Quality Improvement Made Simple What . - Health Foundation
Quick guideAugust 2013Qualityimprovementmade simpleWhat everyoneshould know abouthealth care qualityimprovement
This is the second edition of the guide and wasinitially published in August 2013.The design of the guide was updated in 2016 toreflect the Health Foundation’s revised branding,but no changes have been made to the content.Quality improvement made simpleis published by the Health Foundation,90 Long Acre, London WC2E 9RAISBN 978-1-906461-47-8 2013 The Health Foundation
Contents1Introduction22What are ‘quality’ and ‘quality improvement’?53The roots of quality improvement154Quality improvement approaches215Underlying principles276Frequently asked questions347Where can I find out more?43References47 1
Introduction1
Improving quality is about making healthcare safe,effective, patient-centred, timely, efficient andequitable. In the history of the NHS, there hasnever been such a focus on improving the qualityof health services.This guide focuses on one important elementof the quality agenda: quality improvement.It looks in particular at what are known asorganisational or industrial approaches to qualityimprovement. These aim to bring about a measurableimprovement by applying specific methods withina healthcare setting.This is not a ‘how to’ guide. Instead, it offers a clearexplanation of some common approaches used toimprove quality, including where they have comefrom, their underlying principles and their efficacyand applicability within the healthcare arena.Who is this guide for?This guide provides an overview of organisationalor industrial approaches to quality improvement.It is written for a general healthcare audience andwill be most useful for those new to the field ofquality improvement, or those wanting to bereminded of the key points.Introduction3
Why focus on qualityimprovement?The Health Foundation believes that there is acompelling case for applying organisational orindustrial quality improvement approaches tohealthcare.1 We think that all staff have a roleto play in ensuring that healthcare servicescontinue to improve.At present, the evidence is clear that healthcare is notalways safe and can lead to poor patient experienceand outcomes.2 At the same time, the economicdownturn means an end to year-on-year financialincreases. Healthcare services are being challengedto respond to this not through indiscriminate cuts,but by improving efficiency, driving up quality andreducing levels of harm.Improving the quality of services is also a keyrequirement within the NHS, supported byinitiatives such as quality accounts and theCommissioning for Quality and Innovation(CQUIN) payment framework.4Quality improvement made simple
What are‘quality’ and‘qualityimprovement’?2
The terms ‘quality’ and ‘quality improvement’mean different things to different people in differentcircumstances. This can be confusing. This sectionlooks at common definitions of both terms, andsummarises how they are broadly understood.What is quality?Within healthcare, there is no universally accepteddefinition of ‘quality’. However, the followingdefinition, from the US Institute of Medicine,is often used:[quality is] the degree to which health servicesfor individuals and populations increase thelikelihood of desired health outcomes and areconsistent with current professional knowledge.3The Institute of Medicine has identified sixdimensions of healthcare quality.3 These statethat healthcare must be: safe effective patient-centred timely efficient equitable.6Quality improvement made simple
The dimensions of qualitySafeTimelyAvoiding harm topatients from carethat is intended tohelp them.Reducing waits andsometimes harmfuldelays.EffectiveEfficientProviding servicesbased on evidenceand which produce aclear benefit.Avoiding waste.Person-centredEquitableEstablishing apartnership betweenpractitioners andpatients to ensurecare respects patients’needs and preferences.Providing care thatdoes not vary in qualitybecause of a person’scharacteristics.What are ‘quality’ and ‘quality improvement’?7
The Health Foundation regards quality as the degreeof excellence in healthcare. This excellence is multidimensional. For example, it is widely accepted thathealthcare should be safe, effective, person-centred,timely, efficient and equitable.Therefore, leaders need to actively consider thesesix dimensions when setting their prioritiesfor improvement. Often the dimensions arecomplementary and work together. However, therecan sometimes be tensions between them that willneed to be balanced. It is also important to take intoaccount different stakeholders’views about whatthey feel matters and what the priority areas of focusshould be within an organisation.8Quality improvement made simple
What is quality improvement?There is no single definition of quality improvement.However, a number of definitions describe it as asystematic approach that uses specific techniquesto improve quality. One important ingredient insuccessful and sustained improvement is the way inwhich the change is introduced and implemented.Taking a consistent approach is key.This guide draws its definition of qualityimprovement from that provided by Dr JohnØvretveit, a leading expert on quality in healthcare,in his report Does improving quality save money?,which states:The conception of improvement finally reached asa result of the review was to define improvementas better patient experience and outcomesachieved through changing provider behaviourand organisation through using a systematicchange method and strategies.1The key elements in this definition are thecombination of a ‘change’ (improvement) and a‘method’ (an approach with appropriate tools), whilepaying attention to the context, in order to achievebetter outcomes.What are ‘quality’ and ‘quality improvement’?9
How can we improve quality?The Health Foundation believes that a combinationof approaches is needed to ensure sustainedimprovements in healthcare quality.There are a number of external influences thatneed to be considered and used, where possible,to drive improvements in quality. These includeprofessional requirements, centralised governmentinitiatives and economic drivers, such as theCommissioning Quality and Innovation (CQUIN)payment framework.There are also a range of models and methods thatindividual organisations can put in place themselves.These were originally developed within anorganisational or industrial context. Organisationsdevelop and set their own goals, with full staffengagement, and employ a systematic approach toimplementing change and monitoring progress.The focus of this guide is on these organisationalor industrial approaches to quality improvement.We believe they have an important part to play intransforming services and driving up quality.10Quality improvement made simple
What would improve quality?Quality improvement draws on a wide variety ofmethodologies, approaches and tools. However,many of these share some simple underlyingprinciples, including a focus on: understanding the problem, with a particularemphasis on what the data tell you understanding the processes and systems withinthe organisation – particularly the patientpathway – and whether these can be simplified analysing the demand, capacity and flowof the service choosing the tools to bring about change,including leadership and clinical engagement,skills development, and staff and patientparticipation evaluating and measuring the impact of a change.Regardless of the approach used, how the change isimplemented – including factors such as leadership,clinical involvement and resources – is vital.What are ‘quality’ and ‘quality improvement’?11
The NHS Change Model4 highlights the followingkey areas for consideration: leadership for change spread of innovation improvement methodology rigorous delivery transparent measurement system drivers engagement to mobilise.How the implementation is managed will dependvery much on the context of the particularorganisation making the change, and requirescareful consideration. For more information aboutthe underlying principles of quality improvement,see Section 5.Quality improvement approaches andsustainable changeOnly around two-thirds of healthcare improvementsgo on to result in sustainable change that achieves theplanned objective. Therefore, leaders need to thinkcarefully about how they can embed positive changeand make it sustainable.12Quality improvement made simple
There is evidence that sustainable change is morelikely to result from a model that involves patientsand staff in developing, designing and implementingchanges than from a ‘command and control’/topdown model.Quality improvement in commissioningThere is growing awareness among healthcareproviders of how industrial quality improvementapproaches can benefit healthcare providers. Butit is also important that commissioners have anunderstanding of these methods. Commissionershave a specific role to play in contracting for qualityand ensuring that quality improvement approachesare being used to redesign and improve services.The commissioners’ role includes: building measures of quality and safety intocommissioning specifications and, whereappropriate, incentives and penalties putting in place monitoring and managementregimes that assess quality and patient safetyprocesses putting the emphasis on assuring quality and safetyin evaluating current and potential providersWhat are ‘quality’ and ‘quality improvement’?13
looking at governance and leadership on theseissues, rather than merely policies and procedures assessing for themselves how care is provided onthe ground, and how the culture and values ofthe organisation are expressed in behaviour using the CQUIN payment framework as a routeto reward providers for quality improvementAt the heart of every commissioner–providerinteraction should be discussions about what is beingdone to improve quality.By developing a better understanding of qualityimprovement approaches, commissioners willbe better placed to ask the right questions aboutproviders’ focus on improvement and the progressthey are making. This will help commissionersensure that quality is the driving factor in theirrelationships with providers.14Quality improvement made simple
The roots of qualityimprovement3
Most of today’s quality improvement methods weredeveloped in industry and have been adapted foruse in other sectors, such as health. These industrialapproaches have been used within healthcare for thepast 30 years, but their use has not yet been embeddedthroughout healthcare organisations. Perhaps becauseof this, the evidence base for their effectiveness isrelatively limited, although it is expanding with theincreasing interest in improvement science.5The roots of many quality improvement approachescan be traced back to the thinking about productionquality control that emerged in the early 1920s.During the 1940s and 1950s, quality improvementtechniques were further developed in Japan,pioneered there by the US experts W EdwardsDeming, Joseph Juran and Armand Feigenbaum andthe Japanese expert Kaoru Ishikawa. Don Berwicklater became known for his work in the UnitedStates, leading the pioneering work of the Institutefor Healthcare Improvement.6These leaders in quality improvement have builta body of knowledge about implementing andsustaining change across a range of industries,including healthcare. There are a number of qualityimprovement approaches that draw upon the workof these pioneers. See Section 4 for details of some ofthe most common approaches.16Quality improvement made simple
Pioneers of qualityimprovement approachesJoseph Juran published The quality controlhandbook in 1951.7 His philosophy focused onthe role of management responsibility for quality.An important aspect of Juran’s work was his focuson staff empowerment. Juran recognised thatevery individual in the workplace needed to takeresponsibility for quality improvement, and that ifstaff were not empowered to do so, results wouldbe limited. In this respect, quality improvement isregarded as an ongoing process and part of everydaybusiness and work.Armand V Feigenbaum was chief ofmanufacturing for General Electric in the 1960s andthe originator of ‘total quality control’, which hedefined as:an effective system for integrating qualitydevelopment, quality maintenance and qualityimprovement efforts of the various groups withinan organisation, so as to enable production andservice at the most economical levels that allowfull customer satisfaction.The roots of quality improvement17
Feigenbaum saw quality as a way of managing,rather than a series of projects, and viewed it as theresponsibility of everyone in the organisation. Heproposed three steps to quality: quality leadership,modern quality technology and organisationalcommitment.8Kaoru Ishikawa made many contributions to thefield of quality improvement, including a range oftools and techniques. See, for example, his causeand effect ‘fishbone’ tool.9 His emphasis was onthe human side of quality. The concept of qualityimprovement as a fundamental responsibility ofevery member of staff became a key componentof the Japanese approach to quality improvement.Ishikawa’s work focuses on the idea of kaizen (aJapanese word that can be roughly translated as‘continuous management’). This concept, developedby Japanese industry in the 1950s and 1960s, is acore principle of quality management today, andholds that it is the responsibility of every staffmember to seek to improve what they do.1018Quality improvement made simple
W Edwards Deming developed a 14-pointapproach to quality improvement and organisationalchange in the 1980s.11 Deming was also the creatorof the Plan, Do, Check, Act cycle of continuousimprovement, which later became Plan, Do, Study,Act (see page 24). This approach is used in manyquality improvement approaches within theNHS today.12 His work has been underpinned
The Health Foundation regards quality as the degree of excellence in healthcare. This excellence is multi-dimensional. For example, it is widely accepted that healthcare should be safe, effective, person-centred, timely, efficient and equitable. Therefore, leaders need to actively consider these six dimensions when setting their priorities for improvement. Often the dimensions are .
quality improvement essentials—critical elements successful quality improvement programs have in common. This executive report defines quality improvement in healthcare, describes critical quality improvement considerations, components, and tools, and identifies the top five quality improvement essentials: 1.
Quality improvement in mental health is broadly similar to quality improvement in other health care settings 43 Appendix 1: Quality improvement methods 44 . organisations have embraced quality improvement strategies and what has enabled them to do so. In parti
Quality Assurance and Improvement Framework Guidance 2 Contents Section 1: Quality Assurance and Improvement Framework 1.1 Overview 1.1.1 Quality Assurance (QA) 1.1.2 Quality Improvement (QI) 1.1.3 Access 1.2 Funding Section 2: Quality Assurance 2.1 General information on indicators 2.1.1 Disease registers 2.1.2 Verification
8 KCPHD Quality Improvement Plan 2014 The KPHD Quality Improvement Leadership Team's (QILT) purpose is to create and maintain an internal system of quality improvement for the Kittitas ounty Public Health Department that is clear, simple, and quantifiable. QILT strives to create a system that: is realistic to implement,
WEYGANDT FINANCIAL ACCOUNTING, IFRS EDITION, 2e CHAPTER 10 LIABILITIES Number LO BT Difficulty Time (min.) BE1 1 C Simple 3–5 BE2 2 AP Simple 2–4 BE3 3 AP Simple 2–4 BE4 3 AP Simple 2–4 BE5 4 AP Simple 6–8 BE6 5 AP Simple 4–6 BE7 5 AP Simple 3–5 BE8 5 AP Simple 4–6 BE9 6 AP Simple 3–5
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continuous improvement process. Central to this is the requirement for services to have an effective self-assessment and quality improvement process. All services must have a quality improvement plan. Next assessment and ratings The results of next assessment and ratings show services are demonstrating a commitment to ongoing quality improvement.
