MEASURE IT, IMPROVE IT: the Safer Patients Initiative and quality improvement in subcutaneous insulin therapy for hospital in-patients.

AIMS: NHS Tayside, UK, identified risks with subcutaneous insulin therapy for hospital in-patients: overlooked abnormal blood glucose readings; prescription errors and failure to administer insulin. Involvement in the Safer Patients Initiative provided opportunities to use different methods of quality improvement, to create a process that facilitated prevention, detection and mitigation of diabetes management problems for in-patients requiring subcutaneous insulin therapy. The aim was to explain these methods, their use and results obtained.
METHODS: A failure modes effect analysis identified present risks in the process of subcutaneous insulin therapy. In response, an evidence-based care cluster was developed and used to design a new insulin prescribing chart. The chart was introduced and modified using small tests of change [plan-do-study-act cycles (PDSAs)]. Compliance data on completing the actions required by the chart were gathered (small-scale audits), and results displayed (process run charts) to those delivering care.
RESULTS: Practice improved over the 9 months: patient identification: 97-100%; identification of insulin device 11-100%; insulin administration 75-95%; hypoglycaemic control 85-94%. The chart prompted compliance with the evidence base, identified trouble-shooting actions to mitigate arising problems and presented opportunities to educate non-specialist staff.
CONCLUSION: Using these methods ensured changes were evidence-based, posed negligible risk to patients and provided a set of tasks against which compliance could be measured to assess changes to practice. Implementation through PDSAs allowed the chart to be adjusted to fit the context and meet the needs of those using it, while preserving the evidence base.