We start this week by returning to the concept of quality improvement (QI) (first mentioned in Week 1) and the range of tools and techniques that have been associated with it in healthcare.
As we saw in Week 1, raising quality is the primary objective of healthcare improvement. A commonly used definition of quality is provided by the Institute of Medicine: ‘the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’. This might include a variety of outcomes, including efficiency, safety, effectiveness of clinical diagnosis and treatment and various patient-level outcomes including access to services and wider measures of wellbeing and satisfaction. All these dimensions chime with the Institute for Healthcare Improvement’s (IHI) ‘no needless’ framework, stressing six dimensions: no needless deaths; no needless pain or suffering; no helplessness in those served or serving; no unwanted waiting; no waste; and no one left out.
Achieving quality has also been associated with changing the way clinical work is organised and the way decisions are made. As Professor Øvretveit has argued, it is essentially about ‘changing provider behaviour and organisation through using a systematic change method and strategies’.
There is a wide range of tools and methodologies of QI which encourage practitioners to take a rational, planned approach towards change, drawing heavily on evidence. An early example of this is Walter A. Shewhart’s framework for continuous quality improvement, which poses three main questions: are we doing the right things?; are we doing the right things right?; and how can we be certain that we do things right the first time and every time? Another example is the plan, do, study, act (PDSA) cycle, originating from the work of W. Edwards Deming. In recent years, this has been widely used in healthcare settings and encourages an approach to continuous improvement where changes are tested in small, incremental 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?’; and ‘what changes can we make that will result in improvement?’
Most of the tools and methodologies associated with QI originate from private industry and have subsequently spread to services, including healthcare. Specifically, these can be traced back to ideas about production quality control that emerged in the early 1920s in the US and were then later implemented with considerable success in Japan during the 1940s and 1950s. Often this work is associated with pioneering quality experts such as W. Edwards Deming, Joseph Juran, Armand Feigenbaum and Kaoru Ishikawa.
Central to the work of Deming, for instance, was the understanding that obstacles to enhanced quality and efficiency are often systemic. He noted that:
“The supposition is prevalent the world over that there would be no problems in production or service if only our production workers would do their jobs in the way that they were taught. Pleasant dreams. The workers are handicapped by the system, and the system belongs to the management.”
To address this he suggested that improvement efforts needed to be underpinned by a ‘system of profound knowledge’. This highlights the way in which different aspects of a system – for example, technical sources of variation and the psychology of production workers – interact with each other and how leaders who ignore this complexity, even if they have good intentions, may exaggerate problems. He emphasised the need for a strong commitment from management with quality improvement included in long-term mission statements and also shifting the emphasis of quality control from inspection to prevention.
Another influential quality expert, Joseph Juran, developed the ‘quality trilogy’, emphasising planning, control and improvement as a universal way of thinking about quality, which fits all functions and levels. First, quality planning is the beginning point at which an organisation focuses on the process of planning for quality. The needs of the customers are understood and then captured in the specifications for products or services. Quality planning also involves the design of a process that meets those specifications. Second comes quality control, defining the characteristics that need to be measured: units of measure and frequency of measurement. Finally, comes quality improvement which should be performed by a series of well-defined projects (following the PDSA model described earlier). This is the step toward reaching new heights in quality.
Another 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.
These ideas and others have influenced the genesis of many quality improvement tools and methods that are widely used today. Six Sigma, for example, is a systematic approach towards understanding how an organisation’s customers would define ‘defects’ (within its products or services) and then applying statistical methods to monitor variation and target improvement efforts. Statistical process control is another approach which differentiates between natural variation (known as ‘common cause variation’) and variation that can be controlled (‘special cause variation’).
Other quality improvement methods are more systemic and strategic in focus. Total quality management (TQM), sometimes known as continuous quality improvement, focuses on the role of the people within an organisation to develop changes in culture, processes and practice. Business process reengineering goes even further, calling for a fundamental rethinking of how an organisation’s central processes are designed. Hence, organisations such as hospitals might be restructured around key processes or activities (such as care pathways) rather than specialist functions. Finally, lean is a quality management system that draws heavily on the experience of the Japanese car manufacturer, Toyota. As we shall see in later steps, lean is about strategically redesigning production processes to limit waste by improving the flow of production and using ‘pull’ mechanisms (responding to demand).
In more recent times these various tools and methodologies have become increasingly popular beyond manufacturing, including healthcare. An early pioneer of this work was Don Berwick in the United States, one of the founders of the Institute for Healthcare Improvement (IHI) and president and CEO until 2010. The IHI, based in Boston, is a leading innovator in healthcare improvement worldwide and has had considerable influence on the application of quality improvement in the healthcare sector. As we shall see, others have followed this example, leading to the emergence of a separate discipline (and profession) of ‘improvement science’ within the healthcare field.