{"id":28,"date":"2015-07-08T13:40:01","date_gmt":"2015-07-08T13:40:01","guid":{"rendered":"https:\/\/staffblogs.le.ac.uk\/sapphire\/?p=28"},"modified":"2025-02-26T13:26:19","modified_gmt":"2025-02-26T13:26:19","slug":"theory-and-quality-improvement","status":"publish","type":"post","link":"https:\/\/staffblogs.le.ac.uk\/sapphire\/2015\/07\/08\/theory-and-quality-improvement\/","title":{"rendered":"A Practitioner&#8217;s Musings on Theory and Quality Improvement"},"content":{"rendered":"<p style=\"text-align: center\">I am a PhD student and a practicing extended scope physiotherapist and I\u2019d like to find out how my NHS colleagues can use information from quality improvement projects to change care for the better. If your quality improvement project has worked, helping others to understand what you did (so that the same results can be achieved somewhere else) is an important but often neglected task. Thus, I wonder\u2026 how should information about quality improvement be shared and presented so that quality improvement interventions can be reproduced in new contexts?<\/p>\n\n\t\t<style type=\"text\/css\">\n\t\t\t#gallery-1 {\n\t\t\t\tmargin: auto;\n\t\t\t}\n\t\t\t#gallery-1 .gallery-item {\n\t\t\t\tfloat: left;\n\t\t\t\tmargin-top: 10px;\n\t\t\t\ttext-align: center;\n\t\t\t\twidth: 25%;\n\t\t\t}\n\t\t\t#gallery-1 img {\n\t\t\t\tborder: 2px solid #cfcfcf;\n\t\t\t}\n\t\t\t#gallery-1 .gallery-caption {\n\t\t\t\tmargin-left: 0;\n\t\t\t}\n\t\t\t\/* see gallery_shortcode() in wp-includes\/media.php *\/\n\t\t<\/style>\n\t\t<div id='gallery-1' class='gallery galleryid-28 gallery-columns-4 gallery-size-medium'><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/staffblogs.le.ac.uk\/sapphire\/2015\/07\/08\/theory-and-quality-improvement\/emma-jones-blog-turned\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"225\" src=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-turned-300x225.jpg\" class=\"attachment-medium size-medium\" alt=\"\" aria-describedby=\"gallery-1-36\" srcset=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-turned-300x225.jpg 300w, https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-turned.jpg 469w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-1-36'>\n\t\t\t\tWe can share information face-to-face at work . . .\n\t\t\t\t<\/dd><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/staffblogs.le.ac.uk\/sapphire\/2015\/07\/08\/theory-and-quality-improvement\/emma-jones-blog-3-2\/'><img loading=\"lazy\" decoding=\"async\" width=\"200\" height=\"300\" src=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-31-200x300.jpg\" class=\"attachment-medium size-medium\" alt=\"\" aria-describedby=\"gallery-1-39\" srcset=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-31-200x300.jpg 200w, https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-31.jpg 245w\" sizes=\"auto, (max-width: 200px) 100vw, 200px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-1-39'>\n\t\t\t\tor in lectures and teaching sessions . . .\n\t\t\t\t<\/dd><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/staffblogs.le.ac.uk\/sapphire\/2015\/07\/08\/theory-and-quality-improvement\/emma-jones-blog-2\/'><img loading=\"lazy\" decoding=\"async\" width=\"225\" height=\"300\" src=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-2-225x300.gif\" class=\"attachment-medium size-medium\" alt=\"\" aria-describedby=\"gallery-1-30\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-1-30'>\n\t\t\t\tor in academic journals . . . \n\t\t\t\t<\/dd><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/staffblogs.le.ac.uk\/sapphire\/2015\/07\/08\/theory-and-quality-improvement\/emma-jones-blog-4\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"199\" src=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-4-300x199.jpg\" class=\"attachment-medium size-medium\" alt=\"\" aria-describedby=\"gallery-1-32\" srcset=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-4-300x199.jpg 300w, https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-4.jpg 396w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-1-32'>\n\t\t\t\tor even on Twitter!\n\t\t\t\t<\/dd><\/dl><br style=\"clear: both\" \/>\n\t\t<\/div>\n\n<p>In the first blog post of a short series I will get to grips with the basics:<\/p>\n<p>What is quality improvement? And what is theory? I\u2019ll need to know at least a little about both of these things, before I can think about how they might work together to make our healthcare system better.<\/p>\n<ol>\n<li><strong><em> What is Quality Improvement?<\/em><\/strong><\/li>\n<\/ol>\n<p>\u2018Quality\u2019 is a late 14<sup>th<\/sup> century word meaning \u2018degree of goodness\u2019. In the NHS, good quality care should include <a href=\"http:\/\/www.england.nhs.uk\/wp-content\/uploads\/2014\/10\/5yfv-web.pdf\">all three domains of quality<\/a>\u00a0&#8211; patient safety, clinical effectiveness, and patient experience. Quality improvement (QI) can involve enhancing any one of these aspects of quality. <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2464920\/\">A longer definition <\/a>explains that QI involves the \u201ccombined and unceasing efforts of everyone\u2014healthcare professionals, patients and their families, researchers, payers, planners and educators\u2014to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development\u201d.<\/p>\n<p>QI often uses specific techniques such as Plan Do Study Act cycles and SPC (Statistical Process Control). Using structured methods helps in identifying problems, selecting and testing interventions, and measuring changes. <a href=\"http:\/\/www.health.org.uk\/publications\/quality-improvement-made-simple\">The Health Foundation<\/a> and <a href=\"http:\/\/www.nhsiq.nhs.uk\/media\/2591385\/siguide.pdf\">NHS England<\/a> have produced helpful guides on how to use such techniques well.<\/p>\n<p>Some great examples of QI projects and interventions were showcased at the recent <a href=\"https:\/\/em.hee.nhs.uk\/health-education-east-midlands-quality-improvement-forum-10-june-2015\/\">Health Education East Midlands Quality Improvement Forum<\/a>. For example, Maheswaran and colleagues at Kettering General Hospital designed some stickers for weekend discharge plans to help doctors to identify quickly whether a patient is medically fit for discharge. More broadly, healthcare staff can intervene in many different ways to improve care.<\/p>\n\n\t\t<style type=\"text\/css\">\n\t\t\t#gallery-2 {\n\t\t\t\tmargin: auto;\n\t\t\t}\n\t\t\t#gallery-2 .gallery-item {\n\t\t\t\tfloat: left;\n\t\t\t\tmargin-top: 10px;\n\t\t\t\ttext-align: center;\n\t\t\t\twidth: 50%;\n\t\t\t}\n\t\t\t#gallery-2 img {\n\t\t\t\tborder: 2px solid #cfcfcf;\n\t\t\t}\n\t\t\t#gallery-2 .gallery-caption {\n\t\t\t\tmargin-left: 0;\n\t\t\t}\n\t\t\t\/* see gallery_shortcode() in wp-includes\/media.php *\/\n\t\t<\/style>\n\t\t<div id='gallery-2' class='gallery galleryid-28 gallery-columns-2 gallery-size-medium'><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/staffblogs.le.ac.uk\/sapphire\/2015\/07\/08\/theory-and-quality-improvement\/emma-jones-blog-5-2\/'><img loading=\"lazy\" decoding=\"async\" width=\"169\" height=\"300\" src=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-51-169x300.jpg\" class=\"attachment-medium size-medium\" alt=\"\" aria-describedby=\"gallery-2-37\" srcset=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-51-169x300.jpg 169w, https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-51.jpg 313w\" sizes=\"auto, (max-width: 169px) 100vw, 169px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-2-37'>\n\t\t\t\tHealth Education East Midlands Quality Improvement Forum 2015 Programme\n\t\t\t\t<\/dd><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/staffblogs.le.ac.uk\/sapphire\/2015\/07\/08\/theory-and-quality-improvement\/emma-jones-blog-6\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"169\" src=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-6-300x169.jpg\" class=\"attachment-medium size-medium\" alt=\"\" aria-describedby=\"gallery-2-34\" srcset=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-6-300x169.jpg 300w, https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-6.jpg 545w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/dt>\n\t\t\t\t<dd class='wp-caption-text gallery-caption' id='gallery-2-34'>\n\t\t\t\tPoster by Maheswaran and colleagues from the Quality Improvement forum\n\t\t\t\t<\/dd><\/dl><br style=\"clear: both\" \/>\n\t\t<\/div>\n\n<ol start=\"2\">\n<li><strong><em>What is theory?<\/em><\/strong><\/li>\n<\/ol>\n<p>A theory is a set of interrelated ideas and can provide a foundation for understanding something. Scholars love theories, but clinicians use them too, probably more often than we think during our everyday work.<\/p>\n<p>One example that fits this definition is the <a href=\"http:\/\/www.patientsafetyfirst.nhs.uk\/ashx\/Asset.ashx?path=\/Intervention-support\/Human+Factors+How-to+Guide+v1.2.pdf\">Swiss cheese model<\/a> of patient safety, originally proposed by James Reason. There is debate over its status as a <em>theory <\/em>of accident causation as it functions like a <em>\u2018model\u2019,<\/em> and recent criticism has highlighted the limitations to its usefulness. Despite these problems, the image of \u2018Swiss cheese\u2019 as a process of identifying error is still recognisable by a large proportion of clinical staff. We tweet Swiss cheese images\u2026\u2026. A lot!:<\/p>\n<div id=\"attachment_35\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-7.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-35\" class=\"size-medium wp-image-35\" src=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-7-300x183.png\" alt=\"Society of Hospital Medicine 2015 conference - #HospMed15\" width=\"300\" height=\"183\" srcset=\"https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-7-300x183.png 300w, https:\/\/staffblogs.le.ac.uk\/sapphire\/files\/2015\/07\/Emma-Jones-Blog-7.png 610w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-35\" class=\"wp-caption-text\">Society of Hospital Medicine 2015 conference &#8211; #HospMed15<\/p><\/div>\n<p>And our professional bodies (such as the <a href=\"http:\/\/www.rcn.org.uk\/development\/practice\/cpd_online_learning\/making_sense_of_patient_safety\/core_concepts_in_patient_safety\">Royal College of Nursing<\/a>) encourage us to recognise the Swiss cheese model so that we can understand how to make our patients safer.<\/p>\n<p>Personally, I associate the Swiss cheese model with meetings we hold at the hospital when we needed to address a complaint. In these situations the model was used to identify a trigger for the error &#8211; such as chaotic working environments, stress, too little staff, or frequent staff changes &#8211; because this is what starts the cascade towards an accident. We then try to recognise the things that errors hate \u2013 safe communication, clear agreements, and calmness even in emergencies. By reflecting on what happened and by working through the holes in the cheese we can then come up with a solution to make sure the accident does not happen again.<\/p>\n<p>Another example of everyday use of theory is in behaviour change, which has been used in the routine management of low back pain, and is recommended by the National Institute for Health and Clinical Excellence (NICE) <a href=\"https:\/\/www.nice.org.uk\/guidance\/cg88\">guidance<\/a>. This means using practical techniques such as signed exercise agreements, verbalising goals, or providing written educational material in order to alter patients\u2019 day-to-day habits and thus reduce their pain. These techniques have all grown out of the scholarly work on behaviour change theory, and they have been critical to maintaining good patient care throughout my 14 years in practice as a physiotherapist.<\/p>\n<p>Until recently I hadn\u2019t thought about how much I already use theory in my clinical work. In my next blog I\u2019m going to think about theory I\u2019m not already using, and how it might help me in my ability to carry out quality improvement work. Watch this space!<\/p>\n","protected":false},"excerpt":{"rendered":"<p>I am a PhD student and a practicing extended scope physiotherapist and I\u2019d like to find out how my NHS colleagues can use information from quality improvement projects to change care for the better. If your quality improvement project has worked, helping others to understand what you did (so that the same results can be [&hellip;]<\/p>\n","protected":false},"author":217,"featured_media":36,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[14],"tags":[18,17,16,15,19,4],"class_list":["post-28","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-research-in-practice","tag-clinical-practice","tag-qi","tag-quality-improvement","tag-research-in-practice","tag-swiss-cheese","tag-theory"],"_links":{"self":[{"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/posts\/28","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/users\/217"}],"replies":[{"embeddable":true,"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/comments?post=28"}],"version-history":[{"count":1,"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/posts\/28\/revisions"}],"predecessor-version":[{"id":40,"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/posts\/28\/revisions\/40"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/media\/36"}],"wp:attachment":[{"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/media?parent=28"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/categories?post=28"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/staffblogs.le.ac.uk\/sapphire\/wp-json\/wp\/v2\/tags?post=28"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}