- Quality improvement
A formal approach to the measurement and analysis of organisational systems, processes and policies and the continued efforts and strategies to enhance outcomes
In the hierarchical approach, it is management’s job to distil strategy, issue instructions and create a system of compliance. In the quality improvement approach, it is management’s job to enter a deep and authentic listening relationship with the clinicians and teams within the organisation, to remove the barriers to achieving high-quality outcomes and to ensure that the systems that support the work are efficient and effective enough for financial balance and the delivery of strategic goals.
Whereas traditional hierarchical management focuses on control and as a consequence tends to centralise power (State Services Authority, 2013), the quality improvement approach focuses on alignment and tends to decentralise power – ultimately to clinical teams. In many healthcare organisations, the traditional model of management is still dominant, and managers who adopt a quality improvement approach have to display considerable courage and resilience to achieve results in this quite different way of seeing the world.
History of quality improvement
Walter Shewhart and W. Edward Deming
In 1924, Walter Shewhart was working in the inspection engineering department of the Western Electric Company in the United States when he produced a single-page memorandum for his boss that contained two revolutionary ideas that remain at the heart of quality improvement thinking to this day. The first was that to improve the quality of a finished product, the organisation should stop taking an ‘inspection’ approach, which examined products that had already been made, and instead focus on the processes that went into production and ensure these were working properly to deliver the required outcomes. The second idea was that the organisation should apply statistical methods to look at data over time, studying variations in processes to identify where changes needed to be made to improve outcomes (Berwick, 1991; Best & Neuhauser, 2006).
These ideas come together to form one of the basic building blocks of quality improvement: that of statistical process control, which is defined as a philosophy, a strategy and a set of methods for ongoing improvement of systems, processes and outcomes. It is based on learning through data and founded on the theory of variation (Carey, 2003). In its simplest form, this idea states that there are two basic types of variations in processes. Common cause variation arises inevitably, because of the nature of the process under consideration, and needs to be accepted as a natural part of the management system. Special cause variation arises because of unusual factors bearing on the process (Kolesar, 1993; Mohammed, Cheng, Rouse & Marshall, 2001).
- Statistical process control
A philosophy, a strategy and a set of methods for ongoing improvement of systems, processes and outcomes
Shewhart’s work came to be known to the young physicist and mathematician W. Edward Deming in the 1920s, and Shewhart became a mentor to Deming in the 1920s and 1930s. Deming both internalised Shewhart’s work and extended and developed it in the course of his career (see https://www.deming.org). He had a more philosophical outlook than Shewhart and developed the ideas of process management by providing a more comprehensive conceptual framework, with four main principles (Anderson, Rungtusanatham & Schroeder, 1994). Taken together, these create a particular way of seeing the world. The four principles are discussed below.
Work happens in systems
This is important in thinking about improving healthcare for two main reasons. Firstly, it warns against falling into the trap of blaming individuals when things go wrong – it is important to look first at the system they are operating within for causes of quality or safety problems. When thinking about changing systems, it is also crucial to continually remember the importance of teams rather than individuals. Secondly, the principle gives power to thinking about what is happening in the wider care system when trying to address a particular improvement.
Understanding variation is fundamental
One of Shewhart’s basic principles of quality management is that there are two types of variations in a system, which have been introduced already: common cause variation and special cause variation (Berwick, 1991). The basic idea behind the principle is that the process with the smallest possible range of variation will be the most efficient.
It is essential to appreciate psychology
In healthcare improvement, appreciating psychology is of particular importance in developing leadership relationships necessary to gain commitment and permissions to design and sustain positive changes. To lead change effectively in a clinical environment, it is essential to acknowledge that almost all health professionals feel a vocational commitment to their work, have the interests of patients at heart and come to work wanting to do a good job. It is more often poor systems rather than bad people that cause problems with quality.
To act as a change agent, we must develop a theory of knowledge
In both individual change projects and leadership as a whole, it is important for leaders to continually reflect on how they are interpreting information and developing their view of the world, as individuals and within teams. Over time, one of the challenges of creating sustainable change is to grow the capability of teams to better grasp their situation and to have the confidence to experiment to improve it. This can be done only when people feel they understand their system, and to lead teams to this understanding requires the development of a theory of knowledge.
Brent James
After attending one of Deming’s seminars in the late 1980s, Dr Brent James went on to lead the development of the quality improvement movement at Intermountain Healthcare in Utah. The Intermountain system was cited by President Barack Obama (2009, June 15) in 2009 as a place ‘where high quality care is being provided at a cost well below average … excellence that we need to make the standard in our healthcare system’, and James was named fourth among Modern Healthcare’s ‘50 most influential physician executives’ (n.d.) in 2013. These results have been achieved through the systematic implementation of a quality improvement philosophy.
The seminal text that brought quality improvement into the mainstream of healthcare leadership was Crossing the quality chasm, published in 2001 (Institute of Medicine, 2001). It should be required reading for all practising and aspiring healthcare leaders.
An outpatients service has a chronic problem with access, and there is pressure from funders and the local hospital board to reduce waiting times for patients referred by local general practitioners. Without taking a systems view, managers might be tempted to simply increase capacity by putting on extra clinics for a time. This will give short-term benefits, but the problem is likely to recur and may get worse. With a quality improvement perspective, a deeper reform approach will look at what happens before and after the outpatients clinic, and it will include general practitioners and surgeons at the start of the process of designing the solution, so that the reasons for referral can be addressed, as well as the potential need for more operations after patients have been seen in outpatients.
Characteristics of quality and service improvement
There are eight characteristics of a quality improvement approach (Buttell, Hendler & Daley, 2008; Health Foundation, 2010). In healthcare, the method is patient-centred, professionally respectful, team-based, disciplined in project management, information-rich, evidence-based, process-focused and sustainable. From the literature and the author’s experience, each of these is essential to delivering sustainable improvements at the level of the clinical team, organisation, region or nation.
Patient-centred
The term patient-centred in healthcare settings refers to the respect of and response to patient and consumer values, needs and preferences. The Australian Commission on Safety and Quality in Healthcare (2010, p. 7) lists the dimensions of patient-centred care as: ‘respect, emotional support, physical comfort, information and communication, continuity and transition, care coordination, involvement of family and carers, and access to care’.
Many clinicians will quickly and rightly claim that their work is automatically patient-centred; after all, what do we think is going on in each clinic, ward or operating theatre? And on the one hand, this is certainly true. The sort of patient-centredness defined here, though, goes beyond the duty of the clinician to give the best care possible to the patient in front of them. It extends to whether patients feel valued, whether they have been involved in decisions about their care, whether they have had their preferences respected and whether the overall services (including all the steps that lead into the clinic room as well as those that continue beyond it) have been thought about from a patient’s point of view.
Also of great importance in public health systems is the leadership role to organise care so that it is not only the patients who get seen whose interests are looked after, but also those patients who are not seen. In other words, while a doctor may have a paramount duty to the patient in the room, healthcare leaders also have to think about the populations that may need diagnoses or interventions and how best to organise services based on the disease in populations rather than just on those who are accessing services today. The technique associated with this characteristic involves leaders truly internalising in their own thinking a radically patient-centred outlook as one of the cornerstones for their quality improvement approach (Berwick, 2009).
Professionally respectful
There are many managers who behave as if they do not understand the value of clinical professionals, or allied health professionals; or, even if they do understand it, they do not behave appropriately. Almost all senior doctors, nurses and allied health professionals will have completed more than 15 years of education, training and experience to achieve their standing and will have a vocational commitment to their work (Elston, 1991).
Unless healthcare managers and leaders begin their work (before the first conversation has been held) from a position of essential respect for the authority and status of clinicians, they are both unlikely to succeed in working with individuals and teams in a healthcare environment and – worse – likely to do harm to either morale or patient outcomes. Paradoxically, professional respect is also the only approach through which an effective challenge can be made to clinical practice. This is because it is only when a healthcare leader is in a relationship of mutual respect and trust with senior clinicians that a challenge from ‘outside’ the professional circle will be accepted and given attention (Harrison & Ahmad, 2000). Without this relationship, any changes beyond the superficial level will be ignored, rejected or subverted.
The technique associated with this characteristic involves leaders understanding that professional respect should not be an attitude, but a discipline – and one that should be practised daily. Out of this discipline comes the ability to discern whether concerns being raised should lead to abandoning a plan or finding a different way forwards, or whether the time is simply wrong to make a change. Professional respect is essential to remaining open to the possibility that some unsuspected safety risk has been highlighted.
Team-based
Because of Deming’s insistence on focusing on the system as a whole, quality improvement changes can be properly designed only on the basis of respectful engagement with the interprofessional care team. The simple reason for this is that even the simplest interactions between patients and the care system will involve at the very least managers plus doctor, or managers plus nurse or allied health professional. The more complex interventions, of course, involve multiple teams and particular sequences of care. It is simply not possible to get the information needed to design and implement a change without having reasonable representation in the process, and any changes made without this rounded perspective are highly likely to fail, or indeed be unsafe.
The technique associated with this characteristic involves leaders identifying at the beginning of a change process the key people who need to be involved in leading the change (McGrath et al., 2008). This may not always be the people in the most senior positions (though they will need to give their permissions), but it must include key representatives from each of the main professional groups, and administrators.
Disciplined in project management
There are several standard methodologies for project management internationally, perhaps the most widespread for major projects being PRINCE, which stands for PRojects IN Controlled Environments (United Kingdom Department of Finance and Personnel, 2014). While these can have a tendency to be overelaborate, it is essential to initiate quality improvement work within a formalised framework of project management discipline.
The techniques associated with this characteristic involve the following elements. Firstly, an unambiguous top-management sponsorship must be secured that includes an emotional commitment to the goals of the project. This is essential, since it is rare that a sustainable improvement can be delivered without some changes to resource allocation (in terms of money or time), investment, policy, procedures, leadership or structures. Solutions will often have all or many of these ingredients – it is the recipe that is unknown at the outset of the work. Top-management sponsorship is crucial because of the risk clinicians and clinical teams take in agreeing to embark on a change process, and healthcare leaders should be able to give a true and authentic agreement that the organisation shares the goals of the team and will do what is necessary to support the change.
Secondly, every change process should commence with a project initiation document containing a clear statement of who will be involved in the process (refer to the discussion above about whole-team involvement), what the goals of the project are and who the top-management sponsors are.
Finally, at the outset of the change, a clear statement of the criteria of success for the change should be clarified and agreed with the team concerned, expressed as SMART or SMARTT targets. These criteria can be changed or added to in the course of the project, but only by reference back to, and with the agreement of, the team concerned.
- SMART
Targets that are Specific, Measurable, Achievable, Reasonable and Time-bound
- SMARTT
Targets that are Specific, Measurable, Achievable, Realistic, Timely and Tangible
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