6. Frequently asked questions


Q. Are there examples of industrial models of quality improvement being applied successfully in healthcare?

There are relatively few examples (in the UK or elsewhere) of the wholesale application of industrial models of quality improvement in healthcare. In the UK, the Royal Bolton Hospital NHS Foundation Trust was one of the first to take a whole-organisation approach to introducing Lean thinking across a hospital, in an approach called the Bolton Improving Care System. In the United States, some hospitals, and groups of hospitals, have taken a whole-organisation approach to quality improvement. For example, Cincinnati Children’s Hospital prides itself on measuring improvement across the organisation in terms of safety, efficiency and patient-centredness.

Because quality improvement is a long-term strategy, it requires the measurement of impact over a considerable length of time. Most health organisations that have used quality improvement approaches report some benefits – particularly at the start of the initiative, when staff engagement and motivation is high. Healthcare organisations are highly complex, and improvement interventions will vary in their application from place to place and context to context. This makes overall evaluation of their efficacy challenging – whether this is defined as improved efficiency, cost reduction, patient experience or safety.

Q. Can quality improvement save money?

The Health Foundation believes that quality improvement should be a key part of an organisation’s mission because it can improve patient experience and outcomes – and can bring financial and productivity benefits for the organisation. A 2009 review found that quality improvement can make an important, if limited, contribution to the cost-efficiency of healthcare.

For example, continuing with poor or sub-optimal care results in unnecessary costs. Longer stays for patients due to healthcare-acquired problems, such as infections or pressure ulcers, add to hospital costs. Improving care and hygiene standards will reduce costs per case, and can boost productivity such as throughput of patients per bed.

Issues that can be addressed to produce cost savings in healthcare include:

  • delays, such as patients waiting for tests
  • reworking – in other words, performing the same task more than once
  • overproduction, such as unnecessary tests
  • unnecessary movement of materials or people
  • ‘defects’, such as medication errors
  • waste of spirit and skill, through the problems staff face on a daily basis not being addressed.

Q. How can quality improvement approaches help productivity?

A key challenge for NHS organisations over the coming years will be to ensure that they achieve the best possible value for money – with quality of care embedded within that concept.

For providers, reducing variation, streamlining processes, cutting out waste and reducing errors can contribute to more a productive system and workforce. From a commissioner’s perspective, evidence shows that there can be variation in the value for money achieved by different commissioning bodies. This suggests that there is scope either for improving quality outcomes without increasing spending, or for retaining current outcomes while spending less.

Incentives within contracting also contribute to the drive to improve quality. For example, the CQUIN payment framework is the mechanism through which commissioners are able to contract for quality improvement, and the way providers are able to secure resources additional to those specified in the contract for services.

Q. Why is there such a focus on variation in quality improvement?

There are two broad types of variation in healthcare: variation in the organisation of services or processes and variation in clinical practice. Quality improvement approaches are focused on improving processes, systems and, sometimes, clinical practice.

Variation in the systems and processes adopted in healthcare leads to inefficiency, waste and increased waiting times. In clinical processes, variation from an established evidence-based best practice can result in error and harm, as well as poor outcomes for the patient. Addressing this can be described as increasing the reliability of care – a key component of which is standardisation.

However, a certain amount of variation is considered normal, so it is important to understand how variation works. Many quality improvement approaches assess whether a system, process or clinical practice is within control limits. They then use this as a key measurement tool, to help understand the level of variation in the system and to measure it over time.

Q. Can quality improvement have unintended consequences?

At times, change in one area can cause pressure in another. This is known as ‘unintended consequences of quality improvement’. For example, improved early discharge may lead to increased readmission. In these circumstances, leaders need to anticipate and monitor for these potential consequences using a set of balancing measures, and may need to make decisions about scheduling or sequencing of initiatives. Quality improvement is likely to be more effective if it is addressed at a whole-system level rather than a number of disconnected projects, and must be approached as a long-term, sustained change effort.

Q. Do we need a team of experts to lead quality improvement in our organisation?

Quality improvement approaches are underpinned by a philosophy and a set of competencies. For this reason, research indicates that quality improvement initiatives are more successful if frontline staff are supported by facilitators who have capability in quality improvement methods, approaches, tools and techniques. However, building the organisation’s capability for quality improvement is also important, and this should be part of the organisation’s overall quality improvement strategy.

What is the link between quality improvement and patient safety?

In recent years it has been widely recognised that unnecessary harm happens in the process of providing healthcare. Quality improvement approaches are increasingly being used to address these system failings. The reliability of the application of evidence has been used as a key approach in several national initiatives to encourage healthcare organisations to measure and aim to reduce harm.

Q. What are the barriers to successful quality improvement?

In a study of 14 quality improvement programme evaluations, 10 key challenges were consistently identified from the programmes. These were:

  1. convincing people that there is a problem
  2. convincing people that the solution chosen is the right one
  3. getting data collection and monitoring systems right
  4. excess ambitions and ‘projectness’
  5. the organisational context, culture and capacities
  6. tribalism and lack of staff engagement
  7. leadership
  8. balancing carrots and sticks – harnessing commitment through incentives and potential sanctions
  9. securing sustainability
  10. considering the side effects of change.

However, the evaluations also showed that if you take the time to get an intervention’s theory of change, measurement and stakeholder engagement right, this will deliver the enthusiasm, momentum and profound results that characterise improvement at its best.

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