Quality Improvement Activity Report
Quality Improvement Activity Report
Activity title: Head/ Neck Cancer Surgical Ward Nutrition Support
Team: Food service staff, allied health professionals (dietitian & speech pathologist) and nurses
PLAN
Problem/ Issue to be addressed?
Setting: Head/ neck cancer surgical ward
Relevant background to the problem:
Several patients who have been prescribed Ensure Plus (ready-to-drink nutritional supplements) claimed not receiving their drinks regularly to the dietitian on review. However, a large number of bottles accumulated in the ward pantry, which represents several days of supplementation for each patient.
Rationale for change:
Possible lack or miscommunication between staff members and unclear guidelines on delegation of responsibility, which is probably due to: lack of training, short staff, inadequate labelling of nutritional supplements, poor communication on supplement delivery.
Problem:
Patients not receiving their nutritional supplements regularly but a large number of bottles accumulated in the ward pantry.
Associated risks (if the problem is not addressed):
Patients are unable to meet nutritional requirements (especially protein and energy for cancer patients) and thus malnutrition can happen.
Relevant BPDs, standards or policies:
Aim (desired outcome)
What are you trying to accomplish Should be a big picture statement e.g. To implement or,
To improve.or,
To facilitate..Objectives
Your objectives should be
SPECIFIC
MEASURABLE
ACHIEVABLE
REALISTIC
TIMELY
May be several, would suggest a minimum of 2-3 and maximum of 4-5 would be appropriate
Actions planned
What are you going to do to achieve your outcome?
What stakeholders will you need to involve? These are essentially your strategies to achieve the objectives make sure you are referring back/linking these to your goal and objectives
Other actions considered
What other solutions did you consider and why did you discard them?
NB This is not part of the normal report form but it will demonstrate the process your group has used to weigh up the various options What were the other approaches you considered in the brainstorming tutorial and why did you not choose this approach?
Performance Indicators/ Measure(s)
How will know things have improved?
What will be monitored/evaluated?
Refer to week 7 lecture for info on this what are your measurable outcomes?
Baseline Data is there any?
Using the indicator/measure(s) identified above, what baseline information is needed before making any changes?.What information would you need to be able to measure change?
Where did you start?
EVALUATION METHOD
How will you know it is working? List the methods used to see whether the objectives are achieved and when eg XXX audit in 6 monthst.
Procedure template
Procedures describe how a policy will be implemented and provide step-by-step instructions.
Name of PROCEDURE:
Approved By:
Take an educated guess at who your lead staff would be on the project it might be a food service manager, or director etc
Approved On: DD/MM/YYYY
Purpose/objectives
Why do we have this procedure?
This procedure ensures that.
Context Background
A concise statement on the application of the procedure. This section can also contain background information that may help the reader better understand the procedure.
Scope
Who and what does the procedure apply to? Does it apply to everyone and everything?
Definitions
Any acronyms or jargon words used?
PROCEDURE CONTENT
What steps need to occur to achieve the objectives?
This can be an attached flowchart, table or checklist
Useful links
Related documents/ policies etc
Acknowledgements
Reference to policies or documents from other hospitals/ agencies, legislation, documents used to inform this procedure
Consultation
Who was on the procedure working party?
Who was consulted?
Who would you need to meet with from the various healthcare teams to upskill them on your intended project solution this should include people that you need to help carry out any actions in your plan.
Review
When is the procedure due for review?
Accountabilities
Who is responsible for the procedure? List individual job titles and/or departments and what part of the procedure they are responsible for.
COMMUNICATION
How will it be communicated to the relevant stakeholders, what training if any will be required?
