Approaches and methods

Many of today’s quality improvement approaches and methods were originally developed in industry and have been adapted for use in other sectors, such as health care. These industrial approaches have been used extensively within health care for the past 30 years to improve specific care processes and pathways, but their use has only been embedded throughout a few large health care provider organisations (see Section 5). Perhaps because of this, the evidence base for their effectiveness is relatively limited, although it is expanding with the increasing levels of research into the implementation and impact of quality improvement interventions.

The roots of many quality improvement approaches and methods 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 American experts W Edwards Deming, Joseph Juran and the Japanese expert Kaoru Ishikawa. More recently, Don Berwick has become known for his work in the US, leading the pioneering work of the Institute for Healthcare Improvement (see Section 6). Several quality improvement approaches and methods draw from the work of these pioneers.

This section describes some of the most popular quality improvement approaches and methods. The evidence has not yet evolved to the point where one approach can be recommended above another. The choice of approach or method is likely to depend to some extent on the nature of the problem being addressed and its context. Whatever approach or method is used, discipline is important, particularly in terms of fidelity to the underlying principles described in Section 3.,

Model for improvement

This is an approach to continuous improvement where changes are tested in small cycles that involve planning, doing, studying, acting (PDSA), before returning to planning, and so on., These cycles are linked with three key questions.

  • ‘What are we trying to accomplish?’
  • ‘How will we know that a change is an improvement?’
  • ‘What changes can we make that will result in improvement?’

Each cycle starts with hunches, theories and ideas and helps them evolve into knowledge that can inform action and, ultimately, produce positive outcomes. To measure the impact of each change, tools such as control charts are used (see Section 3).


This approach has its origins in Japan’s car industry. It is a quality management philosophy based on two core values – to make customer value flow and respect for people. In health care, Lean emphasises the patient’s central position to all activities and aims to eliminate or reduce activities that do not add value to the patient. This is achieved by applying Lean’s operational principles, which involve five steps for continuous improvement.

  1. Defining what is value-adding to patients.
  2. Mapping value streams (pathways that deliver care).
  3. Making value streams flow by removing waste, delay and duplication from them.
  4. Allowing patients to ‘pull’ value, such as resources and staff, towards them, so that their care meets their needs.
  5. Pursuing perfection as an ongoing goal.

Clinical microsystems

These are small groups of people who work together regularly to provide care to a specific group of patients.,, This approach is based on the principle that the quality, safety and person-centredness of an entire health care system is largely determined by what happens in its constituent microsystems.

A systematic approach has been developed to improve microsystems focused on the 5Ps: patients, people, patterns, processes and purpose. Assessing the 5Ps helps to identify opportunities for improvement, which are then addressed using the model for improvement approach.

Experience-based co-design

This is an approach that was designed in the UK – for and with the NHS. It aims to improve patients’ experience of services, through patients and staff working in partnership to design services or pathways., Data are gathered through in-depth interviews, observations and group discussions and analysed to identify ‘touch points’ – aspects of the service that are emotionally significant. Staff are shown an edited film of patients’ views about their experiences, before staff and patients come together in small groups to develop service improvements.

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