Quality Improvement Basics
- What is Quality Improvement?
- How do we define quality?
- The importance of Quality Improvement in health and care
- What is a culture of continuous improvement?
- Guiding principles for continuous Quality Improvement
- Why stakeholder feedback in Quality Improvement matters
What is Quality Improvement?
Quality Improvement is the process of continuously striving to improve services, products or processes. It is a systematic and coordinated process that includes:
- the identification of problems;
- the systematic use of data, methods and tools to design and select solutions; and
- real-time measurement of baseline data and improvements.
It includes the combined efforts of everyone – health and care professionals, patients and carers, partners, advocacy groups and more – in making changes that will improve patient outcomes, system performance and effectiveness, as well as patient and workforce experience.
The linked aims of improvement: What is QI and how can it transform healthcare?
The process is a cycle and does not end. Quality Improvement, and indeed healthcare, cannot reach its full potential unless change-making becomes an intrinsic part of everyone’s job, every day; and unless those closest to the issues affecting care are given the time, permission and resources to speak up and share solutions to the challenges faced.
As The Health Foundation points out in QI Made Simple, “Done well, Quality Improvement can deliver sustained improvements not only in the quality, experience, productivity and outcomes of care, but also in the lives of the people working in healthcare.”
There are a range of different methods and tools in Quality Improvement, from Lean Six Sigma to The Institute for Healthcare Improvement (IHI)’s Model for Improvement, but as The King’s Fund states: “There is no clear evidence that one approach is superior to others. Rather, it is the process of having a systematic approach to Quality Improvement and applying this consistently that is important.”
As much as a set of tools and a methodology, Quality Improvement can also be thought of as a mindset. In addition to technical skills, there are behavioural ones whereby stakeholders (health and care professionals and patients alike) resist the inertia and safety net of thinking, “that’s the way we’ve always done things,” and are humble and curious to look for opportunities to learn and improve. The IHI talk more about this in this here.
How do we define quality?
In England, a single definition of quality for the NHS was first set out in High Quality Care for All in 2008, following the NHS Next Stage Review led by Lord Darzi. This definition sets out three dimensions to quality:
- clinical effectiveness: quality care is care which is delivered according to the best evidence as to what is clinically effective in improving an individual’s health outcomes;
- safety: quality care is care which is delivered so as to avoid all avoidable harm and risks to the individual’s safety; and
- patient experience: quality care is care which looks to give the individual as positive an experience of receiving and recovering from the care as possible, including being treated according to what that individual wants or needs, and with compassion, dignity and respect.
High quality care requires all three dimensions to be present.
Definition of quality, Quality in the New Health System
The definition also states that those providing services should be:
- well-led: open (collaborating internally and externally) and are committed to learning and improvement;
- sustainable: using resources sensibly and efficiently, providing fair access to all according to the needs of the population; and
- equitable: providing care that does not vary in quality because of a person’s characteristics.
In Crossing the Quality Chasm, the US Institute of Medicine defines six domains of healthcare quality – or six areas for healthcare to improve on:
- Safe: avoiding harm to patients, reducing the hazards and risk from the care itself.
- Effective: providing evidence-based care and refraining from providing services that are unlikely to be of benefit.
- Patient-centred: putting people in control of their own care and ensuring that care is responsive to individual patient preferences, needs and values.
- Timely: reducing waiting times for care and avoiding needless, harmful delays.
- Efficient: avoiding waste – from duplication to lost records, and even lost ideas.
- Equitable: ensuring that care is of the same quality regardless of patient characteristics such as gender, ethnicity, location or socio-economic status.
The importance of Quality Improvement in health and care
Quality Improvement exists in all industries, however it is most often written about and discussed within the health and care sector. Extending beyond traditional problem-solving, Quality Improvement in healthcare is important for solving complex problems where an immediate solution is not known and where the nature of the problem is not fully understood. It is a process for designing, implementing and monitoring changes in healthcare services to improve or maintain the quality of care.
A focus on Quality Improvement in health and care has many benefits. It can:
- improve patient safety, care delivery and patient outcomes;
- enhance patient experience;
- improve systems and processes, reducing inefficiencies and waste to make best use of resources (across time, finance, assets and equipment, and people);
- reduce errors;
- better prepare a team or organisation to handle large-scale emergencies or events, as illustrated during the COVID-19 pandemic;
- provide a systematic and scalable way of tackling the challenges (both large and small) faced by a team, department, or organisation;
- ensure data is used to both uncover problems and effect solutions;
- build participatory change, by using the expertise and contributions of those closest to the issues – service providers and service users – to identify issues and solutions; and
- release the creativity and innovation necessary to tackle complex issues which may have remained unsolved for many years.
All methodologies for Quality Improvement in health and care (e.g. Lean Six Sigma, or IHI’s Model of Improvement) share a systematic approach that is both inclusive and scalable. But Quality Improvement is more than a set of tools and a methodology: it is a mindset that feeds organisational culture.
What is a culture of continuous improvement?
A culture of continuous improvement is one in which incremental positive change is built into the mindset and fabric of an organisation. It is an approach whereby everyone in an organisation – leadership, management and employees – is empowered and motivated to make tomorrow better.
McKinsey & Company lists continuous improvement as one of four recipes for superior organisational health.
Creating a continuous improvement culture requires commitment and persistence. It requires an understanding of the current mindsets influencing employee behaviour and then a clear plan for how these mindsets can be shifted to engage the entire workforce in a drive for improved performance and innovation.
This sounds like an ambitious undertaking. However, by creating an environment in which staff can provide feedback about their daily work, and then participate in improvement and decision-making processes such as providing simple feedback mechanisms for staff to voice their ideas for change, the foundations of a culture of continuous improvement can be laid.
Small practical changes such as this can make a big difference with benefits extending beyond those immediately involved. Moreover, 100% adoption in new improvement programmes is not required for the culture to begin to shift. Even starting with a small group of participants, the subsequent impact can be profound. We call this the ‘halo effect of engagement’.
With a handful of champion participants, increasing numbers of colleagues will start to:
- feel the benefit from the improvements made;
- become aware of a new way to improve;
- feel lifted by the enthusiasm of engaged participants and energised by their sense of ownership;
- feel part of a collaborative environment; and
- feel encouraged to get involved as well.
Guiding principles for continuous Quality Improvement
A key element to embedding continuous Quality Improvement is to ensure everyone has an opportunity to participate. It requires moving beyond the old model of decision-making powers being held by a few at the top, which results in overburdened leaders, unengaged followers and top-down change.
A continuous improvement model is one of collaborative change in which everyone plays a role in improving their workplace. By giving everyone a voice, 24/7, regardless of role, and enabling people at all levels to provide real-time insights, you can start to understand what matters to the workforce; create continuous, real-time touch points; and improve staff experience by creating an open and collaborative culture.
There are a few guiding principles to help teams achieve this:
- Firstly, it is important to replace top-down and project-based mentality with tools and techniques to support everyone to identify and solve problems themselves, emphasising the importance of small, incremental improvements. This may require training and a new system for ensuring everyone’s voices can be heard in real time.
- Additionally, it is important to provide ongoing communication and progress updates, celebrate successes, and ensure staff are able to take ownership and feel proud of their achievements.
- Involving patients, service users and their carers is also central to creating a continuous improvement culture.
- Getting commitment from leaders at all levels is essential, including a commitment from leaders to demonstrate the new behaviour expected from staff. It is important they understand the long-term approach needed for success, as well as how to shift behaviour away from the old model of top-down change.
- It is crucial to convey that this new way of working is not a separate job, but part of the everyday responsibilities of all staff. Leaders should still ensure there is adequate time and resources allocated for staff participation, particularly for training activities.
Why stakeholder feedback in Quality Improvement matters
Health and care delivery involves the complex coordination of a multidisciplinary group of clinical and non-clinical staff, as well as patients and their family members; and delivering safe, quality care requires effective communication and collaboration across the team, department and organisation.
Stakeholder feedback in Quality Improvement is essential so as to ensure those who are most impacted by the quality measures – whether that be patients, carers, clinicians or other members of staff – are best placed to identify problems and come up with solutions, enabling teams to tap into their collective intelligence.
Moreover, as engagement increases, so does stakeholder experience and in turn, healthcare delivery and patient outcomes. We call this the ripple effect of engagement as shown below:
If we give key stakeholders a voice, support them to suggest solutions to the challenges they face and involve them in decision-making, we can create a ripple effect; improving staff and patient experience, the quality of care delivery and patient outcomes.
As Helen Bevan, the Chief Transformation Officer at NHS Horizons, put it: “The more that people participate, the more power is created.” She uses the term “new power”, coined by authors Jeremy Heimans and Henry Timms, saying that, “New power is like a current; it surges with energy when people come together with a shared purpose.”
