Table 1

Suggested quality improvement tools

Stage of project	Tool	What is it?	How to use	Example
Identifying problems	Fishbone (cause and effect).	Cause and effect analysis helps you to think through the causes of a problem, including possible root causes, before you start to think of a solution – not just symptoms.	Create diagram to identify all possible causes of a problem.	Figure 2. Antibiotics in sepsis.
	Process map,	Diagrammatic representation of all steps within a patient pathway.	To understand the ‘flow’ of patients and to identify replicated and redundant processes.	https://improvement.nhs.uk/documents/2143/conventional-process-mapping.pdf
	Root cause analysis (‘5 whys’ is a similar, simpler tool).	To identify the ultimate cause (s) of failure within a process.	To understand key elements of process and where they have failed.	https://improvement.nhs.uk/documents/2156/root-cause-analysis-five-whys.pdf
	Heathcare failure modes and effect analysis.	To identify where a process could fail.	To understand key elements of process and where they could fail.	https://www.patientsafety.va.gov/professionals/onthejob/hfmea.asp
	Driver diagram.	Similar to fishbone diagrams, driver diagrams can be used to illustrate your theories for cause and effect in your system.	It is helpful to create driver diagrams during the initial planning stages of a change programme.	Figure 3. Example driver diagram.
Developing aims	SMART Aims	An aims statement should be included stating what you want to achieve from your project and timeframe for completing it.	You should include the following elements: Specific: don’t just say ‘we will improve time to triage’. Measurable: has a numerical target that can be measured (eg, reduction in time to triage by 30 min). Achievable: is the goal possible? Relevant: is it patient centred and/or linked to strategic aims of your institution? Time-bound: dates should be provided for when you want to achieve this aim by.	‘We aimed to reduce average time to triage by 30 min (from 60 min) at North Bristol Hospital by December 2019’.
	Pareto diagram, dot voting, priority matrix.	These tools all evaluate possible interventions to establish which to use.	To select ‘best’ intervention in the context of the individual setting.	https://improvement.nhs.uk/documents/2137/pareto.pdf
	De Bono’s Thinking Hats, ‘Breaking the Rules’, ‘Fresh eyes’, ‘Stop before you start’, TRIZ and so on.	These are variety of tools that give a systematic approach to creative thinking regarding problems and potential solutions.	For use in small groups when considering possible interventions.	https://improvement.nhs.uk/documents/2167/six-thinking-hats.pdf
Measurement for improvement	Plan, Do, Study, Act (PDSA) Cycles	This model for improvement provides a framework for testing small-scale interventions in a structured way prior to whole system change. A high-quality QI project will include a number of PDSA cycles testing small interventions over time.	The four stages of the PDSA cycle are: Plan: the change to be implemented. Do: carry out the change. Study: collect data before and after the change to see if an improvement in chosen outcome was achieved. Act: plan next change cycle or implementation.	Figure 4. The PDSA cycle model for improvement.
	Control charts, such as: Statistical Process Control (SPC) chart (run charts are similar, but simpler).	A graph showing a measure (eg, time to triage) over time. We suggest a minimum of 25 data points, together with means and some upper and lower control limits as lines.	Control charts are used to understand the scale and variation of the problem. It is encouraged that specific interventions (PDSA cycles) are illustrated on SPC charts to allow the reader to determine whether the intervention leads to improved process measures.	Figure 1. An example of run chart and SPC chart. Different ‘rules’ exist for SPC and run charts defining sufficiency of data, trends and shifts/changes (see explanation in figure legend).