Key questions for planning and delivering quality improvement

Q. What are the challenges to delivering quality improvement?

A. In a review of 14 quality improvement programme evaluations funded by the Health Foundation, 10 key challenges were consistently identified from the programmes. These were:

  1. convincing peers that there is a problem
  2. convincing peers that the solution chosen is the right one
  3. getting data collection and monitoring systems right
  4. excess ambitions and ‘projectness’ – treating the intervention as a discrete, time-limited project, rather than as something that will be sustained as part of standard practice
  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 review 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 results that characterise improvement at its best.

Q. Can quality improvement have unintended consequences?

A. Quality improvement does not always work and can have the unintended consequence of diverting resource and attention without producing benefit. Sometimes, change in one area can cause a negative effect in another, for example, improved early discharge might lead to increased readmission. In other instances, the overall impact of a quality improvement effort may be negative. Leaders need to anticipate and monitor for these potential unintended consequences using a set of balancing measures and may need to make decisions about scheduling or sequencing of initiatives.

The scale of a quality improvement intervention, and the extent to which it is coordinated with other improvement efforts, also matters. An isolated small-scale intervention to solve a problem in a specific team or service may end up duplicating work carried out elsewhere or, by adopting a solution that varies from standard practice, it could create a potential safety risk.

Quality improvement is likely to be more effective if it is undertaken as a health care organisation or system-wide effort. Improvements to care processes and pathways need to be considered holistically, rather than as disconnected interventions, and then approached as a long-term, sustained change effort. An integrated, system-level approach also allows a broad range of skills and expertise to be deployed to solve improvement challenges.

Q. What skills do improvers need?

A. Quality improvement requires both technical and relational skills., As well as understanding how to plan, implement, measure and refine improvement interventions using recognised methods, such as PDSA cycles, improvers need to be able, among other things, to describe their intervention effectively and convince others to work with them. Negotiation skills, the ability to read people and situations effectively and work well in a team are vital to getting an intervention up and running.

Practical skills, such as the capacity to manage time effectively, identify the right priorities, and keep a project delivery plan on schedule, are also essential. Equally important are learning skills, particularly the ability to reflect, both individually and as a group, on the lessons learned from each step of an intervention – and to use these learnings to refine the improvement approach. Successful improvers have often developed certain ‘improvement habits’, which help them to get their ideas off the ground and ensure that their intervention is sustained. These habits are summarised in Figure 1.

Figure 1: The habits of improvers

Source: The habits of an improver: Thinking about learning for improvement in health care. The Health Foundation; 2015.

Q. What role do senior leaders play in quality improvement?

A. Support from senior organisational or system leaders is often vital to the success of an improvement intervention. As well as ensuring that improvement teams have the resources they need to plan and deliver their intervention, senior leaders in large provider organisations, such as NHS trusts, can help to unblock barriers and give teams the time and space to test and refine their intervention.

Senior leaders, particularly board members, also have a critical role to play in creating a positive organisational culture, which has consistently been associated with improved quality outcomes., They can do this by placing improvement at the centre of their organisational strategy and fostering a learning culture in which front-line teams feel psychologically safe to question existing practice, report errors and try new methods.

Q. Can quality improvement approaches be applied across whole organisations?

A. There are many examples of the successful use of quality improvement methods to improve processes and outcomes in individual teams, services and care pathways in primary, secondary, community and social care settings. However, it is rarer to see these methods implemented in a coordinated and systematic way across large provider organisations or whole health systems.

A study of 1,200 US hospitals found that although 69% had adopted a quality improvement approach such as Lean, only 12% had reached a ‘mature, hospital-wide stage of implementation’. This is due, in part, to the fact that it takes a great deal of time, resources and planning to implement an organisation-wide approach to improvement. However, many health care providers from around the world that have adopted an organisation-wide approach believe that the investment required has been justified by the long-term performance benefits it has delivered. In England, for example, many of the NHS trusts rated as outstanding by the Care Quality Commission have an established organisation-wide improvement approach in place.

Health Foundation analysis has found that effective organisation-wide approaches to improvement consist of four key elements.

  • Leadership and governance. Visible and focused leadership, for example, in an NHS trust, at board level, accompanied by effective governance and management processes that ensure all improvement activities are aligned with the organisation’s vision.
  • Infrastructure and resources. A management system and infrastructure capable of providing teams with the data, equipment, resources and permission needed to plan and deliver sustained improvement.
  • Skills and workforce. A programme to build the skills and capability of staff across the organisation to lead and facilitate improvement work, such as expertise in quality improvement approaches and tools.
  • Culture and environment. The presence of a supportive, collaborative and inclusive workplace culture and a learning climate in which teams have time and space for reflective thinking and feel psychologically safe to raise concerns and try out new ideas and approaches.

Underpinning these four elements is an improvement vision that is understood and supported at every level of the organisation. This vision is then realised through a coordinated programme of interventions aimed at improving the effectiveness, safety, efficiency, timeliness, person-centredness and equity of the organisation’s care processes, pathways and systems.

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

A. Many large health care provider organisations, such as NHS trusts, have created a central improvement team to support front-line teams as they design and implement improvements to care processes and pathways, and to oversee organisation-wide improvement efforts. However, these organisations are not solely reliant on central teams’ expertise. They have also developed improvement capability at every organisational level, from the board downwards, so that all leaders, managers and front-line staff have an understanding of quality improvement approaches, methods and principles, and how to effect change in complex systems such as health care.

This is particularly important in smaller organisations, such as GP practices, that do not have the resources to recruit a dedicated improvement lead. Smaller organisations will also benefit from the opportunity to share improvement skills and learning within networks of professionals and organisations.

Q. Can quality improvement improve productivity and save money?

A. Quality improvement can improve patients’ experiences and outcomes, and produce financial and productivity benefits for the health care system.

Continuing with poor or sub-optimal care results in waste, and this creates unnecessary costs. For example, longer hospital stays for patients due to health care-acquired problems, such as infections or pressure ulcers, not only cause poorer health but add to costs. In this context, improving care can reduce the costs and boost productivity.

The potential for cost savings can be realised by addressing:

  • delays, such as waiting lists for diagnostic 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
  • impaired morale caused by staff working in frustrating systems and cannot offer the best level of care.

In many cases, the capacity freed up from productivity gains made through quality improvement does not result in actual cash savings. Instead, this capacity is used to meet additional or previously unmet service demand.

When quality improvement leads to lower bank and agency staff costs, the reduction of procurement activity or the decommissioning of a fixed asset, it can produce cash savings that can be identified in annual financial reports. However, it is important, when calculating these savings, to include any costs incurred in the planning and implementation of the improvement.

To assess the return on investment from its application of quality improvement methods at scale, one health care provider, East London NHS Foundation Trust, has developed a framework with seven domains. As well as focusing on cost avoidance and reduction, it includes a domain on staff experience, highlighting evidence suggesting that providers with happier, more engaged staff have better patient outcomes and improved financial performance. The trust proposes that by giving front-line teams the autonomy to address the challenges that matter most to them and their patients, quality improvement plays a critical role in improving staff engagement and, in turn, the organisation’s overall performance.

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

A. Variation in health care can be warranted and unwarranted. This is because some degree of variation is considered normal, as it allows health services to be responsive and patient-centred.

Variation can be due to chance or random variation, for example, demand-side factors such as patient need and social demographics, or supply-side factors such as clinical practice. These can all lead to variations in inputs, processes and outcomes of care.

Unintentional deviation, or unwarranted variation from normal practice, is a form of variation in health care that can lead to inefficiency and waste. In clinical practice, variation from an established evidence-based best practice could result in error and harm, resulting in poor outcomes for the patient. Addressing unwarranted practice variation using quality improvement approaches and methods can increase the reliability of care.

Many quality improvement approaches assess whether a pathway, process or clinical practice is operating within control limits. These control limits are used as a key measurement tool to understand the level of variation in the system and to measure it over time. As well as being able to identify, measure and analyse variation, it is vital that health care systems, providers and commissioners have the necessary quality improvement capability, time and resources to address any unwarranted variation.

Q. What is the relationship between quality improvement and quality planning, control and assurance?

A. The approach taken by health care systems and organisations to manage quality usually consists of four interrelated elements:,

  • Quality planning. Understanding the needs of the population and service users, for example, through equity needs assessments, and designing interventions to meet those needs.
  • Quality control. Comparing the level of performance of a system or organisation against adopted standards or benchmarks that are locally developed and owned, such as quality dashboards and scoreboards, for the purposes of internal scrutiny and oversight.
  • Quality assurance. Independently gathering evidence in a systematic and transparent way to provide confidence that a system is meeting internal or external standards, for example, through clinical audits, clinical incidence reports, staff surveys and external inspections of standards.
  • Quality improvement. Using a systematic approach involving specific methods and tools to continuously improve the quality of care and outcomes for patients and service users.

The term ‘quality management system’ is sometimes used to describe the full cycle of planning, control, assurance and improvement that takes place in many health care systems, organisations and services. It is also a term used at a national policymaking level.

An understanding of when and how to use each of these four elements, and how to create an appropriate balance between them, is important. At national level, for example, it is important that quality assurance and control initiatives are complemented by sufficient support for quality improvement and planning at both a system and organisation level.

As well as the four elements listed, a quality management system requires a learning system. This includes processes for creating evidence, including evaluation to understand what is working for whom, and methods to identify and spread knowledge, such as learning networks. The effectiveness of a quality management system also relies on the presence of a set of behaviours, attitudes, relationships and skills that enable improvement.

Q. Can quality improvement contribute to environmental sustainability?

A. Environmental sustainability is a core dimension of the quality definition adopted by the NHS. The Centre for Sustainable Healthcare has developed a SusQI framework for integrating sustainability into quality improvement. This framework provides an approach where outcomes of service are measured against environmental, social and economic costs and impacts to determine value. Some examples of environmental issues that have been tackled through quality improvement include:

  • staff and patient travel patterns, with a view to reducing the length and frequency of journeys and using more sustainable transport modes
  • prescribing behaviours, for example, by promoting a switch to greener asthma inhalers
  • procurement and consumption patterns, for example, by reducing paper use and purchasing recycled paper.

    Q. How can successful quality improvement interventions be spread more widely?

    A. In health care, a variety of mechanisms are used to spread improvement interventions. Social movements, such as professional networks and communities of practice, play an important role, as do organisational networks and collaborations. Quality improvement collaboratives are also used to spread successful innovations.

    However, spreading an intervention that has worked well in one setting to other health care services, organisations or systems can be complicated, even if there is good evidence of its benefits. A key challenge is in identifying those aspects of the intervention that should remain fixed and others that can be adapted to fit each new setting. An intervention cannot simply be ‘lifted and shifted’ intact from one setting to another.

    Each setting will present a different range of opportunities and barriers to implementation. In some settings, for example, cultural or professional beliefs and practices may impede its success and in other settings, strong support from an influential clinician or leader may generate an opportunity. In summary, spreading an intervention takes time and resources and needs careful planning.

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