3. The roots of quality improvement


Most of today’s quality improvement methods were developed in industry and have been adapted for use in other sectors, such as health. These industrial approaches have been used within healthcare for the past 30 years, but their use has not yet been embedded throughout healthcare organisations. Perhaps because of this, the evidence base for their effectiveness is relatively limited, although it is expanding with the increasing interest in improvement science.

The roots of many quality improvement approaches can be traced back to the thinking about production quality control that emerged in the early 1920s. During the 1940s and 1950s, quality improvement techniques were further developed in Japan, pioneered there by the US experts W Edwards Deming, Joseph Juran and Armand Feigenbaum and the Japanese expert Kaoru Ishikawa. Don Berwick later became known for his work in the United States, leading the pioneering work of the Institute for Healthcare Improvement.

These leaders in quality improvement have built a body of knowledge about implementing and sustaining change across a range of industries, including healthcare. There are a number of quality improvement approaches that draw upon the work of these pioneers. See Section 4 for details of some of the most common approaches.

Pioneers of quality improvement approaches

Joseph Juran published The quality control handbook in 1951. His philosophy focused on the role of management responsibility for quality. An important aspect of Juran’s work was his focus on staff empowerment. Juran recognised that every individual in the workplace needed to take responsibility for quality improvement, and that if staff were not empowered to do so, results would be limited. In this respect, quality improvement is regarded as an ongoing process and part of everyday business and work.

Armand V Feigenbaum was chief of manufacturing for General Electric in the 1960s and the originator of ‘total quality control’, which he defined as:

an effective system for integrating quality development, quality maintenance and quality improvement efforts of the various groups within an organisation, so as to enable production and service at the most economical levels that allow full customer satisfaction.

Feigenbaum saw quality as a way of managing, rather than a series of projects, and viewed it as the responsibility of everyone in the organisation. He proposed three steps to quality: quality leadership, modern quality technology and organisational commitment.

Kaoru Ishikawa made many contributions to the field of quality improvement, including a range of tools and techniques. See, for example, his cause and effect ‘fishbone’ tool. His emphasis was on the human side of quality. The concept of quality improvement as a fundamental responsibility of every member of staff became a key component of the Japanese approach to quality improvement. Ishikawa’s work focuses on the idea of kaizen (a Japanese word that can be roughly translated as ‘continuous management’). This concept, developed by Japanese industry in the 1950s and 1960s, is a core principle of quality management today, and holds that it is the responsibility of every staff member to seek to improve what they do.

W Edwards Deming developed a 14-point approach to quality improvement and organisational change in the 1980s. Deming was also the creator of the Plan, Do, Check, Act cycle of continuous improvement, which later became Plan, Do, Study, Act (see Section 4). This approach is used in many quality improvement approaches within the NHS today. His work has been underpinned by his system of profound knowledge, which offers insight into how to make changes that will result in improvements in a variety of settings. Crucially, he highlighted how different elements interacted with each other – for example, arguing that knowledge about psychology is incomplete without knowledge about variation. Organisations can harness this knowledge to drive forward improvements.

Don Berwick is President Emeritus and Senior Fellow at the US Institute for Healthcare Improvement (IHI), where he was President and Chief Executive Officer for nearly 20 years until 2010. The IHI, based in Boston, is a leading innovator in health and healthcare improvement worldwide and has had considerable influence on the application of quality improvement in the healthcare sector.

The IHI has adapted the US Institute of Medicine’s six dimensions of quality (see Section 2) into a ‘no needless’ framework, which aspires to promote:

  • no needless deaths
  • no needless pain or suffering
  • no helplessness in those served or serving
  • no unwanted waiting
  • no waste
  • no one left out.
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