Posted on: 2 July 2021
July 2021 
75 QI projects showing improvement across CNWL
Photo: Passiflora alata in the Temperate House, Kew Gardens, Peter Smith
New beginnings
The CNWL QI Practicum has begun with a launch call for project team members from 24 projects across CNWL. This month we report on the launch call and introduce some topics that will not only be useful to teams in the Practicum, but helpful for anyone contemplating or starting a QI project.
Our lead article covers the importance of getting to know your problem; it is often tempting to ‘dive in’ and start making changes for improvement without first gathering your knowledge about the issues. We learn from the article why it is important to get to grip with your problem before progressing and discover some ways of exploring the problem.
We also discuss some useful tools for helping you understand what it is that you want to improve. The Fish Bone Diagram (or cause and effect diagram) is a great way of thinking around your problem, whilst our QI tip of the month, The 5 Whys Strategy, can help you get to the root cause.
And not to forget our usual recap of Bitesize QI dates, open for any staff to book via LDZ.
We welcome your feedback and if there is anything you would like to see in future editions of the newsletter, do please get in touch by e-mailing cnw-tr.improvementsupport@nhs.net.
Starting your QI project: Knowing your problem
Once you decide that you want to get going with a QI project, it can be easy to dive into the work and start doing lots of ‘stuff’. Awash with change ideas we are raring to go and starting doing things that will solve our problem. Or will they? Do we know enough about our problem and the system we are working in to dive straight into our project?
Improvement projects almost always need to be led and carried out by staff who are also carrying full workloads, so you don’t have any time or energy to waste by focusing on red herrings or simply staying in your comfort zone. QI methodology is based on understanding the systems and processes that we work in and making changes to improve these systems and processes. The nature of our work can mean that we are very familiar with parts of a system, but not always the wider system and how it links together. We might think we know exactly where our problem lies, but often there are other factors at play that we are less familiar with. Because of this, it is always recommended that teams starting out with an idea for improvement take some time to explore and define their problem. Front loading this work can save you time, energy and frustration in the longer run.
Fishbone Diagrams (aka Cause and Effect diagrams)
The Fishbone diagram gets its name from its distinctive shape - it looks like the bony shape of a fish.
Fishbone diagrams allow teams to identify, explore and display all possible causes related to a problem or issue. They are a great team exercise, getting people talking about what might be sitting behind your area of concern. They can be used when you start out on your journey, and again as you learn more about your system and what might be making a difference. They are best done with a group that knows something about the area you are exploring.
Example of a blank Fishbone template:
Make sure everyone agrees with the problem statement. This is your starting point. The rest of the exercise will help you to explore the what, who, how, when of your issue.
Your central line represents the backbone. You should now draw on the major headings that you think are important to this issue. These can either be what you feel are ‘causes’ behind your issue, or steps in the process. Connect them to the backbone of the fish.
There is no perfect set or number of headings to use in your fishbone, and you should allow them to fit the problem and not try to shoe-horn your problem into a set of standard headings. However, many teams start off with a possible six headings and work from there (see diagram below) - you may find useful to get going.
You don’t need to use all six, and you may want to change some. For example, you might want a category for Patients and/or Families. Skills/Knowledge might fit better than methods.
Tailor this for your needs.
Some teams prefer to use different parts of a process as their category headings. This can work really well if you have explored your process using a process map or flow chart and want to get into more detail about how different parts of the process might affect the problem you want to address.
Once you have agreed your headings and drawn out your fishbone, start to brainstorm your list of ideas. Use sticky notes to allow you to move the ideas around the diagram until the group is happy with what they have prepared. You can either add the sticky notes to the category as you go along, or spend time to brainstorm the full list of ideas and then allocate. Both work - the key thing is to keep the flow of ideas coming. If you start to focus on individual categories too early, you may find you lose some of this creativity.
Once you have added some information to each of the ‘bones’ – ask yourself why these things happen. The ‘5 Whys’ tool may be useful to help structure your conversation, but any conversation to explore what is going on is fine. This should help you to identify the root causes, or likely root causes sitting behind your problem. This information can be used to help define your aim.
News from the Practicum 2021
#CNWLQIPracticum2021
Over 90 CNWL staff were welcomed on 24 June by Con Kelly, CNWL Chief Medical Officer to the Launch Event for the CNWL QI Practicum 2021. In welcoming staff, Dr Kelly urged Practicum participants to be curious and expect to work hard, but also to have some fun on the journey.
Stressing the importance of service user and carer involvement, Simon Edwards, Trust wide QI Clinical Lead, introduced the Service User and Carer Involvement Team, who talked about the benefits of service user and carer involvement.
Participants also heard about the QI story of Shannon Ward, who took part in the CNWL Practicum in 2019-2020. Cassandra Balisson, Ward Manager, shared their impressive results that show a 52% reduction in assaults, as well as reductions in the numbers of restraints, seclusions and distressed behaviours. Inspirational stuff!
We embraced the power of the Practicum community and each of the 24 project teams got a chance to cheer to make themselves heard and we were suitably impressed by their hopes for the Practicum programme: improvement, empowerment, change, learning and engagement all featured prominently in their word cloud.
Now that the fanfare of the launch call has stopped echoing, we look forward to starting work on each project with a prep call in mid-July to begin understanding the issues and problems to be improved.
QI Tip of the month: The 5 Whys Strategy
The 5 Whys Strategy is a simple tool to help you explore and uncover the root of a problem. You can use it when starting out with your quality improvement journey to explore your problem or area of concern. It can also be used at any time during your improvement work to tease out whether you are focusing your work on the right areas.
The 5 Whys can be used on its own - and is particularly suited to simple or moderately difficult problems. It can also be used to help explore more complex cause and effect, for example to interrogate a Fishbone diagram.
5 Whys is best used with a group who are familiar with the area of concern that you are going to discuss.
Note: As you work through your chain of questions, you may find that someone has failed to do something that they should have done. However, 5 Whys is not about pointing the finger or assigning blame. It allows you to ask why that happened – recognising that human error is often a result of poor processes. This then opens up the potential to explore areas for improvement within your processes.
Upcoming Training Dates
Bitesize QI
Dates for the ever-popular monthly 3-hour virtual QI training on the model for improvement and how to set out on a QI project are bookable on LDZ at: https://cnwllearning.org/login/index.php
Search for ‘Bitesize QI’ to find the course, which is available on these dates all starting at 9.30am:
- Tuesday 13 July 2021 – extended by half hour to include Life QI for QI Practicum attendees
- Tuesday 17 August 2021
- Tuesday 14 September 2021
- Tuesday 12 October 2021
- Tuesday 16 November 2021
- Tuesday 14 December 2021
Useful links
Contact information for Improvement Advisors:
Diggory Division - Michele Dowling: michele.dowling@nhs.net
Goodall Division and Corporate - Peter Smith: petersmith3@nhs.net
Jameson Division - Geetika Singh: geetika.singh@nhs.net
CNWL QI Microsite: www.qi.cnwl.nhs.uk
Life QI: www.lifeqisystem.com/
IHI Open School: www.qi.cnwl.nhs.uk/training-and-events/online-qi-training
If you want to get in touch please contact us here: cnw-tr.improvementsupport@nhs.net