5. Underlying principles of quality improvement


In the previous section we looked at some of the most common quality improvement approaches. Despite their different names and apparent differences in methods, most quality improvement approaches share some simple underlying principles.

Data and measurement for improvement

Measurement and gathering data are vital elements of any attempt to improve performance or quality, and are also needed to assess its impact. However, measuring for improvement differs from the two better-known types of measurement: measuring for research, which tests whether an intervention works, and measuring for judgement, which helps managers gauge performance.

In contrast, when measuring for improvement, the learning develops through the process. As a result, the hypothesis will change throughout the project and the data will be ‘good enough’ rather than perfect. Instead of asking whether an intervention works, it involves asking how the intervention can be made to work in a given situation and what will constitute ‘success’.

It is also important to measure change over time, using methods that make it possible to separate out improvement, or deterioration, from the expected level of performance variation.

Understanding the process

Access to data is vital when assessing whether there is a problem. However, it will not in itself explain why the problem exists. This is where understanding the process becomes important.

Process mapping is a tool used to chart each step of a process. It is commonly used to map the pathway or journey through part or all of a patient’s healthcare journey, and supporting processes. Process mapping is extremely useful as a tool to engage staff in understanding how the different steps fit together, which steps add value to the process, and where there may be waste or delays.

Mapping patient journeys involving multiple providers is also invaluable to identify any quality problems at the interfaces between teams and organisations.

Improving reliability

Once a process is understood, a key focus of quality improvement is to improve the reliability of the system and clinical processes. Ensuring reliability mitigates against waste and defects in the system, and reduces error and harm.

Systematic quality improvement approaches such as Lean (see Section 4) seek to redesign system and clinical pathways, create more standardised working and develop error-free processes that deliver high-quality, consistent care and use resources efficiently.

Demand, capacity and flow

When there are backlogs, waiting lists and delays in a service, a common response to these problems is to say that there is a capacity problem – in other words, that there are insufficient staff, machines or equipment to deal with the volume of patients. However, unless there has been measurement of the demand (the number of patients requiring access to the service) and the flow (when the service is needed), it is impossible to say whether there is a capacity shortfall. It may simply be that the capacity is in the wrong place, or is provided at the wrong time.

For a process improvement to be made, there needs to be a detailed understanding of the variation and relationship between demand, capacity and flow. For example, demand is often relatively stable and flow can be predicted in terms of peaks and troughs. In this case, it may be the variation in the capacity available that causes the problem (for example, staff sickness or unplanned leave).

Enthusing, involving and engaging staff

Evidence about successful quality improvement indicates that it is not necessarily the method or approach used that predicts success, but rather it is the way in which the change is introduced. Factors that contribute to this include leadership, staff engagement (particularly of clinicians) and patient participation, as well as training and education.

It is important not to underestimate the importance of involving all relevant staff, including non-clinical staff, who are often the first point of contact for patients. Breaking down traditional hierarchies for this multidisciplinary approach is essential to ensure that all perspectives and ideas are considered.

Engaging frontline clinical staff is crucial for any quality improvement programme, but it can be challenging. Many clinicians will be keen to improve the quality of the service they offer, and will already have done so through methods such as clinical audit, peer review and adoption of best practice. However, they may be unfamiliar with quality improvement approaches.

For this reason, capability building and facilitated support are key elements of building clinical commitment to improvement. Other important aspects include:

  • involving the clinical team early on when setting aspirations and goals
  • ensuring senior clinical involvement and peer influence
  • obtaining credible endorsement – for example, from the royal colleges
  • involving clinical networks across organisational boundaries
  • providing evidence that the change has been successful elsewhere
  • embedding an understanding of quality improvement into training and education of healthcare professionals.

Clinicians are more likely to engage with the process if the main emphasis appears to be on improving quality rather than cost-cutting measures.

Involving patients and co-design

Patients, carers and the wider public have a significant role to play – not only in designing improvements, but also in monitoring whether they have the desired impact. This is particularly important because they are the only people who really experience the patient pathway from start to finish.

Staff must constantly ask the question ‘How do we know what constitutes good care?’ If patients and carers are engaged in quality improvement, they can help provide the answer.

Patients may define quality differently from clinicians and managers. What they view as the ‘problem’ or value within a system may be surprising. So leaders need to question how patient involvement is being embedded in their organisations’ quality improvement programmes.

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