Reflective Template:  Quality Improvement Activity (QIA)

This reflective template has been designed to use with the SOAR Database (Scottish Online Appraisal Resource).  When you have completed this reflection, please upload it to SOAR / Form 3 and submit it to your interview to share with your Appraiser.	3-step guide to completing this form:

1)	Save this form (using “Save As”) to your computer (e.g. My Documents, Desk top), and customise the file name (e.g. QIA Reflection 2012)
2)	Proceed to filling out the form - when finished, Save and Close the document.
3)	Login to SOAR and Upload this file from where you had saved it (from step 1), either to the Documents Library, or directly to Form 3.	

This reflection template form should be used for Domain 2: Safety and Quality.
The boxes will expand automatically as you type into them.
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What supporting information have you provided for your QIA?
A paper published on the feasibility of screening for and treating vitamin D deficiency in forensic psychiatric inpatients.	

What strengths or achievements does it demonstrate?
The study demonstrated serious and significant vitamin D deficiency and insufficiency in over 90% patients. DXA scans on two patients with secondary hyperparathyroidism demonstrated osteopenia. The work required clinical knowledge, leadership, commitment, negotiation skills, multi-disciplinary working, administration and statistical expertise. After being rejected for publication in the BJGP because of a lack of relevance, the project won the RCGP Enterprise Award (Vulnerable Groups category) in 2012.	

Did you encounter any difficulties in this process?
The work took 6 years to complete and required the hospital research committee then 2 NHS REC ethics committees’ approval. Information had to be understandable to patients with learning difficulties. Some patients were too ill to be screened and unable to provide informed consent. There was a lack of resources, particularly staff and training in basic data collection. RMOs and management were concerned about issues raised by the project (security, grounds access, medication, sun screen, and cost of additional medication).  I had to contact my defence union to ensure that medico-legal concerns regarding treatment were addressed. I had no access to statistical support and had to overcome barriers to taking anonymised data out of the hospital. I sought advice of the Scottish Government and Glasgow University before finally finishing the paper. The paper was rejected by 3 journals before being accepted by the Journal of Forensic and Legal Medicine.	

Have you been able to make any changes as a result of undertaking this activity?
The Scottish Medicines Committee approved the prescribing of cholecalciferol (vitamin D3) in September 2012. My preference was to prescribe vitamin D alone as there is evidence that calcium in combination with vitamin D may increase the risk of cardiovascular disease. I am now prescribing vitamin D supplements ward by ward on a case by case basis. 	

What have you learned from undertaking this activity?
In addition to the clinical significance of the study, completion of the project demonstrated that perseverance pays off.	

Is there anything else that you would like to/ need to do to follow it up?
Assess the impacts of vitamin D supplementation: biochemical, clinical, cost and patient feedback. Identify the difference between those who take vitamin D supplementation and those who don’t. Compare the differences between the groups who take vitamin D supplementation: patients on metformin, various antipsychotics and anticonvulsants, effect of renal disease and obesity. The RCGP Enterprise Award provided £1000 to evaluate the effect of treatment.