Approaches to Quality Improvement

Vincent Baxter (Improvement Manger) from the emergency care intensive support team (ECIST) discusses some common approaches used to improve quality.  

 

Improving quality is about making healthcare safe, effective, patient-centred, timely, efficient and equitable. One important element of the quality agenda is quality improvement. In this article I discuss some common approaches used to improve quality, including where they have come from and their underlying principles.

According to the Health Foundation (2013) there is no single definition of quality improvement. However, several definitions describe it as a systematic approach that uses specific techniques to improve quality. One important ingredient in successful and sustained improvement is the way in which the change is introduced and implemented.

Dr John Øvretveit, a leading expert on quality in healthcare, in his report Does improving quality save money? states:

“The conception of improvement finally reached as a result of the review was to define improvement as better patient experience and outcomes achieved through changing provider behaviour and organisation through using a systematic change method and strategies”.

The key elements in this definition, according to the Health Foundation (2013) are the combination of a ‘change’ (improvement) and a ‘method’ (an approach with appropriate tools), while paying attention to the context in order to achieve better outcomes.

There are a range of quality improvement models and methods. These were originally developed within an organisational or industrial context. In today’s healthcare environment these tools have an important part to play in transforming services and driving up quality.

Despite the wide variety of quality improvement methodologies, approaches and tools, many share some simple underlying principles, including a focus on:

• understanding the problem, with an emphasis on what the data tells you.
• understanding the processes and systems within the organisation – particularly the patient pathway and whether these can be simplified.
• analysing the demand, capacity and flow of a service.
• choosing the tools to bring about change, including leadership and clinical engagement, skills development, and staff and patient participation.
• evaluating and measuring the impact of a change.

Several approaches put quality improvement theory into practice. No one approach is better than the others, and some may be used simultaneously. Three of the best-known approaches to quality improvement are:

 

The model for improvement which includes plan, do, study act (PDSA)

This is an approach to continuous improvement, where changes are tested in small cycles, that involves planning, doing, studying, acting (PDSA), before returning to planning, and so on. These cycles are linked with three key questions:

1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in improvement?

Each cycle starts with hunches, theories and ideas and helps them evolve into knowledge that can inform action and, ultimately, produce positive outcomes.

 

Statistical process control (SPC)

This approach examines the difference between natural variation (known as common cause variation) and variation that can be controlled (special cause variation). The approach uses control charts that display boundaries for acceptable variation in a process. Data are collected over time to show whether a process is within control limits in order to detect poor or deteriorating performance and target where improvements are needed. When an improvement is made SPC can be used to measure its impact and evaluate its worth.

 

Theory of constraints

The theory of constraints came from a simple concept similar to the idea that a chain is only as strong as its weakest link. Just as the strength of a chain is determined by its weakest link, the limiting step and its constraint determine the throughput or work rate of a team, process or hospital. Knowing where the constraints are enables you to focus improvement efforts and employ specific operational management techniques to increase and maintain throughput.

 

Quality and service improvement tools

The approaches described above are based on two of the underlying principles of quality improvement, measurement for improvement and demand and capacity.

The model for improvement and SPC charts are two of the many measurement for improvement tools available. These tools use data to identify areas for improvement, and when used in tandem with other tools, such as those for mapping processes, will support continuous service improvement.

Measurement for improvement is different to using measurement for judgement and measurement for research.

• Measurement for judgement is aimed at measuring performance against a target or standard.
• Measurement for research purposes is concerned with the acquisition of new knowledge.
• Measurement for improvement is about measuring change when we are working to improve a process or service.

Understanding and managing demand and capacity is a key approach to removing some of the visible and hidden backlogs along the patient pathway. Variation between demand and capacity can disrupt flow and lead to queues forming. By measuring and comparing demand, capacity, activity and backlog queues can be managed. This is because bottlenecks in the patient pathway can be identified. These can then be managed by making the necessary improvements to maintain the flow of patients and prevent queues forming. There are several proven approaches that can be used to manage the patient pathway, to optimise the use of available capacity to meet demand and improve the patient experience, the theory of constraints is one example.

 

Context

Regardless of the approach used, how the change is implemented – including factors such as leadership, clinical involvement and resources – is vital. According to the Health Foundation (2013) only around two-thirds of healthcare improvements go on to result in sustainable change that achieves the planned objective. Therefore, leaders need to think carefully about how they can embed positive change and make it sustainable. There is evidence that sustainable change is more likely to result from a model that involves patients and staff in developing, designing and implementing changes rather than from a ‘command and control’/top down model.

 

Conclusion

According to The King’s Fund (2017) Quality improvement is not an easy option and is not for the faint-hearted but committing to and investing in improvement is the right thing to do for patients, carers and staff. Quality improvement is a systematic approach based on iterative change and continuous testing and measurement. The models described above are just some of the proven tools, theories and techniques that can be used to design and implement quality improvement projects.

 

References

Health Foundation. Quality improvement made simple: What everyone should know about healthcare quality improvement. London: Health Foundation, 2013.

Øvretveit J. Does improving quality save money? A review of the evidence of which improvements to quality reduce costs to health service providers. London: Health Foundation, 2009.

The King’s Fund. Embedding a culture of quality improvement. London: The King’s Fund, 2017.