Step-by-step project example

This example is made up, but it includes parts from a real project done at the John Hunter Children’s Hospital's Paediatric Sleep Unit (JHCH PSU). It shows, step-by-step, how to set up and complete QI projects.

Step 1: Decide what needs to be improved

The JHCH PSU faced long waitlists, worsened by disruptions from the COVID-19 pandemic.
Analysis of waiting times and patient feedback showed significant delays in accessing sleep disorder diagnostics.
Discussions with sleep lab technicians, paediatric respiratory specialists, and nurses confirmed that the waitlist issue was well-known and affecting patient care.
There was broad agreement among unit staff and stakeholders that addressing these waitlists was a priority.
The Nurse Manager of JHCH Ambulatory Care gave approval to tackle the problem and agreed to sponsor the project.

Step 2: Assemble your team

We pulled together a small group to work on the project:

Project Sponsor	Nurse Manager of JHCH Ambulatory Care
Project Lead	Nurse Unit Manager of the Paediatric Sleep Unit
Project Manager	Hospital Scientist
Advisor	HNEkids Project Manager
Consumer representative	Consumer

Step 3: Craft your aim statement

We worked on the aim statement through several versions, making sure it was clear and achievable.

First draft

First Draft: "To reduce wait times for sleep studies at JHCH."

Feedback: This version is too broad. It doesn't say how we'll measure success or when we want to achieve this by.

Revised draft

Revised Draft: "To reduce in-lab sleep study wait times by 20% within the next year."

Feedback: Better, because it includes a clear target and deadline, but it doesn't explain how we'll achieve this or who specifically we're trying to help.

Second revision

Second Revision: "To decrease pediatric sleep study wait times by introducing more flexible scheduling options by the end of the year."

Feedback: This starts to address 'how' by mentioning flexible scheduling, but it's still not clear on the impact we expect or the full scope of who it affects.

Final aim statement

"To reduce the JHCH pediatric sleep study waitlist by 20% and enhance accessibility for high needs children/families and those with barriers to attending in-lab sleep studies by March 2024"

The final version is detailed and direct. It sets a clear goal for waitlist reduction, targets improving access, mentions a specific timeline, and focuses on children with high needs, making it a SMART aim.

Step 4: Explore existing solutions

To find the best way to tackle our waitlist challenges, we looked at what others have already done successfully.

Literature search:

How we searched	We used databases like PubMed and Google Scholar, searching for terms including "paediatric sleep studies," "home sleep testing," and "sleep study waitlist management."
Choosing articles	We picked recent articles (from the last five years) that talked about reducing wait times and reducing in-lab sleep studies. These articles helped us understand what has worked well in other places, including at home sleep studies.
Learning from research	The research showed that using technology, like telemedicine and at home sleep studies technology, could be very effective.

What we found out

Paediatric home sleep studies are successful 87% of the time, with most guardians reporting that their child slept as well or better than they do in a hospital (Russo et al., 2021).
The accuracy of measuring sleep issues at home is similar to those conducted in hospitals (Green et al., 2022).
These studies reduce waiting times and travel for families, which helps those living far from hospitals (Russo et al., 2021; Green et al., 2022).

Talking to other hospitals

We spoke with other paediatric sleep medicine teams at Sydney Children's Hospital Network and Royal Children's Hospital in Melbourne to learn about how they manage sleep study waitlists and any new methods they are trying.

Step 5: Map the current process

We mapped the current process for sleep studies in JHCH, from referral to completion.

Step 6: Collect baseline data about the problem

To better understand the issues in the Paediatric Sleep Unit, we focused on gathering important information from family experiences and how well the in-lab sleep studies were managed.

Family experience survey

Purpose	Findings
Find out what difficulties families face during in-lab studies, especially those with multiple children, parents working shifts, or children with behavioral issues.	Many families mentioned problems with scheduling and managing appointments, with children with behavioral issues feeling particularly stressed.

In-lab study metrics

Data points	Results
We looked at average wait times from when a study was referred to when it was completed, how often studies were completed on the first try, and how well the diagnostics worked.	The average wait time for a study was six months, and about 75% of studies were completed successfully on the first attempt.

Step 7: Brainstorm the causes of the problem

The project team met in a room with sticky notes and pens. We had 5 minutes to quietly write down what we thought caused the waitlist problems in the Pediatric Sleep Unit, using one sticky note per idea.

This is what our brainstorm session looked like:

Once all ideas were on the table, we began to group the sticky notes into themes to better understand the root causes and potential areas for change.

We turned/reoriented our sticky notes to the side to form the bones of our driver diagram, making the "themes" the primary drivers, and the "ideas" the secondary drivers.

We lined the ideas (secondary drivers) up vertically and added lines to show which theme (primary driver) each idea was linked to.

Step 8: Brainstorm and prioritise change ideas

In this step, we had a brainstorming session to think of changes for each secondary driver. We gave everyone 3 minutes for each driver to silently write their ideas on sticky notes. Then we added them to the driver diagram, taking out any repeated ideas.

Once we finished adding the change ideas, we made an electronic version of the driver diagram to save as an appendix in our final project report. Electronic driver diagrams can be made in QIDS or PowerPoint using the SmartArt function.

After that, we all looked at each change idea together, talking about whether they were easy or hard to do and if they would make a big or small difference. We placed each idea on a scale to show the feasibility vs potential impact of the idea. In doing this, we found that offering sleep studies at home would be both feasible and highly impactful.

Step 9: Test changes with PDSA cycles

We used PDSA cycles, which are steps for testing changes, throughout the project, starting with the 'Sleep Studies at Home' test. First, we tried it with a few patients to see how it went. Here are two PDSA cycles that show how we made our methods better based on what we learned from these first tries.

First PDSA cycle

Plan: Trial home sleep studies with 5 patients who have accessibility issues or high anxiety about hospital visits. Provide basic written instructions for equipment setup.
Do: Implement the studies, with equipment sent to patients’ homes and initial phone support provided.
Study: Analyse the data quality and collect feedback, noting that families requested more visual guidance for setup.
Act: Decide to create detailed video instructions to improve the setup process based on feedback.

Follow-on PDSA cycle

Plan: Expand the test to 20 patients, incorporating video instructions for equipment setup to enhance understanding and ease of use.
Do: Distribute home sleep study kits with access to online video instructions; offer real-time video call support during setup.
Study: Evaluate the effectiveness of the video instructions through feedback on ease of use and data completeness.
Act: Use video instructions as a standard part of the home sleep study process and prepare for broader implementation.

Step 10: Decide on overall measures for your project

To properly check how well the Sleep Studies at Home initiative is working, we needed to set clear goals and measure our progress against them. Here's how we did it:

Outcome measures

Reduction in wait times: Our main goal is to cut down the wait times for sleep studies by 20% by the end of the year. We'll do this by comparing this year's average wait times to last year's, after we start doing more sleep studies at home.

Process measures

Percentage of Home Sleep Studies: We'll keep track of how many sleep studies are done at home compared to in the clinic to make sure we're increasing the number of home studies as planned.

Patient setup success rate: We'll watch how often patients set up their home sleep study equipment correctly on the first try, with help from our new video instructions.

Balancing measure

Impact on in-lab study analysis: We need to watch if doing more home sleep studies makes it slower or harder to analyse the data from in-lab studies. This is important to make sure that adding more home tests doesn’t cause delays or problems with our traditional in-lab studies.

Step 11: Collect and analyse data

To see how well the "Sleep Studies at Home" project worked, we looked at stories and survey data from patients and their families. This helped us see the benefits and areas where we could improve.

Qualitative evidence

Impact stories	Jamie’s experience: Jamie had a successful home sleep study which was less stressful because it was done in a familiar place. This shows it's good for kids who are sensitive to new environments. Pip’s experience: After a home sleep study, Pip got a fast diagnosis and treatment, showing how quick and effective the service can be in urgent situations.
Consumer feedback	Families liked the home testing because it's easier, especially for those with many children or parents who are shift workers. Children with behavioral issues felt less stressed and anxious doing the test at home. Families noted less disruption to their routines and better sleep during home tests.

Impact stories

Jamie’s experience: Jamie had a successful home sleep study which was less stressful because it was done in a familiar place. This shows it's good for kids who are sensitive to new environments.

Pip’s experience: After a home sleep study, Pip got a fast diagnosis and treatment, showing how quick and effective the service can be in urgent situations.

Consumer feedback

Families liked the home testing because it's easier, especially for those with many children or parents who are shift workers.

Children with behavioral issues felt less stressed and anxious doing the test at home.

Families noted less disruption to their routines and better sleep during home tests.

Quantitative evidence

Survey responses from 44 families	Ease and acceptability
80% liked the flexibility of testing at home. 73% found it more convenient. 64% preferred the comfort of being at home. 95% of families were happy with the testing process. 74% would choose home testing again for future tests.	86% said home testing was less stressful than in-lab tests. 85% felt more comfortable doing the test at home compared to the lab. 77% found home testing easier than in-lab procedures.

Over 250 at-home studies were conducted during the project, effectively reducing the JHCH paediatric sleep study waitlist by 20%.

Step 12: Sustain the gains and spread the success

In the final phase of the "Sleep Studies at Home" project, we focused on cementing the gains and ensuring the initiative could be expanded effectively.

Comprehensive guidelines and educational materials were developed for staff and families to standardise the use of home sleep study equipment.
We trained all sleep unit staff to conduct both in-lab and home studies, enhancing flexibility and maintaining service quality.
Equipment standardisation across settings reduced costs and improved data consistency.
We gathered robust evidence to validate the effectiveness of home studies, aiming to support future Medicare coverage applications.

Following the completion of our project report using the HNEkids template, we are considering submitting our findings to an upcoming respiratory conference to share our successes and learnings with a broader audience.