A Practical Guide to Quality Improvement for Burn Care

IDENTIFY THE PROBLEM

A PRACTICAL GUIDE TO QUALITY

IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

CONTENTS

3

Introduction and background

Introduction to the participants and their QI projects

5 7

8 Steps to carrying out quality improvement

8

STEP 1: Identify the problem

10

STEP 2: Build a team

13

STEP 3: Understand the problem

22

STEP 4: Create a SMART aim

25

STEP 5: Strategies for change

33

STEP 6: Measuring throughout

36

STEP 7: Analyse and respond

39

STEP 8: Building on success

43

Overcoming challenges

47

Summary

Links to further information

49

Acknowledgements

49

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

INTRODUCTION AND BACKGROUND

Why is quality improvement important? Quality improvement (QI) in healthcare is crucial in order to improve treatment outcomes and patient experience. Quality improvement projects work to make care safer, more effective and economical, to ensure equity and access to care, and simply to ensure that patients get the best care possible. In low-resource settings, the focus is often solely on service delivery, i.e., managing high patient demand with limited human resources, equipment and general logistical infrastructure. However, providing care without questioning if it can be improved eventually results in poor care. Whilst there can be many barriers to focusing on quality improvement in these settings, it is important to try and overcome these obstacles and work on improving systems and patient care through evidence-informed, focused interventions.

Hiba , a nurse on a burns unit in Palestine, explains why nurses and other front line staff are so important for QI projects

This document is a learning resource providing a structured overview of quality improvement implementation, aimed specifically at healthcare professionals working in low-resource settings who are committed to improving their workplace.

A practical guide to quality improvement

This guide provides a step-by-step process to creating a quality improvement project in a low-resource healthcare setting, from identification of the problem to collecting data and creating a project, right through to maintaining and sustaining change. This resource is based on the framework created by the Centre for Global Burn Injury Policy and Research and Interburns, which was used to run a quality improvement course in Malawi.

This course in 2019/2020, funded by the UK’s National Institute for Health Research, was designed for burn care nurses from Malawi and Ethiopia who wished to create posititve change in the burn units where they worked. Although all examples here are from nurses working in burn care, QI projects can also be carried out by therapists, dieticians, clinicians and other healthcare workers.

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INTRODUCTION AND BACKGROUND

For a small QI project, change is possible just with the locally available resources. Burn nurse, participant of the quality improvement course in Malawi, organized by the Centre for Global Burn Injury Policy and Research Malawi quality improvement course: overview The quality improvement course in Malawi aimed to train burn nurses to critically evaluate their burn unit and identify a problem which they felt they had the power to change for the better. Participants were introduced to specific skills to help them design and deliver a QI project, including project planning, data analysis, and leadership. These nurses undertook quality improvement projects as part of this course, following the eight-step plan created by the Centre for Global Burn Injury Policy and Research. Details of the participants’ projects are used, with their permission, to provide real-world examples of how such projects can work in practice.

How to use this guide? Make sure to read about the

participants and their QI projects in the next section before working through the eight steps. You will find that real life documents and data from these projects are used to give you an idea what these steps can look like. These real life examples are all from Malawi and Ethiopia, showing the barriers and facilitators faced by the participants when implementing their projects in low-resourced settings. This practical guide provides a basic outline of the eight steps of a quality improvement project, and we encourage you to work through these with your own QI project in mind. There are also links to some videos and further material for self-study if you would like to know more about quality improvement processes after working through this guide.

FUNDED BY

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

INTRODUCTION TO THE PARTICIPANTS AND THEIR QI PROJECTS

Olive and Ziphilly Ziphilly and Olive are two nurses from Malawi who created a QI project with the aim of improving vital sign recording and fluid monitoring for patients in the burn high dependency unit (HDU) from 50%- 90% over a three-month period. They found that a lack of recording material, high workload, knowledge deficit and unavailability of visible guidelines all contributed to poor recording. To help with this problem they worked hard to provide monitoring equipment such as pulse oximetry and thermometers specifically for burn HDU nurses to use. Orientation and reorientation of nurses on monitoring and documentation of HDU observation charts was organised for both new and existing nurses. from patients and their families about the lack of privacy during dressing changes, Ephrem and Kibrom decided to implemented a QI project which championed the use of a screen during dressing changes. This project aimed to increase privacy for patients, especially between men and women on the same wards, by providing a screen to create male and female areas. They communicated the plan to use screens when undertaking wound dressings at the weekly all-staff meetings. The changes were picked up by his colleagues and the project has increased patient privacy and health worker professionalism.

Daniel Daniel, a nurse from Malawi, created a QI project which aimed to improve documentation of dressing changes. He felt the current system did not help with continuity of patient care, timely care or communication between health workers. Once he had assessed the baseline issues, the main problems were a gap in knowledge surrounding documentation of dressing change and time pressure. He created a short wound dressing documentation form to prompt assessment and maintain an accurate record of progress. After creating this form, in collaboration with colleagues, he provided an orientation for staff and a visual display of how to complete the form. The aim of the new form was to shorten the time to complete it and provide a uniform, step by step approach in dressing change documentation. Daniel’s aim was to improve documentation completion from the baseline of 44% to 90%. After three months a positive change was reported, when 85% of dressing changes had accurate documentation.

Ephrem and Kibrom Ephrem and Kibrom are nurses working in different hospitals in Ethiopia. After hearing of a number of complaints

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INTRODUCTION

Feedback sessions every two weeks and monthly prizes for the best documentor helped monitor the progress of the project and incentivise the nurses to get involved. At the end of the project there was an increase to 78% documentation and nurses were more confident and knowledgeable in fluid monitoring and vital sign documentation.

Richard Richard is a nurse from Malawi who decided to focus his QI project on the use of pain medication during wound dressing changes. He found that within his unit many patients were experiencing a lot of pain during dressing changes as they either had no medication or were administered the medication during the change, which was too late to have the desired effect. A baseline study found that only 20% of patients were receiving adequate pain medication. The aim of Richard’s project was to improve this to 90% over a five- month period. New guidelines were developed through consultation with doctors, nurses, the palliative care team, pharmacy staff, patient attendants and clinical officers. In addition, the nurses in charge of the unit were given ownership to ensure strong morphine is in stock on the wards at all times. At the end of the five-month period 66% of patients reported that they had received sufficient pain control, up from 20%.

Patricia K and Patricia N In Malawi, senior nurse Patricia K. focused her QI project on improving hand hygiene in health workers at her hospital. As she could not be there for the entire project, her colleague Patricia N. took over some of the running of the project. Upon assessment it became clear that there was a lack of infrastructure in terms of both sinks and hand rub contributing to a low level of hand hygiene. Also, there were no reminders about hand hygiene anywhere in the unit. The baseline data collection found that the availability of hand washing stations was at 37% and hand hygiene practice was completed 5% of the time. Patricia created a hand hygiene committee to monitor, influence and sustain the project. Additionally, hand rub and hand washing stations were sourced and then placed strategically around the unit. Staff communication took place through meetings and posters. Throughout the process, feedback was given about the progress on the change in practice, which helped to address behavioural barriers as well.

Taweni

Taweni is a theatre nurse from Malawi. It had become apparent to Taweni that the instrument decontamination in her unit was not to the highest standard, which can be problematic and cause infection when there is reuse of instruments. Taweni aimed to improve scrub nurse decontamination of instruments from 50% to 100% over a five-month period. Taweni implemented several strategies for change including training for both new and old staff and visual posters demonstrating the process of decontamination.

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

8 STEPS TO CARRYING OUT QUALITY IMPROVEMENT

Identify the problem

STEP 01

Identify where things need improving and what can be done in a single project. Build a team Think about who you will need to work with to make your project a success. Understand the problem Learn about tools to investigate the cause of your problem and create a baseline assessment. Create a SMART aim Develop a structured and realistic aim for your project. Strategies for change How to change the causes of your problem? In this step you think through time, cost, communication and what you will do exactly to establish the change you want. Measuring throughout

STEP 06 STEP 07 STEP 08 STEP 02 STEP 03 STEP 04 STEP 05

Only measuring again and again will tell you whether things are changing for the better.

Analyse and respond Learn to work with PDSA cycles.

You Plan-Do it-Study it-Act upon it to see if your changes are working and to make adjustments where needed. Building on Success Make sure to maintain and sustain the changes you worked so hard for!

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IDENTIFY THE PROBLEM

STEP 1: IDENTIFY THE PROBLEM

It may seem obvious, but the first step of a QI project is to IDENTIFY the problem. To do this, you must also understand what SHOULD be happening in practice, so you can create an effective project that addresses the problem in a meaningful way.

How do you identify a problem? If you are a clinical member of staff you may already have a topic in mind that you want to work on, or maybe you want to do a QI project, but you don’t have a clear idea yet. Either way it is important to observe the area of interest to see what is currently happening in practice. Other methods to identify a problemmight include: clinical audits, incident reports, patient outcomes. See some examples of our participants when they were at the “Identifying the problem” stage, in the example overleaf.

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

The Problem

The identification of the Problem

• Through random observation by health workers in the unit it was found that handwashing was only done: after patient procedures, after exposure to bodily fluids and after removing gloves for the sake of removing glove powder. • Ideally, every patient room should have a handwashing sink/bucket. In this unit most of them were broken and some rooms did not have sinks at all. • There was also poor/no supply of hand rub • Puts patients more at risk of nosocomial infections by cross contamination therefore can increase length of stay in hospital and have a negative impact on treatment outcomes. Through patients’ feedback in the logbook and personal experience it was highlighted that there were no screens used during burn dressing changes to separate men and women, due to lack of room and resources. This created a lack of privacy for patients.

Insufficient handwashing

Example where Patricia compares how it is happening in practice to how it SHOULD be happening.

Lack of privacy during burn dressing changes

Ephrem and Patricia both specify the method they used to identify their problem.

Be mindful that the problem you intend to investigate is manageable and that you have the power to change it. These QI projects focus on small steps; while the final aim may be to reduce patient mortality, this will inevitably involve multiple steps that need to be addressed one at a time.

Top Tip FOCUS ON WHAT MATTERS TO YOU AND YOUR TEAM when you start to look for improvement ideas think about the ‘things that always seem to cause problems or don’t seem to make sense.’

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BUILD A TEAM

STEP 2: BUILD A TEAM

Once you have an idea of the challenge you want to tackle, you must take time to think about who are the appropriate stakeholders to involve, and then start to BUILD A TEAM of committed and informed individuals to carry out the change. ENGAGING the right people from the start will give you the best chance of ensuring sustainable success. Who should you include? Consider what expertise and influence you might need in the team. It may be necessary to include a wide variety of individuals who will be able to support decisions and/ or carry out actions. Your teammight include doctors, nurses, therapists, a representative frommanagement, technicians, porters or cleaners in your hospital, and patients and their families – the important thing is to include the most relevant people who can bring about change.

It can be useful to do a stakeholder analysis at the start of your project, to ensure you have contacted and involved all the relevant people from the start.

Example of a stakeholder analysis from Olive and Ziphilly’s project to improve vital sign and fluid balance monitoring and documentation.

List any stakeholders who you will need to involve and how you will contact them

Stakeholder

Role

Method of contact Meetings, face-to-face, Whatsapp, notice boards

Nurses

Do observations

Pharmacist

To provide material resources Face-to-face, phone and memo Approval of supply of equipment Face-to-face, memo

Management

Clerk

Collection of observation charts Face-to-face

Non governmental organisation (NGO)

Financial support for observations charts

Proposal writing, e-mail, face-to-face

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

An example from Patricia’s handwashing project in which she describes her team.

Stakeholder analysis

Stakeholder

Role

How can they be engaged/ contacted Call for a meeting, discuss with them about the project (orientation)

Nurses/health workers Implementation or changes put in place

Patients

Assist with change processes and evaluation Assisting with resources

Patient health talks or meetings weekly Write them and call for a meeting

Partners/Funders (e.g. NGO)

Hospital management

Providing material, resources and maintenance

Discuss with them verbally

Patricia also used the table below to think about the type of stakeholders that should be involved in her project. Some stakeholders, such as the patients, will feel the impact from the change while their influence to bring about change is very small or non-existent. At the other extreme, hospital management carries a lot of power and influence about whether the change is implemented and in which way, but they will not be impacted themselves by these changes. Such a table can help you think about how to approach different stakeholders.

High power

Hospital management

Health care workers

Project team: health workers in burns unit, visiting nurses & medical students. Patient’s guardians were also included as caretakers and to remind health workers to wash hands.

Low power

Partners Low impact

Patients High impact

Define roles – Make sure you define roles clearly. Who will lead the project? Will there be a Champion for your project? Does someone frommanagement need to be included? Think about how the different stakeholders can influence and are impacted by the project.

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BUILD A TEAM

Example from Olive & Ziphilly’s project.

QI team composed of unit manager and 4 nurses. Every 2 weeks the QI team were measuring the effect of the change by assessing the patient observation chart against the data collection tool. Identified Champions for the project. Involving stakeholders to provide monitoring equipment. Why this team? Definite, predefined roles. Appropriate, committed individuals.

CHALLENGES OLIVE & ZIPHILLY ENCOUNTERED:

SOLUTIONS:

• Continue supportive supervision of HDU champions. • Involving stakeholders throughout change process. • Orientation policy to all new nurses and student nurses.

• Staff compliance to change in absence of leaders. • Rotation of nursing students and deployment of new nurses.

Top Tip Network with those who have a similar passion and interest to help keep motivated and provide advice on how to overcome barriers to change.

The QI team for Olive & Ziphilly’s project checked the patient observation data sheets every two weeks.

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

STEP 3: UNDERSTAND THE PROBLEM

Once you have your team, and you know the problem area you want to address, it is crucial to fully UNDERSTAND what might be causing the problem, and think it through THOROUGHLY to ensure your project will be as effective and fitting for the local issue as possible.

What tools can be used to help you INVESTIGATE your problem?

There are multiple tools that you can use to understand your problem better. You do not have to use every tool for your QI project, but whichever you choose, use it well to identify the root causes of the problem, and think through all aspects of the issue you are addressing. Don’t forget to think about the contextual factors which are contributing to the problem in your particular area, as these may vary from hospital to hospital and ward to ward.

You can find more information about these tools and templates on the Institute for Healthcare Improvement website: “Quality Improvement Essentials Toolkit” http://www.ihi.org/resources/Pages/Tools/ Quality-Improvement-Essentials-Toolkit. aspx

TOOLS TO UNDERSTAND YOUR QI PROJECT:

✔ Fishbone diagram

✔ Driver diagram

✔ 5 Why’s

✔ Process mapping

✔ Workflow diagram

✔ SWOT analysis

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UNDERSTANDING THE PROBLEM

Fishbone diagram, also known as a cause and effect diagram, aims to help us identify the possible causes of an event, outcome or issue. To help us consider the issue from different perspectives the diagram breaks down the potential causes into the following categories: equipment, process, people, materials, environment and management.

Example: Patricia used a fishbone diagram for her project on hand hygiene:

FISHBONE DIAGRAM

PEOPLE

MATERIAL

No team leaders Workload

EQUIPMENT

No towels

Inadequate personal hand rub bottles

Some sinks no water

No hand rub dispensers

Inadequate sinks and taps

Skin drying

Having no hand rub

No checklists

Inadequate staff

Having no soap

POOR HAND HYGIENE AMONG HEALTH CARE WORKERS

Role models

Training

No guidelines in rooms

Inadequate space in some rooms

No task allocation

Some sinks are closer than others

No supervision

ENVIRONMENT

OTHER

METHOD

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

Driver diagram – These diagrams help us plan what improvement activities we might to work on. The diagram starts with the overall aim of the project and works backwards into primary drivers (these are the big areas that we will need to work on to achieve the aim), secondary drivers (sometimes there are other things that we would need to put in place to make sure What are y ur int rim milestones?

the primary drivers work well) and change ideas (these are the ideas that we would test to see if they help move towards the overall aim by influencing the primary and secondary drivers). When you put all these ideas together, the driver diagram helps the users come up with a catalogue of changes that start to help form a project plan.

Example of a driver diagram from Ziphilly and Olive for their project on fluid and vital sign monitoring.

This is a driver because in order to achieve the aim the staff must know how the HDU forms should be completed.

Smart aim

Interventions

Drivers

Aim

• Continuous supportive supervision • Appoint HDU Champion • Develop a checklist • Orientation to new nurses on observation charts and guidelines Ordering monitoring equipment; equipment to measure vital signs; observation charts; burets and perfusers • Put up guidelines and policies and checklists • Have ward meeting and remind nurses about documentation • Provide assessment cards for nurses • Have orientation pack for new nurses on observation charts.

Improving vital signs and fluid balance monitoring for the High Dependence Unit (HDU) burn patients from 40% to 90% between September 2019 and January 2020.

• Staff compliance. • Adequate knowledge on fluid monitoring. • Availability of monitoring equipment.

Guidelines, policies and standards availability.

In the interventions they list the concrete actions that will help to achieve the Drivers that are identified. For example, there are several ways to remind nurses of the guidelines and policies during their work.

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UNDERSTANDING THE PROBLEM

5 why’s - this is an iterative interrogative technique. Each question forms the basis of the next question, always trying to get to the root of the problem.

Example from Richard’s project on improving pain relief.

Q: Why do few burn patients get adequate pain control before dressing changes? A: Because it is not always prescribed.

01

Q: Why is the pain medication not always prescribed? A: Because the doctors are not informed about the need for the prescription.

05 04 03 02

Q: Why are doctors not informed? A: Because there are no clear guidelines and policies on dressing changes for burn wounds.

Q: Why does the hospital not have guidelines and policies on burn management? A: There has been no formal training for the members of staff in burns who were expected to formulate guidelines and they therefore lack enthusiasm and knowledge.

Q: Why has there been no formal training amongst key individuals on burn management? A: Lack of (financial) support or opportunity.

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

Process mapping – This is a tool whereby we create a visual representation of each step or stage of “how things get done”. This detailed map then allows the users to identify areas where there are strengths and weaknesses in the current process so that improvements and resources can be targeted appropriately.

Example: Taweni made a process map of the decontamination of surgical instruments in the hospital theatres. Next to the tasks she noted her own observations about the process.

DOCUMENTATION OF SURGICAL INSTRUMENTS IN THEATRES

Move instruments to spoapy water (scrub nurse).

Scrub nurse puts instruments in chlorine for 10 minutes.

Scrub nurse disassembles instruments.

Remove gowns.

Instruments arrive in slouce from theatre.

Not always completed.

Instruments not brought to slouce room.

Instruments not disassembled, sharps not correctly disposed of.

Hospital attendants pre-make chlorine solution 7am/4pm Not always 10 minutes, can be less.

Nurse scrubs instruments with brush.

Not dried. No one responsible for this, stay in theater.

Instruments rinsed with water and dried.

Start and end of process

Activity or task

Instruments moved to packing area. (Nurse, Hospital assistant)

Instruments transported to steralisation department

Descision point

Flow line

Workflow diagram, also known as a spaghetti diagram, is another visual tool to help establish an the best lay out of an area, ward or department based on observations of the distance travelled by patients, staff or products. Using this observational method, we can identify areas where time could be saved by preventing unnecessary travel. For example, allocating patient assessment equipment together in the same room or on the trolley where the most frequent assessments take place to prevent having to find or travel to collect multiple pieces of equipment from different parts of the ward or unit.

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UNDERSTANDING THE PROBLEM

Strengths, Weaknesses, Opportunities and Treats (SWOT) analysis can be a helpful tool to check the factors which can affect the success or failure of an intervention.

Example: Olive & Ziphilly’s project on monitoring of vital signs and fluid balances shows an example of a SWOT analysis:

Weaknesses – List the factors that might be barriers to achieving your project objectives.

Strengths – List the factors which are likely to help you to achieve your project objectives.

SWOT ANALYSIS – BURNS UNIT – VITAL SIGNS & FLUID BALANCES Strenghts Weaknesses Availability of guidelines

Nurses knowledge deficit Lack of visible guidelines Lack of monitoring equipment

Approval of management Availability of nursing staff

Opportunities

Threats

Support by management Availability of nurses

Rotation of nurses to other wards Breakdown of monitoring machines and equipment

Threats – list external factors that are likely to have a negative effect on completing your project. What are the things that could stop the project from being successful?

Opportunities – these are things that create chances for things to happen, often these are outside your ward – for example, is there a hospital conference coming up where you could share your ideas?

Top Tip It is important to study the system rather than place blame on individuals for certain failings. For example, using the 5 why’s tool helps identify why staff might behave in a certain way based on the system they are working in.

These techniques are very important for your QI journey. Using these tools in collaboration with your team and stakeholders will make sure you have thought about the problem in enough detail and will help you anticipate barriers as well as strategies to overcome them. These tools will also help you understand what is and is not feasible as a QI project.

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

ASSESSMENT of the problem Once you have started to uncover the potential causes of a problem as a team, using the above techniques, you can take these ideas and create methods to MEASURE them, to assess the size of the problem and identify how much each identified factor is affecting the problem. You must start with a baseline assessment of the problem ; without knowing where you started you won’t know if you have made an improvement. This baseline measurement can also help you identify where to start your project.

The following is an example of how Olive & Ziphilly assessed the problem of recording vital signs and fluid balance, prior to implementation of the final project.

Assessment of the problem

✔ Checklist tool was created which contained 15 indicators of what needed to be done.

✔ Project leaders randomly checked through HDU observation chart documentation and identified vital signs and fluid balance monitoring and documentation on HDU observation charts were not done 2 hourly as per local guidelines.

✔ The problem was communicated to all burns staff during a meeting and the QI team was selected.

✔ The QI team retrieved 20 patient files with HDU observation charts for October and November 2019. The HDU observation charts were assessed against the checklist. 50% had poor vital signs and fluid balance monitoring and documentation.

✔ The problem was presented to the nurses during a meeting.

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UNDERSTANDING THE PROBLEM

Example: Patricia’s project on hand hygiene assessed the problem using two checklists:

The first checklist was used:

• To observe hand hygiene compliance by health workers • To ensure compliance to handwashing at all the 5 moments of hand hygiene

Staff Member Observed

1

2

3

4

5

6

Cadre

Clinician Nurse

Nurse

Nurse

Nurse

Support staff

Moment

YES NO YES NO YES NO YES NO YES NO YES NO

Before touching a patient Before a procedure After procedure or body fluid exposure After touching a patient After touching patient surroundings Additional

Item After removing gloves Unpainted nails

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

The second checklist was used: To assess the availability of hand hygiene resources: sinks, buckets, soap, alcohol rub, hand hygiene posters.

ITEM

COMMENTS

Sinks/buckets are available in all areas as needed Tap water is available in all sinks or buckets Hand washing steps poster is available Hand washing soap is available in all stations Alcohol hand rubs are available Alcohol hand rubs are well stocked Placement of alcohol hand rub is compliant with safety Hand hygiene reminder poster is present Hand hygiene is performed between patients

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............................................................................................................................................................................................................

............................................................................................................................................................................................................

............................................................................................................................................................................................................

............................................................................................................................................................................................................

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This data was collected by a team leader (nurse) each day. This data was collected on 5 consecutive days. Baseline measurements: The overall hand hygiene practice was at 5% and the availability of the hand hygiene resources was at 30%.

Clear quantitative baseline data (figures or percentages rather than descriptive indicators such as ‘poor’ or ‘good’), gives you the opportunity to compare outcomes of similar measurements at later moments to see if you have made a difference.

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CREATING A SMART AIM

STEP 4: CREATING A SMART AIM

Now that you have started to assess the problem, you can start to develop an aim for the project. Using the ‘SMART’ framework will ensure that your goals

are structured, realistic and achievable. A ‘SMART’ aimmeans you make sure it is:

S

M A R

T

Specific What is your specific goal/ intent? Be as concise and precise as possible.

Measurable How exactly are you going to measure the outcomes and baseline?

Achievable Have you thought of the potential barriers to the project, and how you can you overcome them?

Relevant How do you think your project will make a difference to your specific problem?

Time- framed

What is your time-frame? What are your interim milestones?

TOP TIP Create SMART aims which take into consideration your ‘ Sphere of Influence ’. Focus on what is achievable and scale up.

‘Sphere of Influence’ is an area where you have the power to change things

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

Example: Richard formulated the following aim for his project on pain control during dressing changes:

This first sentence gives a concise goal of the project, but it could have been more specific in describing what to change, e.g. prescription of medication, guidelines, training (see Richard’s 5 Why’s in Step 3).

Precise measurements at baseline and to aim for.

Clear time frame.

AIM

• Pain control should improve in burn patients from 20% to 80% between October, 2019 and February, 2020.

• It is a project that is aimed at ensuring that all patients with burn wounds are assessed properly and given adequate pain control to promote cooperation, proper wound care and facilitate wound healing process.

• This is in line with the objective of the surgical department which is to provide specialised individualised quality care to all patients in the department.

Identifies the results of the project on the pain control measurements but also the wider impact on patients and care.

This consideration means hospital policies and management will support the change. Richard is a senior nurse and involved in policy meetings. Make sure while designing your project that you consider what is achievable within your position at work.

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CREATING A SMART AIM

Olive & Ziphilly’s aim provides a great example of how to be as specific as possible. Making the objectives very concrete will help in the next steps when you develop the strategy for your change.

They could have been even more specific in formulating their aim to include what type of documentation and monitoring they mean for their specific hospital.

AIM

• Improving vital signs and fluid balance monitoring and documentation for HDU burn patients from 50.8% to 90% from January 2020 to March 2020 SPECIFIC OBJECTIVES: • To provide adequate knowledge on fluid monitoring and balance to nurses working in burns HDU • To ensure availability of monitoring equipments in HDU • To reinforce nurses staff compliance on fluid monitoring and balance

Once you have created your SMART aim you might want to revisit who is in your team and identify any additional stakeholders who might be affected by your intervention. If you find that there are additional stakeholders who need to be involved you should consider approaching them at this stage to encourage them to get involved as early as possible.

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

STEP 5: STRATEGIES FOR CHANGE

When you have an idea of something you would like to change, it is tempting to jump straight to this step. But why is it so important not to move straight to thinking about how you are going to make change? The steps before this are SO important to make sure you are making changes based on all the relevant information.

You might think the problems stem from one thing, but after assessing the situation you might find the cause is something else entirely. Every step before this ensures your project will be evidence-based, relevant and specific to the problem in your setting and it helps you to anticipate barriers and facilitators.

What is included in your strategy for change? When you start to think about making a change you may find that you can re-design a current system or you may need to design a completely new system. Either way, your strategy should ensure that:

✔ It addresses your SMART aim.

Patricia N tells us how important having the right resources is. https://www.youtube.com/ watch?v=9QTmXTkAnd0 Watch these videos Patricia N and E hrem reflect on the key aspects that you need in your strategy to have your project succeed.

✔ Everyone knows their role and responsibility within the project.

✔ There are feedback methods in place to see how the project is doing during its progress (e.g. audits; patient outcomes; observations; interviewing). ✔ There is space for adaptation/change within the project after you get feedback (see also the PDSA cycles discussed in Step 7).

✔ There is an evaluation plan.

✔ The change you introduce is sustainable after the project has ended.

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STRATEGIES FOR CHANGE

Also, do not forget to think of the practical issues when designing your plan – try to be as specific as possible. You should make a plan for the timing of the project (time plan) , any financial needs (budget) or other requirements (resources) , so you know the requirements and implications of the project. Planning out your project in such a way will also help you understand the things that could go wrong – and gives you time to find a solution.

Planning is an important part of your strategy as it allows you to organise how you will approach the project and the points at which you will need to be meeting with colleagues, collecting and reviewing the project’s progress. However, you will also need to be flexible and adaptable as the project progresses. It is crucial to note that QI is an on-going process, as you progress through PDSA (Plan- Do-Study-Act) cycles (see Step 7). Unlike more traditional research projects, QI does not have a natural “beginning, middle and end” but is a continuous loop. See Richard’s GANTT chart in the overleaf example .

TOP TIP When communicating your ideas consider your audiences – communicating your ideas will work best when you can present a clear advantage compared to current ways of doing things i.e. reduced time, simplifying a procedure, patient improvements and compliance.

GANTT charts, named after the inventor Henry Gantt, are often used as a way to illustrate a timeframe for individual actions and activities as part of a project.

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

Example: Time planning example from Richard’s pain control project

Richard planned to ensure that managers were engaged early and gave permission for the project to go-ahead.

Regular meetings with management to ensure they are aware of progress and early “buy in”

Time

Task

Collection of baseline data Seek authority from hospital managers Meeting with head of department

Initial meeting (formation of QI team)

Formulation of pain control guidelines Orientation of staff Finalise and laminate guidelines - distribute Select pain control campaign for patient involvement in asking for pain relief Follow up data collection Analysis of follow up data Review meetings champions Encourage

Report writing Dissemination

Regular review meetings and dissemination to report on progress, allow for staff feedback and input. Reports for management can help them follow the project and levy additional support.

Regular follow up / analysis to identify areas of progress / intended and unintended consequences over time to inform ‘further action in your project (see PDSA cycles in Step 7)

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STRATEGIES FOR CHANGE

At the start of the project you should work with your team to put together a realistic and itemised budget linked to the specific project objectives and activities. The budget should include any resources that you might need to collect or record the progress of your project i.e. paper, pens and printing costs. You should consider if purchasing additional items is really necessary and/or if there are alternative ways you can complete the project. If not, as a group you should note where extra money will come from. In cases where larger or more costly items are required you may need to consider working with your QI team to put a proposal together.

The project considered resources available at the hospital already which helped reduce overall costs.

Example: Budget example from Patricia’s hand hygiene project

No. Item / resource

Justification

Costs in local currency Provided by the hospital

1 Sink and running tap water in each room

For hand washing of patients and health workers

2 Alcohol based hand rub For hand cleaning by health workers and patients 3 Hand hygiene checklists To measure the changes/ collect data for evaluation 4 Lever arch files (x2) To keep data and the project documents 5 Plain papers (1 ream) For printing and photocopying the check lists, posters and project documents

Provided by the hospital

1000 Kwacha 6000 Kwacha 6000 Kwacha

6 Hand soap

For hand washing to remove microorganisms To paste on each sink and hand rub area to act as reminders

Provided by the hospital

5000 Kwacha

Posters

7

8 Permanent markers/ White board markers

To write when doing presentations

N/A already available

To use during progress meetings and presentations 5000 Kwacha

9 Flip charts

20,000 Kwacha

10 Printing Services

To print checklists, posters and documents For hand washing of patients and health workers

Buckets and basins to make additional hand washing stations

Some could be ordered from hospital stores Others had been previously donated to the unit.

11

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

The below example from Olive & Ziphilly’s project tries to incorporate the above points to create a strategy for change. You can see how they spell out the concrete steps to achieve their aim (see example in Step 4).

STRATEGY FOR CHANGE:

• • Involving stakeholders to provide monitoring equipment such as table and pen, pulse oximetry, buret, and wall clock were put in HDU. • • A motto was made and stuck on the wall. • • Progress of change was communicated through face-to-face, meetings, and notice boards to all the burns team and all stakeholders. • • Supportive supervision by project leaders and champion. • • Visible display of ‘best monthly documenter’. • • Allocation of 2 nurses in HDU per shift. • • Data collection and feedback meeting was done every 2 weeks. • • Reorientation on vital signs and fluid balance monitoring and documentation were held for nursing staff and student nurses working in Burns Unit. • • Change tested by PDSA cycle (see Step 7 below).

Olive and Ziphilly’s equipment

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STRATEGIES FOR CHANGE

Example : Patricia came up with a detailed strategy for change for her hand hygiene QI project.

STRATEGY FOR CHANGE:

• Appoint a team leader each day:

• To ensure the availability of hand hygiene resources. • To assess and record hand hygiene practices for each health worker available on duty.

• To inform hospital’s QI coordinator:

• About hand hygiene problem. • Lobby for supply of handwashing buckets and alcohol hand-rub.

Change is not easy.

• Write posters demonstrating:

• Hand hygiene. • Hand washing steps. • Moments of hand hygiene.

• Put up posters at every strategic point to act as reminders. • Motivate staff by:

• Clear communication and praise. • Train health workers.

• Educate patient guardians on hand hygiene. • Ensure communication using our notice board and via our unit Whats-app group to increase awareness of the project. • Use of video to educate health workers on need for hand hygiene.

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

This is one of Patricia’s posters that shows the correct technique for hand washing.

She thought about many practical aspects:

✔ It reminds everyone to wash hands. ✔ it is written in the local language so that everyone can understand. ✔ it has pictures for those who cannot read. ✔ it is laminated so that it does not become wet.

Nurse explaining the poster next to the hand washing station.

Nurse demonstrating best practice for Patricia’s project.

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STRATEGIES FOR CHANGE

Change is not easy Implementing change is not easy and might not go to plan for a number of reasons. Here are some of the reasons why change doesn’t happen: • More of the same – if people are not used to change, they will suggest more of the same, more people, money, equipment, as the solution. But until you really understand the root of the problem you cannot know if this is the right solution – sometimes it doesn’t need more resources, it needs a new way of working. • Adding more inspection or auditing – this might be another first response that colleagues will suggest, but is not always the solution as it is likely that this does not tackle the root of the problem. This might unnecessarily increase workload or decrease motivation. • Adding more procedures – it is easier to add to an existing system than to change it, but you need to be careful not to end up with an unnecessarily increased workload. Try to think of the whole system and of the long-term sustainability. • Focus on individuals rather than the system – for change to be sustainable, often it is the system that needs to change. Individuals might need training to change with it, but do not focus your change on them. • Searching for the perfect change can stop people implementing any change – however, there will always be unintended consequences and side effects, so while anticipating barriers, testing concrete changes is most important way to make progress. Start by making small incremental changes and scale up once you know these work. How do you get your team on board? Once you have designed your strategy for change, you will also need to consider how you will communicate your intended changes. It is crucial to any QI project that stakeholders are motivated to listen and be part of the changes you are suggesting.

Example : Richard gave presentations in his hospital to a wide range of stakeholders to communicate his project, as you can see in this photo. He also practiced an ‘elevator pitch’, which is a short message to sell your project (i.e., if you ever find yourself in the elevator with the Director of the hospital and you have two minutes to convince him or her to support your project, what would you say?) Find Richard’s elevator pitch here.

You can see some other examples in Olive & Ziphilly’s project strategy above. They created a motto for their project and they kept track of the best documenter of the month. Such ideas keep interest going and motivate people to stay involved.

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A PRACTICAL GUIDE TO QUALITY IMPROVEMENT FOR BURN CARE in Low-Resourced Settings

STEP 6: MEASURING THROUGHOUT

As mentioned in Step 3: Understand the Problem, you should plan to measure your change in order to identify if improvements are being made and if not, where you might need to re-consider your approach. During a quality improvement project you should collect data at a number of points. COLLECTING DATA only at the beginning and end, as you might see in a typical research project, will not be enough as you may need to make ADJUSTMENTS to your plan if you are not seeing an improvement, or in some cases you may need to stop the change if it is having a negative impact on the problem. When considering how you will measure your project results you need to think about: • How you will know whether or not you have achieved the desired outcome; • What information is currently available or could be easily collected These measures might include audits, patient feedback and/or observations. You will need to consider which is most appropriate and the key strengths and limitations of each method.

Common pitfalls with measurements: • Measuring too few variables – therefore not being able to demonstrate change has happened. • Measuring too many variables – getting confused results when not all variables are relevant to the change. • Not measuring frequently enough – means you have no chance to adapt your strategy throughout the project.

For your project, you need to decide:

In each of these examples nurses had to review and change an element of what they were measuring to make sure that they were measuring the right things , at the right time . • Which measurement tools are the best to investigate the change? • What are you going to measure? • How often are you going to measure?

Example of not measuring specifically enough: Olive & Ziphilly describe their measurement tool:

Olive & Ziphilly started with 10 different indicators that they

• Same checklist used to collect baseline data was used for measuring change progress; • A QI team checked patients observation charts in the files against the checklist tool which contained 15 indicators. • Data was collected using a data collection tool using a scoring system of 0, 1, 2 for every indicator and then put in a graph. • Data was collected every two weeks. • The tool was able to identify progress on every indicator and also helped to identify areas to focus change interventions.

were measuring. They found that the indicators

that they included were not specific enough to identify the precise areas which needed to be considered to improve documentation.

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