QI showcase: No so fine motor skills

Thank you for having me. 

So, I work both in the community and also, as I am today, at Luton & Dunstable Hospital, which is great. 

I did a program focused on quality improvement. To be honest, I hadn't really heard much about it before. We did some research, and I thought, "What is this?" Initially, I found the experience a bit frustrating because we were told this wasn’t about making changes straight away. It was about observing and watching first. I think I found that very helpful—this concept of sitting, watching, and identifying the problem before acting too quickly has hugely changed my practice. 

I think it was Einstein who said, "If I had 24 hours to live, I'd spend 23 hours thinking about the solution, and only one hour acting on it." That’s a real lesson I’ve learned. 

I’m going to walk through three slides discussing the deep dive, the design, and the delivery of this quality improvement project. 

I work in Community PTRS, and we’re based in a fantastic city. However, I was getting a bit frustrated, so we were encouraged, as part of this course, to think about what’s frustrating us. What is it that makes you think, “I wish this would change”? For me, there were several things. It’s a fantastic organisation, but there were also a few constraints. 

I mentioned to my supervisor that one thing that really annoyed me was that the pencils in my clinic couldn’t be sharpened, or I’d move to different rooms and things were very inconsistent. It sometimes felt like I couldn’t do a full assessment. I had an inkling that my colleagues were also struggling with doing fine motor assessments in the way we really wanted. I was encouraged to look into this, as it seemed to be a people problem and an environmental issue. 

So, I came up with a problem statement: The missing and shabby equipment—like unsharpened pencils—was affecting the way parents perceived our confidence in assessments. This reduced the quality of our work and sometimes forced us to skip essential fine motor skills tests. 

I started by doing some initial research, such as surveys with my team, asking about what was working well and what wasn’t. This led me to believe that equipment in the clinic rooms, like pencils and crayons, were often unusable, or they were stored inconsistently. I created a background statement to provide more context. There are eight clinic rooms, and the equipment was often not maintained well. 

We also mapped out the process—how we prepare the rooms at the start and how the fine motor skills assessments are completed at the end. In between, there are several steps, such as checking the equipment and ensuring the children actually use it, rather than it just sitting unused. 

We then used a fishbone diagram, which I had never heard of before but turned out to be very helpful. It helped us focus on the equipment, process, and people issues. 

One issue around equipment was that many clinicians didn’t know where the equipment was kept, so they were missing items like pencils. There was also a lack of equipment and upkeep. There were no pencil sharpeners, which might seem like small things but make a big difference. We also had issues around accountability—who was responsible for the budget or for maintaining the equipment? 

These were the factors I focused on. We were encouraged to focus on one or two of these issues, so I spent most of my time observing, sitting back, and watching how things happened—how children in the clinic accessed equipment, and asking parents about their thoughts and experiences. 

The next step was designing our PDSA cycle. I had to create a clear SMART statement, which was very hard to do, but in the end, I came up with: By August 2023, all children who need fine motor skills assessments will be properly assessed, assuming it is a priority during that visit. 

The two measures I focused on were: 

I did a weekly review of clinic rooms and reports, scoring the equipment condition on a simple 0-2 scale. For the second measure, I looked at whether fine motor skills assessments were performed. 

We also brainstormed some ideas for potential changes using the PDSA cycle, such as having colouring competitions or using baskets to organize the equipment. We rated these changes based on three criteria: Is it logical? Is it quick and easy? Does it excite me? The checklist idea was logical and easy but didn’t excite me, so we decided not to use that. 

There were four main PDSA cycles. Each cycle allowed us to implement and assess changes, and the feedback from colleagues—both clinical and admin staff—was fantastic. They helped me understand the problems better and provided ideas for improvement.