a court if called as a witness at some point in the future (even years later).

Quality Improvement (QI)

We need to update some of our vocabulary to embed these concepts in our quality improvement activities; perhaps we could create names such as evidence-based quality circle for QCC (quality control circle) and evidence-based quality project for QIP(quality improvement project) or PIP (performance improvement project)!

QI Journal (Outline)

Part 1: project & team particulars
  1. QI Initiative or Project Title
  2. Team Particulars
Part 2: problem description
  1. Historical Situation
    • Graph historical data of the project problem
    • Document current practices involved in the project
  2. Published Standards
    • EBM literature review
    • Collect standards from accrediting authorities
  3. Current Situation
    • Do a gap analysis of the differences between the current situation and published standards
  4. Problem Description
    • Briefly describe the problem being addressed
    • Gaps between the current situation and your improvement objectives
    • Describe some of the challenges with the current situation
  5. Indicators:
    write down in detail the indicators (outcome, process, balancing) that will be tracked and graphed in your improvement work. Define each indicator using the headings: indicator, numerator, denominator, exclusions, frequency, data source, person responsible for data collection and validation.
  6. Improvement Objective
    State what you seek to achieve. Ensure that the objective has a boundary, a numerical goal (baseline to specified time), timeframe and guidance. Use SMART paradigm.
    If this is a continuation of a previous quality improvement project, and the results meet the requirements of a Legitimate QIP, use the improvement half-life (t½) to set objectives (numeric goal and time-period in which to achieve it).
Part 3: root cause analysis
  1. Fishbone diagram with EBM causes
  2. Brainstorm possible root causes using 5 Whys tool
  3. Put similar root causes into groups
  4. Decide on the titles of the groups as the main categories for the fishbone diagram
Part 4: changes development
  1. List fishbone categories on the left column of table
  2. In the right-hand column, list proposed changes to address the issues identified in each category.
Part 5: change idea pdsa cycles
Document the testing journey for each change in the order provided below:
  1. PLAN (Document the following) 5W2H tool
    The predicted results following the implementation of the change
    Why? Why will it be done? justification, reason
    What? What will be done? action, steps, description
    Where? Where will it be done? location
    When? When will it be done? time, dates, deadlines
    Who? By whom will it be done? responsibility for action
    How? How will it be done? method, process
    How much? How much will it cost? cost or expenses involved
  2. DO (Document the following)
    • How you carried out the plan
    • Describe what happened
    • What data did you collect
    • What observations did you make?
  3. STUDY (Document the following)
    • Analyze the results
    • Compare the results to your predictions in the PLAN
    • Document what you learned from the change
  4. ACT (Document the following)
    • Make a decision about the change
      • Accept (result acceptable; continue more cycles)
      • Adapt (result somewhat acceptable; continue more cycles after strengthening the action plan)
      • Abort (action has no result; abandon it and consider designing a new action)
    • What ideas do you have for the next PDSA cycle?
Part 6: changes worksheet
List the changes the team promised from Part 4. Note when the change was started, when it ended (where applicable) to enable you to annotate the results. Decide whether the changes were effective or not on the end date of a testing cycle. Also include the output indicator which will be tracked for every change.
Part 7: tracking progress
  1. Continue your run chart during all PDSA cycles
  2. Annotate graph to show dates each change was introduced
  3. Show data tables for numerator, denominator, rate as defined in Part 2 for indicators
  4. Give brief explanations for any notable trends in the graph
  5. Notes on the indicators: wrote down any additional comments you may have on the performance of indicators. Write anything derived from the changes worksheet and the graph that might explain the performance trends of the improvement objective.
Part 8: final report
  1. Write down any additional comments you may have on the performance of the project. Write anything derived from the changes worksheet and the graphs that might explain the performance trends of the improvement objective.
  2. Lessons learned
  3. Next steps