Hi, I'm Laura Playforth. My background is in emergency and critical care, and after a number of years as a first opinion GP vet, I've spent the last 12 years at Vets Now. My current role is professional standards director with responsibility for maintaining and progressing our clinical and professional standards across the company.

I've recently completed my master's in advancing healthcare practise with the Open University, which was basically all about quality improvement, change management and leadership in healthcare settings. I'm also currently vice chair of the RCVS Knowledge Quality Improvement Advisory Board. And I'd like to talk a little about what we mean by quality improvement, why it's of critical importance in veterinary care, and then discuss some examples of tools that can be used in practise for quality improvement projects and some examples of how we've used them at Vets now.

So this is what I'm aiming to achieve during the webinar. You can see the learning objectives on the screen just now. And by the end of the session, my hope is that I've managed to get across the concept of quality improvement in healthcare, and signposted you to all the tools, knowledge and resources that you need to begin or progress your own projects.

And we'll return to these again at the end of the session for your own reflection. And also feel free to get in touch and give me any feedback on how you think I could have improved delivery to ensure these outcomes are achievable. What does quality care mean to you?

It's really worthwhile at this point, taking the time to think about what quality care means to you as an individual. So take a moment to get a pen and paper, or your phone or tablet or whatever you use, and write down some words and phrases about what quality care means to you. And I can assure you if you do this, you will get much more from this session about how you can apply the techniques and tools that we discuss.

So while you're writing things down, think about how you would describe, describe the care that you aspire to provide. And consider it specifically within your setting and how you provide care to patients. So what's unique about your practise or your hospital, or your journey around people's homes or people's farms, or however you deliver care to your patients.

Also think about your team, what matters to them? So if any of you are listening to this together as a team, then have a chat with each other, particularly if you've got different roles within the team. As different roles will often have different perspectives relative to the role duties.

And what does quality care mean to your patients? Is it focused on welfare, or safety or quality of life, however we assess that, or all of the above? And what does it mean to your clients?

They will have a different perspective on what quality care means to them. You could also consider your recent experiences as a patient yourself or with family. What did quality care mean in that setting?

And whatever definition we decide to use as a profession, you may want to have your own personal or team definition within that. What matters most to you, and this can guide your own quality improvement efforts. So now you should hopefully have some ideas of what quality means to you.

We can review them in light of one of the many descriptions of what quality healthcare looks like. It is very difficult to decide on a definition, particularly when quality seems such a nebulous and subjective concept. And there are a number of different definitions and descriptions, and a number of different frameworks or theoretical structures which have been used to describe quality of care over the years.

One of the most commonly used was developed by the Institute of Medicine back in 2001 for use in human healthcare. And that's the one I'm going to talk about a little bit today. And this framework describes 6 qualities or dimensions of healthcare.

And you can see these listed on the screen. So number one, care should be safe. It goes without saying that the first tenet of healthcare is first to do no harm.

Of course, given what we know about human factors, mistakes are an inevitable part of all aspects of life, and patient safety should focus on mitigating risks because we know that we can never truly eliminate them altogether. And #2, care should be effective, and we should use the best available scientific evidence to support our decision making and reduce unwarranted variation in care. And by unwarranted I mean care which is not supported by evidence.

In veterinary medicine, our evidence is still very much in development, which can lead to additional challenges when we're aiming to practise evidence-based medicine compared to our human colleagues. And why it's vital that the frontline members of our profession are able to be involved in generating evidence as part of QI processes. And I'll talk a little bit more about that later on.

Care should also be patient centred. Providing care that's respectful of and responsive to individual patient factors is really important. What works for one puppy will not work for the next puppy for a variety of different reasons specific to that puppy.

And we always aim to act as the patient's advocate. Of course, in veterinary medicine, similar to human paediatrics, we also need to take into account the wishes, aims and abilities of our pet owners in the same way that paediatric care providers need to take into account parents' wishes and aims. And our pet owners will also feel that they are acting as the pet's advocate in how they see what they feel is the best care for their pet.

And that obviously can differ somewhat from our perception of what we believe is the optimal care. Taking into account our clients' wishes also includes their resources, the resources which they're able and willing to expend on pet care, and this can be both financial and also their time and their skills in providing home care. I'm also a really passionate advocate of shared decision making between pet owners and the clinical team when we're establishing what optimal care looks like in each individual set of circumstances.

But that's a whole different topic for another day. Care should also be timely, reducing waiting times and delays in care. Perhaps less of a concern to us as a profession than our medical colleagues in the NHS but still a really important factor, particularly when considering emergency and urgent care.

And whether we work in emergency care or we work in first opinion practise, emergencies and urgent cases will of course always happen. Care should be efficient. As a profession, we're under continual commercial pressures by clients to keep prices reasonable.

And in order to also allow ourselves reasonable wages and work-life balance, this means efficiency of care is paramount to balance these requirements. And lastly, care should be equitable. Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Although this doesn't particularly apply to our patients, clearly it can apply to our clients. And as we focus on diversity and inclusion as a profession, it is as important when considering access to care by our clients as it is within our professions. So what is quality improvement?

Quality improvement or QI in healthcare can be defined as a systematic approach to the enhancement of care within the dimensions of quality that we've just discussed. It involves the use of quality improvement tools to identify gaps in quality or suboptimal care, to analyse data and to test changes leading to continuous improvement. It's important to recognise that all members of the veterinary team, both clinical and non-clinical, are highly motivated to improve the quality of care for our patients.

And in fact, we do already undertake aspects of quality improvement every day or night of our working lives. The big step change can come by moving from uncoordinated ad hoc activities to more strategic activities and more structured projects where we can assess the impact of our changes and measure successes, or alternatively learn from failures. And I think it's fair to say that I've been involved in both.

Since we've started talking about quality improvement as a profession, there have been numerous questions about how the framework of quality improvement fits with our professional requirements for clinical governance within the code. So clinical governance is the overarching system or framework for understanding, monitoring and continuously improving the quality of services, care and outcomes. To put it simply, clinical governance sets out what we have to do.

Quality improvement, on the other hand, is a systematic approach to the enhancement of performance. It involves the use of QI tools to identify gaps, analyse data and test changes, so quality improvement tell us tells us how we can do it. In order for quality improvement projects to be successfully implemented, we need to have a strong learning culture within the team.

We need to be able to accept errors, and to learn from them, and to be able to acknowledge where we can do better. And that can be very difficult at times. Teams will need strong leaders to lead by example and to help coach and support them through changes, and change in itself can be very disruptive and very difficult to manage.

It's important for quality improvement projects to involve a cohesive team who can support and motivate each other. The team will also need some support in developing skills and those involved in the processes which we're assessing must be consulted periodically to ensure that changes are feasible and realistic and fit within their existing work processes. All the team must be involved and equal importance should be given to the feedback from team members in all roles.

Everyone in the team should be empowered to speak up if they have ideas, or particularly if they have concerns about what's being proposed. Staff also need permission to make spending time on quality improvement a priority. A common misconception is that we don't have time for quality improvement, but we all have the same 24 hours in a day, and we must enable staff to prioritise spending time on these projects for them to be successful.

If you're a practise owner or a clinical manager, it is worth investing time and money into the improving the quality of care your team can provide, not just because it'll lead to better patient outcomes and client satisfaction, but also because it will lead to higher performing and better motivated teams. We all want to feel that we're getting better at what we do and providing great care, and what better feedback to have on that than evidence of the impact that their efforts have made. We also require to have tools to enable us to complete QI projects, and you can see we've got a list here of some of the commonly used tools, including clinical audit, clinical benchmarking, significant event audits, clinical guidelines, and also checklists.

And we're going to discuss a little bit later how some of those can be used practically to support quality improvement projects. So how does the profession feel about quality improvement? In the recent RCVS Knowledge survey of the professions, the vast majority of people, 96%, agree that quality improvement will improve the care that we provide for our patients.

However, 60% of those surveyed have spent less than 3 days on quality improvement in the last 12 months. And actually just over 1 in 10 of us had not taken part in any activity that they considered to be related to quality improvement. And part of the reason for this could be that 80% of respondents felt that they needed training and resources to support their QI activity.

It's not something that we can, we feel we can necessarily embark upon without the right. Knowledge and support behind us. And I've got some good news on some of those support and resources later on.

So, where do we start? There are a number of QI tools that we can use and a number of different places to start a project. So I would like to talk you through an example of a project that we have done at Vets now.

I'm sure many of you will be familiar with the evidence behind the use of checklists in many high safety industries such as aviation and the nuclear industry. By adapting a checklist from human medicine, the World Health organisation safe surgery checklist. This checklist was launched globally by the World Health organisation in 2007.

There is a significant amount of published evidence now to show the impact of the checklist in both human and veterinary medicine. So it felt like a lot of the work on that front had already been done before us. And it was shown in some of the seminal studies to reduce morbidity and mortality of surgical patients by up to 50%, which sounded like a highly significant impact and worthless investing some time and resource.

In So, what did we do? We decided that the safe surgery checklist as it stood, didn't exactly fit our requirements in the out of hours setting. So we decided to adapt the checklist rather than simply adopt it as it was.

It went through a number of trials in our clinics, and it was changed after each trial based on feedback until we came to our current version as it stands today. As I've mentioned previously, it is vital to get the feedback of the teams using the checklist. They're going to be the best people to know which parts are the most beneficial, which parts need altering, because either they don't make sense or they're not necessary, and which parts need removing.

Some parts they will find are perhaps too basic and it's not something that gets forgotten, so it doesn't need to be on the checklist. It also really helps teams to feel engaged with the process of checklist development and therefore, they'll be more likely to appreciate the aims of what we're trying to achieve and the value of using it. And the idea is that then it will get used more often in practise.

And we felt this checklist in particular was a good one to start with because there is such a large amount of evidence already generated, which can help to reassure any sceptics. And we perform a process audit on this checklist alongside our general anaesthetic and sedation monitoring form audit. To ensure the checklist is being completed, and it does currently have a very high completion rate.

So I'd like to talk a little bit about never events. So never events are serious medical errors that should never happen to a patient because they are preventable. And our measurable aims when introducing the checklist were to assure it was all getting, it was getting used in all cavity surgical procedures and to eliminate the occurrence of never events.

And the ones which we focused on were the retention of swabs or surgical instruments after cavity surgeries, as you can see in the x-rays. So fortunately, these were incredibly rare and occurrence prior to the checklist being introduced was about one. Occurrence every 18 to 24 months.

And bearing in mind that's across around 140,000 patients a year. So with such low numbers, it is very challenging to get a statistically significant improvement. But in the 6 years since we introduced the checklist, we've not had a single never event of this type where the checklist was used as intended.

Sadly, the checklist doesn't always get completed in every case for a variety of reasons. And on occasion, completion has been incomplete or not followed the correct process of two people verbally agreeing and jointly completing swab and instrument counts. So errors have still occurred.

Each time an error has occurred, we've been able to learn more about how to make the process clearer and easier, and we've made improvements. So what's next? Following on from the surgical safety checklist, we wanted to develop checklists for other clinical presentations in the emergency setting where we felt care could be improved.

So as you will see here from our Whippit patient in the photograph, this is not a particularly obvious example of this current presentation. It's normally a lot more obvious than what you can see in the photograph. But the area we decided to focus on next, as you can see from her X-ray, was dystopia.

We felt this was a really good area for us to focus on, as it's a presentation we see in our emergency clinics relatively frequently. It's one of the more common surgical presentations, and it's around 3.7% of our cases.

And it's also an area which causes a lot of client concerns for a variety of reasons, which I'm sure most of you will be very familiar with. And it's really important when setting out on a quality improvement project to find out where you are, what's happening in your clinical setting at the moment. How are you doing?

And so that when you begin your project, you'll know which areas to tackle, and you can also assess what success will look like. So this is how we went about finding out where we were in terms of our approach to dystopia cases. As part of our commitment to evidence generation for use across the profession, we share our venom-coded anonymized clinical data with Vet Compass.

And as part of this work, one of our SERT AVP ECC holders, Aoife O'Sullivan, worked with Dan O'Neill and others from Vet Compass to publish a study based on our data on dystopia. This was a very resource intensive process in terms of time and skill input, but it has produced some really robust data. When the paper was completed, we found a number of different areas for improvement in how we were treating our dystopia cases.

Including our approach to diagnostic imaging, assessment and recording of foetal heart rates, and the drug doses used. As I said, it was a very intensive process to publish a paper, but clinical audits can also be performed, and these can be much simpler and still give really important information on your starting point in a certain area. You should also be aware though that you won't always be doing or achieving what you thought.

Sometimes the results of a study or an audit can be really surprising and sometimes even shocking. And obviously this can be quite difficult for staff to realise that there are significant areas where we could do better. But without measuring, we can't begin truly effective improvement, so it's really important to focus on the positives of the end goal.

So it may sound like after such an intensive process, that we didn't need much additional evidence. But actually, it's always useful to combine as much evidence as you can possibly get when deciding how best to approach a quality improvement project. So we also looked at our client concerns, as we've mentioned before, we do get a more significant number of concerns for dystopia cases than most of the presentations for a variety of reasons.

So it was good to review a lot of the complaints and look for common themes and common concerns that are important to our clients. We also reviewed significant event reviews, which is something that we do very routinely now when something hasn't gone to plan, something unexpected has occurred, or actually when there's been a near miss, and they can give really valuable data on areas of risk and areas for improvement. And we also discussed this with our clinical leaders at great length to decide how we would best approach making improvements in this area.

So following on from our assessment of all the evidence and much discussion, we developed and introduced a dystopia checklist. And the aim of this checklist is the same as that of the surgical safety checklist, to identify critical steps in the process that were at risk of getting missed, and to ensure these were checked off to confirm either that they'd been done or that the vet had considered the risks and benefits and pet owners's wishes before reaching a decision. And an example of this is when we're talking about diagnostic imaging.

We need to consider the risks and the benefits, what are we wanting to achieve from using these diagnostic tests. But we can't just have a check box on there to say, yes, an ultrasound has been done or not done, or X-rays have been performed or not performed, because sometimes this will depend on the owner's wishes and the owner's finances as much as it will depend on what the clinician wants to do. And you can see the checklist is set out in a similar way to our surgical safety checklist.

It's got a specific format and a specific look about it, so you can easily identify it as a checklist and a vets now checklist, just by its appearance. It's got some boxes on there to be able to record individual patient data and which staff are involved. And it's split down into different time periods when dealing with this particular case.

So before consultation, during the consultation after. If we're doing medical treatment and also if this is a surgical case, there are specific check boxes to consider for this surgery in particular, before the surgery, during the surgery, and after the surgery. And this would be performed in addition to our surgical safety checklist.

So the surgical aspects on the dystopia checklist are the things that are only specific to dystopias. So here's our whip it again with her super sized puppy after her successful C-section in this case. And this is to emphasise that it is a vital step to ensure that we close the loop on our projects.

So did the change we make actually make things better? Do we have the evidence of that? Or actually, did it make things worse?

Unintended consequences of improvement projects are not uncommon. They can't always be easily anticipated because people will use tools in ways we don't necessarily predict and improvements in one area may cause something else unintentionally to be compromised. Clearly, when we're putting time and effort into clinical care, spending more time on one aspect, is going to compromise time spent in other areas.

So we have to be really wary that that's a possibility, and we have to monitor and assess as to whether that has occurred. We are currently in the process of doing a clinical audit on our dystopia cases to see what improvements, if, if any, hopefully there will have been a lot, have occurred since the original paper was published. And we will also gather feedback on the checklist and make any necessary adjustments.

It's really important to do this, as it should always be a working document, but not too often. Making frequent changes leads to confusion, can lead to disengagement, and it can lead to additional risks when people are not sure which version they're using, and different people are unaware of most recent changes. So unless a critical error is identified, once a year or every couple of years it is fine to do a review once the initial trial feedback has been finalised.

So that's one of the projects that we've done and hopefully illustrates how a few of the quality improvement tools can be utilised together to complete a project. And I use the word complete with hesitation because a quality improvement project is never complete, because the world moves on, technology, knowledge, evidence, drugs and client expectations continually change, and so should our projects. They should always be evolving.

And they should be reviewed periodically for effectiveness and for feedback and. Improvement is a continuous cycle, it never stops. When you want to start quality improvement projects of your own, or to get some new ideas on what tools to use for a more experienced team.

There are a lot of free online resources available. And I've got an illustration up and the address, website address for the RCVS knowledge resources, which I've been part of developing. And these are easily accessible, they're free and they are designed to be suitable for the whole clinical and care provision team.

They cover all the commonly used tools, and they also include a number of case studies of how the tools have been applied in real life clinical scenarios. It's got sample checklists, it's got sample guidelines, and it includes easy walkthroughs showing how to adapt them to your specific clinical setting and how to write them and how to use them in practise. We also have short interactive courses with CPD credit.

On the RCVS Knowledge website and please do follow our CVS Knowledge on social media for the latest updates and the most recent case studies. And if you do have a case study on a tool that you've adapted for use or how your quality improvement projects. Ha Gone, then do let us know, and it's really great to share that learning and knowledge across the profession.

So, once you've had a look at all these tools and the team are feeling confident in their newly acquired knowledge and skills, how do you decide what you would want to do in your clinical setting, and what could you do, what's available? If you work in first opinion practise, then you could start out with an externally supported audit, for example, the vet audit hosted by our CVS Knowledge on post-operative complications. And this is a really good option to start with because the audit has already been set up for you.

It's very easy to do, it takes quite a minimum amount of time and it can be really rewarding. You can enter your data online, there's an easy to complete form, and the recommendation is a minimum of 30 postoperative nutrient cases. But you can add as many as you like, and clearly the more you add, the more accurate your results will be.

And you can then benchmark your clinic or hospital's performance against the average UK results. And this can indicate areas of high quality where the team are doing really well, and also any areas where there is potential for improvement. So that could be a really good starting point with minimal effort, maximum output, which is always good when we're starting out with projects.

You could also start a project following a significant event or a near miss that's actually happened in your clinic. And there are numerous resources available across the profession to support significant event reporting and analysis. And these can help to guide the team through a root cause analysis to uncover all the contributory factors that led to the event.

And the team can then decide what processes can be changed, and the best way to go about it, to minimise the risks of it happening again. And clearly that can be really therapeutic, particularly if there's been any patient harm occurred during the event, which can be very, very emotionally challenging for the staff involved and also obviously for the pet owners. And it reassures staff that all efforts have gone into prevention and making sure this doesn't happen again to something else.

And it's also really positive to be able to report back to the pet owners what process changes you've put in place. And please don't forget to share these stories more widely as well to help others avoid the same issues. And one example of how we do that at vets now is we develop our significant event reviews, the ones we feel are the most important, the most pertinent, the most, going to have the most impact is we develop them into stories and share them in our clinical newsletters and also on our clinical governance platform so that other people can.

Read through and be more aware, and we find that people do like to read them in that form and find them quite interesting and engaging. Clearly it's not a unique format, but it's a tried and tested one that we find works well. It's also good to uncover what the team are passionate about, because it can be really different to what you care the most about.

And driving improvement projects requires enthusiasm and effort, and this can best be maintained through something the team are really engaged with. It's also worth asking the opinion of the team on where they perceive the biggest risks to patient safety to be, because that may be something that you haven't considered. Or they have a different perspective on solving the issue or a different perspective on where the risks could be.

They might also be struggling with something that you haven't picked up on or they're using tools in a different way to the way that you would use them. And that can have different risks associated with it. It could be riskier, it could be less risky.

So making changes to the way you deal with a certain clinical presentation that you see frequently or a process that the team perform often. Can have the biggest overall impact. Even something which seems like a fairly small tweak that improves safety or efficiency when it's something that's done on a really frequent basis can add up to a hugely significant impact which you can measure.

And obviously smaller changes are much easier to implement and much less disruptive. And an example of how we have done this at Vets now is we have our call answering centre, and they input data from the pet owners straight onto our practise management system. But what we found was that the order that they took the information in didn't exactly match the way that it was set out on the practise management system.

So we developed a front interface for the practise management system, which followed the flow of how the call went, and that actually improved the efficiency of Our time taking calls and inputting the data really significantly. You may decide to focus on patient welfare. As an example of this, we at Vets Now have decided to audit the use of our validated pain scale.

Which we implemented a number of years ago, and we've audited this in surgical patients, which are a very obvious and well defined patient population, which clearly require pain scars. And we've assessed how frequently the pain scarring has been repeated. And how the analgesia has been adjusted in response to the pain scores.

And that's been a very valuable exercise for us to do, and clearly can have a massive impact on our patient's welfare. You can also get pet owner feedback either through a survey or a questionnaire, or by reviewing complaints to identify common themes or significant concerns. And how you prioritise what projects you decide to focus on is entirely up to you as a team.

And it will depend very much on your interests and where you perceive the risks are, and also how your specific clinical setting works. It may be that when you're discussing with the team that the staff come up with a number of different proposals, and then it's worth getting someone to go away, perhaps in small groups and develop the proposals, and then you might decide to have a vote on which one to do first. Another way to approach quality improvement is by using evidence already published by others to guide clinical decision making.

So clearly we can do this on an individual basis, but it's a really great team exercise and a much more efficient use of everyone's time to work together to create something like a guideline based on the evidence available. To be able to do this, you need to be able to appraise the evidence and judge the quality of it, and to be able to synthesise lots of different evidence and bringing it together to form some sort of useful and workable summary which can then be applied in practise. And this was one of the things I personally found very daunting within my own studying and my own journey within quality improvement.

A lot of the different statistical methods used can feel quite a different language that you're not used to. And, and not particularly my area of confidence or expertise when I started out for certain. But fortunately for all of us, there are now many, many tools that you can utilise free and online, to guide you through a lot of this process.

And the knowledge summaries created through our CVS knowledge can be a great starting point. And these are a written summary of the evidence available on a very thorough and strategic evidence search. It's a summary of that evidence available to answer a specific question.

And how the question is defined is very important. You can search through already written summaries to get an idea of what's involved. And actually, you might find somebody's already done the work on the topic of your choice.

Which will be brilliant and save you a task. But you can also write one of your own. And having recently finished writing my first summary, I can really recommend it as a process in terms of developing your own skills and your own knowledge.

And I can recommend the guidance on the RCVS Knowledge website. It's very accessible even for people like me who are not a big fan of statistics. Another resource that I found really invaluable is the book on how to read a paper by Doctor Trisha Greenhal.

That's also very accessible, it's an easy read, it's relatively short and it provides a step by step guide. Another resource that I found during my studies was the CASP checklists, and they're freely available online as well. And there's a checklist for each different methodology used in writing a paper.

For example, there's one for randomised controlled trials, and there's a different one for qualitative studies. And it very much guides you through each paper asking specific questions on each section of the paper, which helps to, it helps you to evaluate the quality of the evidence. And there are other checklists of a very similar nature available online.

These are just the ones I found the most helpful as a novice. And it does take time to develop these skills. But you can definitely do it with a bit of effort and a lot of practise.

You can make your own contribution to accessible evidence for the rest of the profession, as well as just for you and your team, which I have found personally very satisfying. And my contribution is a very small one, but if we all make small contribution, we can make a massive difference to the amount of accessible evidence that we're able to utilise as a profession and drawn. So in summary, how can we create successful quality improvement projects?

We need to create the right reflective and supportive team culture with strong and inspirational leaders who are really passionate about improving the quality of care that we provide. My advice, once people are engaged, would be to take care to curb your enthusiasm and start small. It's so tempting to want to change the world and change everything about the way you practise and make it better all in one go.

But actually a small, easy project on something your team does frequently can have a huge impact on patient care and actually a really positive effect on staff morale once you've completed, your first round of a project and got some evidence that you've made a difference. That really makes the staff feel great about what they've achieved. It makes that effort feel worthwhile.

To borrow a phrase from Stephen Covey, also begin with the end in mind. Always define what success will look like and how you're going to measure it. Otherwise you'll have some interesting anecdotes, but no actual evidence of what all your effort has achieved.

And finish what you started. Of course, as I said, no project is ever truly finished when we're talking about quality improvement, but make sure you do measure the impacts of what you've done at the defined point. And keep going.

Don't be discouraged if what you did didn't reach the desired impact. We're often very ambitious when we set goals, and if you set goals of everything at 100% of concordants and 100% of achievement. It's going to be very difficult, if not impossible to ever reach them.

So try to have targets which are realistic and achievable. But also, eventually don't always settle for your original target. You would be happy to reach that during the first stage of a project, but as the project continues over the years, you would expect that you're going to be able to push that up.

So 60%. Concordance with using a checklist might be a really, really strong first start, but several years into the project, you are going to adjust that target to be higher, most likely. And a successful project is one that you can take home, lots of learnings for the future.

So even if you put a checklist in place, and actually, it wasn't used because the staff didn't find it to be as useful as you thought it was going to be, you've actually come away with an awful lot of learning from that process, which can then be reapplied into the next. Generation of that checklist. Don't forget to celebrate, don't forget to celebrate success.

That's really important to keep staff motivated and to share what it is that you've all managed to achieve and what all that hard work has come to in terms of the patient care. Finally, let's return to our learning outcomes. It's worth writing down whether you feel that these have been achieved, and also writing down some notes for future reference and something for you to reflect back on at a later point when you come to start your own projects or when you're at a juncture in your current projects where you're going to change direction or perhaps do something different.

It will also be worth returning to your list of words and phrases about what healthcare means to you and your team. And you might want to revise them after this session, or actually, you might feel that they're great as they are. And you can work with this list and this definition that you've developed to discuss with your teams which QI project you'd like to start, which is going to be your first as a team, or perhaps refine an ongoing project in the light of your priorities.

So thank you very much for listening, if you've made it this far. I hope this has given you some ideas to start your own structured and strategic quality improvement projects, or perhaps to take your projects on to the next level. I'd like to also say that we're really happy to share any of our vets now resources, including copies of our patient safety checklists.

So please do email me if you would like a copy of any of those, and thank you for your time.