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How quality improvement tools can be used to improve care in an IBD Unit

The quality of healthcare services for people living with inflammatory bowel disease (IBD) was the focus of the patient survey and service self-assessment exercise led by IBD UK in 2019-20. Feedback was collated from patients and clinical teams across the UK to build a picture of what was being done well and to identify where standards of care could be raised.

While the aspiration to achieve service goals may at times feel like an impossible conundrum of trying to do more with less, the application of quality improvement (QI) methodology allows us to challenge the impossibility of achieving more with limited resources. 

The Kings Fund refers to QI as “the systematic use of methods and tools to try to continuously improve quality of care and outcomes for patients”. For the Edinburgh IBD Unit (EIBDU), the benchmarking exercise was an opportunity to measure the quality of changes made to their patient services as part of their own QI journey. This journey began around 2017 and included a project to promote innovation, quality, safety and value in their biologics service.

The EIBDU QI Team
  • NHS Lothian is the second largest territorial health board in Scotland, with an IBD prevalence of 1 in 125
  • The EIBDU is the main site in the health board for delivering specialist and tertiary IBD care
  • The EIBDU QI Team meets once a month for the purpose of strategic planning and to work on QI activities 
  • Specialist IBD pharmacists, consultant gastroenterologists, IBD clinical nurse specialists, infusion nurses, service management and the administrative team are all represented in the Team.
Getting inspired and getting focus

A significant event for integrating QI methodology into the EIBDU biologics service was the QI coaching clinic which the team attended, run by the health board’s Quality Directorate. As novices of QI methodology, the team were looking for expert guidance on how to measure the impact of a recently implemented change. This scenario of reactive change and measurement may be familiar to other teams starting out in QI.

Embracing QI strategies and tools has helped the team to meet the challenge of using increasingly complex strategies to deliver optimal outcomes and needs-based care

Instead of coaching them to measure this ‘solution’ using QI tools, the team were coached into taking a ‘balcony’ perspective of their service and patients’ experience. 

Inspired by the peer discussion which had taken place, a second coaching session was arranged to explore the wider QI potential of the service. Armed with sticky notes, marker pens and scrolls of paper, the QI coaching colleague facilitated a process mapping session, helping the team to visualise together the steps involved in initiating and monitoring biologic therapy. This map became their tool for change.

Developing a QI ready team

To consolidate the QI competency required to progress change ideas derived from the process map, team members signed up to a QI skills course delivered locally by the NHS Lothian Quality Academy. Alongside attendance at taught study days, participants were also required to demonstrate the practical application of the learning set by completing their own QI project.

The team used this QI project to give focus to the first steps in their process map by agreeing the aim statement “Improving the initiation of biologic therapy for patients living with IBD” and producing a project charter which described how the improvement would be achieved and measured. 

The team applied various QI tools in this project, including:

  • run chart
  • Pareto chart
  • process map 
  • fishbone diagram
  • patient questionnaire
  • dot voting
  • tests of change. 

This supported learning environment gave the team confidence in their QI capabilities and taught them early valuable lessons. They learned not to decide on the solution before beginning a project, the importance of not making assumptions, and the necessity of gathering baseline data.

QI journey to promote innovation, quality, safety and value in a biologics service

Since the first QI project charter, the EIBDU QI Team have maintained momentum through their monthly meetings, using QI tools such as the Model for Improvement to work through service improvement. The outcomes from this have included: extended professional roles which allow the team to work at the top of their license; enhanced medicine governance; and, innovative new care models for biologic counselling, prescribing, monitoring and review. 

Embracing QI strategies and tools has helped the team to meet the challenge of using increasingly complex strategies to deliver optimal outcomes and needs-based care. As their journey continues, the team continues to thread quality throughout their biologic service by asking, “What went well, what didn’t go so well, and what could go better next time?”

Useful resources

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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