1. A definition of quality improvement in healthcare
2. What is quality improvement in healthcare?
3. What is the process of quality improvement in healthcare?
4. Examples of quality improvements in healthcare
5. Quality improvement in healthcare jobs
The term ‘quality improvement’ refers to the systematic use of methods and tools to try to continuously improve outcomes for patients, and the patient experience.
Why should we care about all of this? After all, it sounds like boring management-speak. But if we dig deeper, it’s actually pretty interesting. It’s all about a philosophy of how you improve things in healthcare. All of us know how much room for improvement there is in healthcare from our own personal experiences.
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Dr Mike Evans [video] describes a philosophy of how you improve things in healthcare which starts with a positive attitude towards continuous improvement, in other words a willingness to experiment and iterate. (As he points out, this attitude is a tremendously helpful not just in our organisations but it’s what we want to see in our patients!). This takes us on to the next question – if we have the right attitude, then how do we actually improve, and how do we use quality improvement to make things better?
In industry, the science of improvement has been around for a long time. Don Berwick was a leading light in translating these methods from industry to healthcare. A paediatrician by background, Don founded the Institute for Healthcare Improvement (IHI) in Boston in the late 1980s. (In 2013 he was asked to carry out a review of patient safety here in the UK, following on from the report into the Mid Staffs hospital scandal).
The scope for healthcare improvement is huge. In 2004 Ross Baker studied 2.5m hospital admissions across Canada. He found an adverse events rate of 13.5%, and observed that 20% of patients either suffered some kind of unnecessary harm (including death) as a result of their admission. In the US an IOM study – in the “To Err is Human” report – showed that between 44,000 and 98,000 patients in die in hospitals each year from preventable errors.
There is a huge amount of low-hanging healthcare improvement fruit to be gathered. Usually these are errors that caregivers know how to prevent but haven’t been able to devise a reliable prevention system. To gather this fruit, we need “systems thinkers” who can look at operational processes with an analytical mindset, find practical ways to improve them, and also lead the change initiatives that will put them into practice.
Also needed are quality improvement software tools like Plio which help to streamline continuous improvement projects by introducing efficient workflows and by reducing paperwork.
Continuous improvement is a circular and iterative process. Most models and methodologies contain four common sense steps, originally described by Deming (he used the word ‘check’ instead of ‘study’ but otherwise little has changed in the intervening 50 years):
Identify a problem (nonconformity) or improvement opportunity (potential gain), and plan for change.
Implement the change on a small scale, with corrective or preventative actions.
Analyze the results of the change and verify whether it was successful or not.
If the change was successful, implement it on a wider scale and assess your results. If the change did not work, begin the cycle again.
Continuous improvement stems from acknowledging that we make mistakes. All organizations make mistakes, but not all learn from them. Why not? Often, mistakes and problems are often seen as evidence of lack of competence and therefore something to be ashamed of, and concealed. This natural human tendency needs to be turned on its head. Problems are an opportunity to learn. Indeed, they are the best source of learning to improve our future performance. This mindset needs to be communicated from the top and reinforced across the organization.
Plio provides a simple How to Guide for setting up your quality improvement program.
The most widely used models for quality improvement in healthcare are Lean, Total Quality Management, Kaizen and IHI’s Model for Improvement.
Lean is a model adapted from the work of Taichi Ohno, who developed the Toyota Production System. A lean organization focuses on the elimination of waste and optimizing operations. Lean is also about building a culture, one that respects all employees and enables them to pursue opportunities to improve their work and share ideas for continuous improvement.
Total quality management also focuses on the cultural dimension. It was inspired by Armand Feigenbaum’s book Total Quality Control, re-examining the techniques of quality control and how those techniques had been successfully exploited in Japan. TQM enjoyed widespread attention during the late 1980s and early 1990s before being overshadowed by ISO 9000, Lean and Six Sigma.
Kaizen tries to improve the organization as a whole by creating a standard way of working, increasing efficiency and eliminating business waste. It includes the 5S method for workplace organization:
This combines elements from TQM model with aspects of Rapid-Cycle Improvement (RCI), in which changes are made and tested over shorter periods, 3 months or less rather than the standard 3 to 12 months. This methodology uses uses Plan-Do-Study-Act cycles (described previously) to test interventions on a small scale.
Methodologies are more prescriptive in nature than models, providing a detailed framework that guides an organization that wishes to implement a continuous improvement model. Two of the most frequently used QI methodologies in healthcare are ISO 9001 and Six Sigma.
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ISO 9001 is a standard methodolgy that was first introduced in 1987 and has been through many iterations since. It took many elements from a previous UK quality management methodology called BS5750. Adopted by the International Standards Organization, it includes a system of certification backed by external audit. Used across many different industries, it is perhaps the most widely adopted of all the continuous improvement methodologies. ISO 9001 puts great emphasis on documentation for this reason can lead to an overly-bureaucratic approach to QI.
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Six Sigma was introduced by American engineer Bill Smith while working at Motorola in 1980. Jack Welch made it central to his business strategy at General Electric in 1995. The goal of the Six Sigma methodology is a defect-free process. Six Sigma refers to six standard deviations from the mean. It indicates the extent to which the organisation complies towards having a defect-free process. Achieving a 6 sigma level means: you make a mistake only 3.4 times out of a million. i.e. out of a million invoices you only have to send 3 credit invoices.
Six Sigma is most popular in the US.
All continuous improvement models and methodologies incorporate the concept of standards. A standard is a document that provides rules & guidelines for the repeated use of a process or procedure, aimed at achieving the optimum outcome.
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The large number of competing approaches, all claiming to be the best way to achieve a similar goal, can leave anyone at a loss as to which is best for them. All the process improvement tools I’ve described share many common features. They share the philosophy that processes can always be improved. They share the assumption of measurement and statistics being a key to improvement. And they share the faith in the power of the caregivers closest to a process to be able to improve it. In my opinion Kaizen is the simplest of the models to understand and to implement in the healthcare environment.
Be pragmatic in choosing a model or methodology. Base your decision on the availability of local resources and skills that can help guide you through to a successful implementation. Find the best consultant or advisor with relevant experience (ideally in a healthcare setting) and use the methods and tools they are most familiar with.
Plio quality improvement software works with any of these common quality improvement models and methodologies and a specific version is available for use in healthcare: http://www.pliohub.com/quality-improvement-healthcare/
Quality assurance (QA) looks at compliance against defined standards, with action taken to deal with sub-par outcomes. Quality improvement (QI) is focused on moving the average higher for all outcomes from a process (see below). QA tends to be defensive with a focus on providers. QI is proactive and preventive in nature, focusing on patient care.
Source: Institute for Healthcare Improvement; Scoville & Lloyd
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Risk can be defined as:
The effect of uncertainty on one or more Key Activities, impacting on the achievement of Outputs and Key Goals
Your hospital might have the best-designed processes in the world, but if these fail to take account of risks, then your performance will be compromised – often catastrophically. For example, you may be dependent on one key supplier for critical surgical supplies. The supplier operates a single factory that is suddenly destroyed by a fire. When you run out of that product, your entire surgery schedule is halted until you can find a new source of supply.
The starting point for risk analysis is to analyse the previous history of incidents, either from past records or from managers’ memories. Another tactic is to look at publicly available risk registers, such as those compiled by local and central government.
Despite the vital importance of these services, they have been somewhat overlooked in national QI agendas. There is much less national quality data available for these sectors. Services are often commissioned through contracts that do not incorporate quality standards. Charities play an especially important role in community care, yet they have relatively little experience with quality improvement techniques.
An additional challenge in community health is that services are provided in a decentralised way, often far from the location of the managers. This can make it more difficult to gather the data on quality that is needed to evaluate current performance and to monitor the effects of improvements.
The quality improvement frameworks and methods I’ve described in this article are equally applicable to community health and to mental health. Given the relative lack of adoption, the potential for quality improvement specialists to make an impact is correspondingly greater.
Ideas for QI projects can come from anyone or anywhere in your healthcare organization. Negative experiences of patients are a good starting point. For maximum impact this is best described as a patient story (see the Esther model, below), and a storyboard can then be developed to illustrate the key aspects of the dysfunctional process.
Here is a selection of idea “storyboards” from the IHI Open School:
Jönköping County Council – Sweden – the Esther model
The Esther model was developed in the late 1990s in Höglandet (Highland) region of Sweden (population: 110,000) to improve the care of elderly people with complex conditions. Dr Mats Bojestig led an action plan for improvement which proved very effective. The project used the negative experiences of an elderly patient, known as “Esther” as the inspiration for improvement. Esther’s experience is described thus:
“ESTHER LIVED ALONE and one morning developed breathing difficulties. After contacting her daughter, who did not know what to do, Esther sought medical advice. She was seen by a district nurse and told to visit her GP. The GP said she needed to go to hospital and called an ambulance. After being admitted to emergency care she retold her story to a variety of clinicians at the hospital during a five-and-a-half-hour wait. Esther saw a total of 36 different people and had to retell her story at every point, while having problems breathing. This process caused Esther to become confused. (In a worst-case scenario, she could have been misdiagnosed with dementia). After her long wait, a doctor finally admitted her to a hospital ward and treatment began.”
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East London NHS Foundation Trust (ELFT) provides a wide range of mental health services and other community health services in London and surrounding areas covering 1.5 million people. A series of ‘sentinel events’ (unexpected instances of serious harm or death to patients) in 2010 prompted a great deal of reflection at board level about the culture of the organisation and what needed to change at every level.
ELFT partnered with the IHI to develop a bespoke training programme (Improvement Science in Action) for anyone in a management role involved in a QI project.
There are now almost 200 active quality improvement projects at ELFT. There was a 42 per cent reduction in physical violence incidents across all East London wards. Direct costs due to physical violence decreased from £119,988 in the six months prior to the project to £61,376 post-implementation (the cost of making improvements was just £2,000).
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Dr Mike Evans describes a quality improvement project in his home hospital in Toronto. Many elderly patients arrive in A&E with fractured hips caused by falls. Delays in surgery were not only painful for the patient but led to increased chances of delirium and depression, longer recovery times and in some instances to premature death. The QI team decided to create a streamlined care pathway for these patients, named HIP. After implementation of the program the number of patients undergoing surgery within 48 hours rose from 66% to 90%, with an accompanying reduction in adverse outcomes.
Dr Noah Ivers analysed the results of 62 quality improvement studies conducted over the last 20 years using data in the Cochrane Central Register. 50% failed to change medical practices and showed either little or no impact on quality of care. Only 28% of projects showed an improvement of at least 10% in the quality of care.
Problems identified by the study include:
- Project not led by a respected colleague
- Lack of sustained effort
- Lack of specific goals and action plans
The administrative burden of a quality improvement program can be significant, and this is a major factor in projects not being sustained. Quality improvement software like Plio should be used to minimise this burden.
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A quality improvement specialist is generally a ‘behind the scenes’ kind of worker who rarely works directly with patients. Instead, he or she focuses on improving the overall level of medical care that a patient will receive when they visit a health facility. Even though the patient may never even know that such a position exists, it can have a tremendous impact on the kind of care they receive.
First and foremost the QI specialist needs a mix of people skills and analytical skills. This is best understood by looking at some of the things a quality improvement specialist will need to be able to do:
Gathering data from the facility related to clinical results and more
Analyzing the different methods that care is delivered and managed
Locating problems that continue to arise with regularity and then addressing those issues
Review all applicable laws, regulations, and compliance issues and then check to see if they are met at the facility
Interview employees to determine their level of knowledge concerning proper patient care
Develop new programs and protocols that lead to improved care
Be familiar with and be able to use software tools for quality improvement (e.g. Plio)
In most cases, taking on a role as a quality improvement specialist will require you to possess at least a master’s degree in a field like nursing, public health, epidemiology, health care administration, or some similar area of study. You’ll also need to gain at least three to four years’ worth of experience in a clinical setting, and some prior experience in the field of quality improvement as well.
Bio of Author:
Steve’s interest in management systems started at Wharton, where he studied for his MBA. He then tried to apply what he’d learned, with varying degrees of success, in two startups that he founded in the early days of the mobile internet. Founder of Trigenix, a mobile software company which was acquired by Qualcomm Inc. Loves cycling and the Cotswold hills.
NHS-provided lists of resources to aid quality improvement programs: