Work & Life
Lucy Pickard, MPH MRCPCH
Quality improvement (QI) is a disciplined effort to make healthcare delivery safer, more effective, patient-centered, timely, equitable, and efficient (less wasteful). These six domains were established by the National Academy of Medicine in 1999 as the tenets of healthcare quality and as a framework for appraisal of QI efforts. Any attempt to improve the care you provide will likely be in one of these domains.
The domains of healthcare quality: safe, effective, patient-centered, timely, efficient, and equitable.
Quality improvement (also referred to as improvement science, health systems research, implementation science) has a storied history, originating from industrial processes used in product development and quality control. The basic QI framework is highly intuitive and has evolved through the lens of healthcare to arrive at the methodologies we employ today, including the Model for Improvement (described below), Lean, and Six Sigma. At the heart of each of these models is a systematic approach to iterative improvement that leads to measurable change.
Iterative improvement is an instinctive concept: Have you ever watched a child try to make a tower of bricks, learning from successes and failures, making small changes with each attempt, and assessing the outcome? Have you ever developed a signature recipe by trying different incarnations and learning from failure when the experimental ingredient did not improve the overall result?
At the heart of quality improvement is iterative change aimed to make healthcare better for our patients and our colleagues.
In healthcare, QI represents a movement or commitment to strive to provide better care for patients. The process of improving healthcare quality has evolved into a science with rigor supported by theory. The various methodologies share the following principles to help us understand, analyse, and communicate our QI efforts:
The evidence, experience base, or confidence that a particular change will result in an improvement: This informs our expectations that a planned change in a process, system, or way of delivering care will lead to benefit and not harm. As with evidence-based medicine, we don’t always have robust evidence for a given course of action so our starting point may be based on experience or evidence from a neighbouring field.
Understanding the now: This requires deep knowledge of the status quo. Through the judicious use of data and meaningful engagement with service users and service providers, we must understand where issues and opportunities lie. Specifically, understanding the current state of the care we deliver will allow us to see the disparity between existing and improved delivery and predict the effect of change. QI methodologies provide useful tools to help understand the now and plan changes (e.g., driver diagrams, stakeholder analysis, process mapping). These tools help us understand the system within which we are working and decide where change will be most effective.
Iterative testing: This involves the act of trying one change and determining why it succeeded or failed, followed by evaluating, learning, and planning the next iteration. The iterations, reflections, learning, and planning of the next cycle are key components of the improvement process to address one of the six domains of healthcare quality (effective, patient-centered, timely, equitable, safe, and efficient).
Measurement: How do we know that a change is an improvement? The science of measuring and testing change runs the gamut from simple to complex, as does collation and representation of the data. At the very least, we must identify a measure from the iterative tests of change that represents a better or worse outcome. Measurement of improvement differs from measures used in research, accountability, or benchmarking: Measures of improvement need to be adequate (rather than exhaustive) and remain continuous throughout testing to demonstrate the impact of the change after each iterative cycle. Thus, a hypothesis must be flexible throughout the process rather than fixed as in traditional research methodology. The aim of measurement is continuous improvement.
Learning: There are many levels and stages of learning during the iterative process as we move from one cycle of testing to planning the next. When a project has succeeded, we also need ways to share what we have learned to benefit other systems and individuals. Perhaps even more importantly is sharing what we learn when tests of change are unsuccessful or result in worse care. Often, the most valuable learning does not come from success but rather from failure. One of the most important aspects of learning from QI iterative cycles is understanding the local context and interpreting variation. For example, why an intervention appears to work in one context and not in another informs the next cycle of testing.
Spreading and sustaining: An idea that has succeeded on a small scale may need to be tested on more individuals and at more sites if we choose to expand the change. An important part of improvement methodology is how to scale up a successful improvement and transform it into a QI change used by others.
The Model for Improvement (MFI) is one of the most widely used methodologies for improving healthcare quality. The MFI was developed from extensive experience in other industries, including the need to understand variation, the need to display and analyse results over time, the importance of understanding systems, and the vital role of learning in the process.
The MFI is an approach to continuous improvement involving changes that are tested in small cycles. The cycles consist of planning, doing, studying, and acting (PDSA) and are based on the following key questions:
1. What are we trying to achieve? This encourages us to consider clearly what this process of improving care is trying to do and to set a clear aim for the work.
2. How will we know that a change is an improvement? This is where we decide the measures we need to use to determine if the iterative cycles of testing are making a difference, either positive or negative.
3. What change can we make that will result in an improvement? Here we consider the changes to our system, or improvement ideas, that could lead to benefit.
• Plan what to do, who will do it and where, and what will be measured?
• Do the test and collect the data
• Study the data and compare it with what was expected
• Act on what you found by adopting, adapting, or abandoning the change you just tested and consider what to do for the next test cycle.
Improvement methods can be applied to the smallest areas of service delivery, from how we insert a cannula for intravenous access, to some of the largest and trickiest problems blighting an entire healthcare delivery service, such as bed management and operating theatre flow. We are most likely to succeed by engaging those directly involved in delivering care as well as service users themselves, and then seeking to solve problems using simple yet rigorous methodology and strong interdisciplinary team work.
When starting a project to improve healthcare quality, here are some tips:
Make a clear goal from the start.
Think carefully about the now and invest in building relationships with staff and service users to really understand the situation before you plan to make any changes.
Set practical and realistic measures that can be collected during normal work flow and do not require additional time. Beware of causing ‘measurement fatigue’ among staff.
Supervisors and champions are key. Find likeminded individuals with whom to partner and share ideas.
Borrow ideas shamelessly from others who have faced the same issues. However, context is key: Be mindful of why a change that worked in one setting or healthcare system might or might not work in yours.
Share without ego: Good ideas need to be spread, failure needs to be learned from.
Just get started: The beauty of iterative improvement is that even your measures will improve each time. The biggest step is the first.
At the heart of quality improvement is the concept of iterative change with the goal of making healthcare better for our patients and colleagues and to throw out two tried and tested maxims: Don’t let perfect be the enemy of good and see what you can do by next Tuesday.
Links to other resources:
Institute for Healthcare Improvement (IHI)
IHI Open School
Quality Improvement Made Simple
SQUIRE – Standards for Quality Improvement Reporting Excellence
International Society for Quality in Health Care
Society of Hospital Medicine Center for Quality Improvement
This expert consult was reviewed by Don Goldmann, MD, Chief Scientific Officer, Emeritus, and Senior Fellow, Institute for Healthcare Improvement (IHI), Professor, Department of Immunology and Infectious Diseases, and Epidemiology, Harvard T. H. Chan School of Public Health, Professor of Pediatrics, Part Time, Harvard Medical School.