Quality not quantity: How small changes can cause a ripple effect in improvement work

A stethoscope.

Delphine Corgié, one of our Project Managers, blogs about how our quality improvement (QI) work is leading to significant reductions in hospital-acquired acute kidney injury (AKI) at Salford Royal NHS Foundation Trust.

In my experience of working in quality improvement with healthcare professionals it has become clear that staff engagement is paramount to the success of any project. This is no different at Salford Royal NHS Foundation Trust who have a dedicated QI team. However, the setup at the Trust is different: as part of the organisation’s culture, continuous improvement is everybody’s business (it is even one of the Trust’s core values), and as such they have set up a network of link nurses for each major QI project across the wards.

In May, the AKI link nurses met for lunch to get up-to-date with their improvement activities and to share ideas. They normally meet as a “collaborative” (for the AKI work) once every three months, but the improvement model they are using relies heavily on networking and sharing their experience, with a view to learning faster and accelerating improvement, which is why they met this time in between learning sessions.

The link nurses were presented with the latest AKI data; the improvement is fascinating to see across the hospital but more importantly across the 13 wards that are actually engaged in this piece of work. The data shows statistically significant drops in hospital-acquired AKI and also in progression from stage one to two or three. Strangely enough, this came as a surprise to the nurses who didn’t expect to see such good news considering they struggle to dedicate time to improvement work when they are so busy on the wards. But this is the beauty of working on a collaborative method adapted from the Institute for Healthcare Improvement, where you are encouraged to do little things that will have a ripple effect on the overall management of patients. This type of improvement can be done as part of the link nurses’ daily job – in their case, raising awareness of simple interventions was enough to impact on the data.  

A graph showing data that demonstrates the reduction in AKI progression for the collaborative wards.

Amazing reduction in AKI progression for the collaborative wards.

Disappointingly, the room wasn’t packed with the expected number of nurses due to the usual pressure on the wards, but good discussions took place regarding other non-clinical but important issues to nurses on the ward, such as efficient use of the electronic tracking boards, training required for improved use of AKI documentation on the electronic patient record (EPR), and general training around AKI for all staff.

A number of simple interventions have already been introduced to improve the management of AKI at the Trust: an alert appearing at the top of a patient record on the EPR system, a simple algorithm (cleverly designed with the SALFORD acronym), a full online training package, ward posters and leaflets.

An example of Salford's acute kidney injury cards.

Salford’s AKI cards (I have one on my badge holder too!)

The AKI collaborative at the Trust seems to me like a success story, although it has been slow to take off and has been affected by the usual ward pressures, the junior doctor strikes, and other usual hospital related challenges. The staff are truly motivated to improve the management of patients with AKI and the data illustrates this clearly. External QI teams are also interested in the work being done here, such as the team members at Oxford University Hospitals NHS Foundation Trust who came along to the last learning session and are keeping in touch to share their AKI improvement journey.

Next, I am keen to see further spread of the good work around the wards and I am now embarking on a journey to develop a support worker link group, while a clinical research fellow is keen to get junior doctors more involved. I am really looking forward to these last few months working with the QI and clinical teams at Salford Royal on this fascinating improvement programme.

More information

For more information about the Managing Acute Kidney Injury Together for better health (MAKIT Better) project, please see the website project pages or contact Delphine Corgié, Project Manager.