Introducing a quality improvement approach: The PDSA cycles

What is quality in health care? Quality can be defined in many ways but in healthcare we regard it as an element of our performance that ensures that our services are safe, effective, timely, equitable, efficient in their use of resources and both patient and family-centred.

Quality improvement originally comes from the manufacturing sector and is focussed on teamwork and a systematic approach to work and the use of tools. In healthcare, the focus shifts slightly to collaboration as driving quality improvement. “The combined and unceasing efforts of everyone to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”. (Batalden and Davidoff 2007)

Is quality improvement the same as research?

Quality improvement is a complex social intervention and, in health care, there are differences between research and quality improvement.

• Health research is discovery and new knowledge. It is pre-planned, scientifically rigorous in its approach and directed at answering a specific question for a specific population using a specific study design.

• Quality improvement is applied by health teams to improving service delivery. It can be described as complex, involving a number of interrelated, nonlinear components which are embedded into social systems and are prone to modification and change. QI is a constantly active and ongoing process which changes to meet ongoing challenges and its key aim is “not to find out ‘whether it works’, as the answer to that question is almost always ‘yes, sometimes’. The purpose is to establish when, how and why the intervention works, to unpick the complex relationship between context, content, application and outcomes” (Walshe 2007).

QI for neonatal care: A case study from Great Ormond Street Hospital, UK

Great Ormond Street is a highly reputed specialist paediatric hospital in London. Neonatal patients at the hospital are placed in one of 22 wards based on their care needs. A nurse advisor, consultant neonatologist and a clinical audit lead initiated a quality improvement project in response to clinical audit data. One of the areas for quality improvement they identified was neonatal jaundice care. This was not being well managed with many variations across the hospital. The team followed the key quality improvement steps to discover, test and refine (using staff feedback) a new e-learning package for managing jaundice within the hospital.

Following the introduction of the training, alignment of jaundice management across Great Ormond Street improved from 62% to 80%. This significantly reduced unnecessary variations in care and improved satisfaction for both staff and parents. The next challenge for the quality improvement team was to sustain this improvement due to the high rate of staff turn over at the hospital.

Applying QI in a local setting

Neonatal care is highly complex and provision varies across different centres in each health system around the world. However, there is good evidence that introducing and following certain processes and standards of care makes a huge difference to the mortality and morbidity rates of premature babies, including reducing their risk of developing ROP.

In each week of this course we introduce you to the key steps of a quality improvement approach called PDSA (Plan, Do, Study and Act). PDSA is a tool that has been successfully used to improve quality of care across many health care settings. Neonatal teams can use it to identify, implement, evaluate and refine the action needed in their setting to improve ROP prevention, early detection, treatment and follow up.

• This week we look at how to identify the key problems or concerns in the health care provision (steps 1 – 4 in the Quality of Care framework below).
• In week 2 we consider how to undertake a PDSA to achieve a change (steps 5 – 9).
• In weeks 3 and 4 we critically appraise examples of completed PDSAs.

Quality of Care framework

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• Step 1. Establish QI leadership group (review guidelines & standards of care)
• Step 2. Situation analysis/assessment of priorities & process
• Step 3. Prioritise problems and list QI interventions
• Step 4. Identify QI intervention to test and bring together QI team to carry out testing

Learning system

• For each QI intervention carry out iterative cycles of Plan, Do, Study, Act (steps 5 – 8)

Decision making

In step 8 of the PDSA cycle (Act) decide whether to:

• Adapt the QI intervention (refine strategies – go to step 5), or
• Adopt the QI intervention (scale up), or
• Abandon the QI intervention (select another QI intervention – go to step 4).

We recommend you download the Quality of Care framework to refer back to as we return to quality of care in weeks 2, 3 & 4.