Quality Improvement in Healthcare – Framework & Methodology

As access to health care services increases across the globe, the need for quality improvement in healthcare has never been this important or this urgent. 

There is really no universally accepted definition of quality in healthcare. However, the definition by the United States Institute of Medicine is widely accepted.

The US Institute of Medicine defines quality as “the degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

It is imperative that quality healthcare services are safe, effective, patient-centred, timely, efficient and equitable. This means that the services provided should not cause injury, infections and harm to the patients. Also, these services should not be underused or overused. Instead, they should be individualized to meet patient’s specific needs and preferences.

In addition, quality healthcare services should provide care that makes the best use of resources for optimal benefit by eliminating wastage, dangerous delays and reduce patient waiting time.

Similarly, quality health care should be free of gender, ethnic and other forms of bias. There should be equitable services for everyone.

Quality Improvement is important because it offers a safe healthcare service for patients. It also encourages teamwork, collaboration and staff motivation.

By end of this article, you will be able to:

• Explain what is quality improvement in healthcare.
• Mention the drivers of quality improvement framework.
• List the methods involved in quality improvement.
• Site examples of quality improvements in healthcare.
• Explain quality improvement definition in nursing.

What is quality improvement?

Although Quality Improvement has no single definition, majority define it as a systematic formal approach that makes use of specific techniques to improve performance and quality.

According to Batalden and Davidoff, Quality Improvement is 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).

Hence, Quality Improvement centres on healthcare safety, patient safety, efficiency, effectiveness and equity. Quality healthcare is the responsibility of everyone. ‘Everyone’ here includes planners and educators, payers, researchers, healthcare professionals, patients and their families. When everyone works together, better professional development, better system performance and better patient and population outcomes are achieved.

It is important to note that for a sustained and successful improvement to be achieved, the approach, method and tools used should be taken into consideration. However, regardless of the approach used, the method of implementing the improvement is vital. Moreover, how the implementation is managed requires careful consideration and is dependant on the particular organization making the improvement.

On the other hand, Quality Improvement methods are used to review structures, systems and processes. They are also used to identify changes that can improve the quality of services, thereby, enhancing patient safety.

Plan Do Study Act (PDSA) Cycle

The most common method of Quality Improvement is the Plan Do Study Act (PDSA). It was originated by W. A. Shewhart and popularised by W. E. Deming.

Some other methods include clinical audit, model for improvement, lean/ Six Sigma, performance benchmarking, communication tools, process mapping, health care failure modes and effects analysis, statistical process control, technological innovations and root cause analysis among others.

Plan Do Study Act is a repetitive cycle that is used to make changes, test the effect of these changes and spread effective changes. It involves four basic steps.

The first step of PDSA is to plan, analyse, determine the cause of the problem and predict the results of the improvement. The second step is to execute the plan one step at a time and find a suitable improvement solution. The third step involves checking and studying the results to see if they are working while the final step of PDSA requires taking necessary action to implement effective solutions to the improvement.

DMAIC for six sigma

Furthermore, PDSA has changed over the years and has become DMAICS (define, measure, analyse, improve and control) for Six Sigma. Six Sigma is a set of techniques and tools used in quality improvement. It helps to improve the quality of outputs by identifying and removing the causes of errors and redirecting these resources for quality and efficiency.

Therefore, Quality Improvement is beneficial as it helps to build a strong team where everyone can contribute meaningfully. Also, it promotes collaboration and motivates staff to provide a high-quality service. In addition, Quality Improvement offers a comprehensive and safe healthcare service for patients.

Quality Improvement Framework

Quality Improvement Framework is developed to influence and guide thinking, planning and healthcare delivery. It stresses on quality, safety and improvement in patient experiences. Its aim is to strengthen the quality and ultimately provide a safe, effective and person-centred care across all services. Quality Improvement Framework is important because it puts in place a long-term progress to improve quality.

QI framework drivers

Quality Improvement Framework consists of a number of drivers that work together to improve quality. Focusing on only one of the drivers will not give the desired effect for quality improvement.

Leadership

First of all, quality improvement can be achieved easily through the leadership of any organization. The leadership of any organization is responsible for shaping culture, creating conditions and modelling behaviour necessary for quality to be achieved. Hence, leadership is at the core of this framework. Leadership is a tool that can be used to ensure that patients are always at the centre of care planning and delivery and that staff are always supported to deliver a safe, compassionate and effective care.

Therefore, board members, senior leaders, managers and clinical leaders must utilize every opportunity they get to show their commitment to building quality by actively demonstrating the organization’s values, paying attention to staff and patients, checking that services provided are qualitative. In fact, leaders are active participants rather than drivers for improving quality care.

Patient involvement

Secondly, engaging and involving patients and their families in the planning, designing and delivery of quality care ensures that they are listened to and their experiences are learnt from. The central focus of this framework is the patient.

It guarantees meaningful partnerships with carers, patients and their families and makes sure that quality care is tailored to patient’s preferences and needs.

Staff engagement

Thirdly, positive staff engagement is essential to achieving quality care. It results in increased staff motivation, better patient experience and fewer errors. As a result, this framework centres on using the staff to inform improvements. In the long run, teamwork, trust, open communication, staff well-being, coaching and mentoring, staff feedback and respect is established.

Standardisation

On the other hand, sustaining quality improvement in healthcare requires promoting and supporting the use of an agreed set of improvement methods. However, it is imperative to use a proven method for improvement to prevent harm and improve care. This can be achieved by utilising incremental improvements through continuous small-scale tests of change and understanding the context when testing and spreading improvements.

Improvement methods should focus on reducing variation and promoting standardisation across care processes. Consequently, this framework focuses on the methods used in building improvement knowledge and skills in transforming healthcare.

Measurements and metrics

Furthermore, measurement and information are fundamental to improving the quality of care. This framework uses measurement and information to highlight when improvements have occurred and when they haven’t, as well as, areas where improvement is needed.

However, the burden of measurement needs to be minimized through smart measurements and measuring only what matters. Also, data collection should be built into routine work and record keeping.

Leadership support

In addition, the executive management team has a key role to play in the governance of an organization because they are accountable for the quality and safety of services rendered. Board members and executive management teams should have the knowledge and necessary skill to use information in an intelligent manner to measure and drive quality care.

This framework focuses on governance as a tool to ensure that learning systems are put in place in order for experiences to be shared an improvement made where necessary. This framework supports strong relationships between patients, frontline staff and senior leaders.

Quality Improvement Methodology

Overetveit defines “improvement as better patient experiences and outcomes achieved through changing provider behaviour and organisation by using a systemic change method and strategies”.

Therefore, for improvement to be realised in healthcare, change is paramount. Effective change is achieved by utilizing specific tools and methods. These methods are distinct in their purpose, so no method is better than the other and some methods and tools could be used simultaneously.

Hence, Quality Improvements employs a wide range of methodologies, approaches and tools to ensure that change is effective. These methods focus on understanding the problem, process and systems within an organization, analysing the demand, capacity and flow of care services, choosing the tools that will bring about effective change and evaluating the impact of the change.

System thinking

One of these methods is system thinking. System thinking considers the physical environment and systems where healthcare is being practised to see whether it is designed to reduce error and promote patient safety as well as best practice.

This method ensures that care is delivered through a system that can be divided into subprocesses.

Psychology of change

Another Quality Improvement method is the psychology of change. This method maintains that leaders who practice Quality Improvement should create a shared vision of the future of the organization with their staff. They should also put strategies in place to ensure that members of staff agree with the vision.

By so doing, all team members have a common goal and can contribute reasonably to the vision.

Theory of knowledge

In addition, the theory of knowledge is a Quality Improvement methodology aimed at making sure that healthcare should be studied by those interested in changing it. It maintains that any change in theories or processes should be tested through the PSDA (Plan Do Study Act) cycle. The PSDA model for improvement provides a framework that develops, tests and implements changes for improvement.

Therefore, this method will encourage refinements and retesting until the change proves to be reliable.

Theory of constraint

On the other hand, there is the theory of constraint that is generated from the idea that a chain is only as strong as its weakest link. This method involves identifying the weak link and recognising the impact of mismatches between the variations in capacity in the process of constraint and variations in demand. Theory of constraint recognizes that movement along a task will only flow at the rate that has the weakest link.

Total quality management (TQM)

Total Quality Management is a method also known as the continuous quality improvement. It is a management method that focuses on developing changes in processes, culture and practises, the role of the people in an organization as well as quality to development.it encompasses leadership, evidence-based decision making, focuses on the patients and a systematic approach to change.

Process mapping

Similarly, process mapping is a method that reviews the entire journey of the patient’s diagnostic pathway with all parties involved. This method enables the identification of opportunities and inefficiencies for improvement. Also, it reveals the necessary steps to be taken, discrepancies, duplication and variations.

Variation method

Furthermore, the variation method is used to test system outcomes. It examines the difference between natural variation and special cause variation.

Since all systems are developed to create outcomes that have a natural variation, organizations that understand variations in data will not overreact to natural data movement on a weekly or monthly basis. In the case where data collected reveals variations that can be controlled, poor performance is detected and points for improvements noted.

Quality Improvement Examples

Use of beta blockers to reduce the risk of heart attack

There are many quality improvement examples from around the world. In the United States, federal and state government, physicians, nurses, labour unions, health plans and other healthcare systems have begun to address some of the setbacks to quality improvement by employing the method of measuring and reporting the quality of care being delivered. By employing this method, clinicians are able to get feedbacks, customers are able to assess the rate of improvement and the quality of care and health outcomes has improved.

For example, despite the fact that it is medically evident that beta blockers can significantly reduce the odds that a patient will have a second, and often fatal, attack, research has shown that this treatment is not often prescribed to patients faced with this problem.

Therefore, the Medical Peer Review Organization (PROs) in Alabama, Connecticut, Iowa and Wisconsin monitored the use of beta blockers in Medicare patients after a heart attack and provided necessary feedback to all practitioners in the state. As a result, the use of beta-blockers increased from 31.8% of cases to 49.7%. This is a good quality improvement example and demonstrates the role of quality in healthcare.

Similarly, the Middletown Regional Hospital in Ohio reported decreased mortality from 10.9% to 6.5% in less than one year by using another life-saving treatment for heart attack patients. In addition, the time from which patients are admitted to the hospital to the time of thrombolytic therapy administration was reduced.

Reducing unnecessary Caesarean section

In another quality improvement example, in 1995, 785,000 out of 4,000,000 women gave birth through caesarean section (CS). This was a CS rate of about 20%. Even in today’s high global CS rate, this rate was relatively high. Back in 1995, it was a lot too high.

The Greater Cleveland Health Quality Choice Coalition produces a biannual health report that documents the outcomes of patients in 27 local hospitals. As a measure of performance in these hospitals, the Coalition was able to tackle the number of caesarean section deliveries.

By so doing, several Cleveland hospitals implemented and developed guidelines that fostered collaborative efforts to improve care, leading to a fall in the aggregate trend of total caesarean section rates. As a researcher with interest in reducing unnecessary CS rate, this is one of my favourite quality improvement examples.

Preventing drug reactions

In addition, preventable adverse drug reactions were responsible for significant mortality every year. As a response to this problem, LDS Hospital in Salt Lake City, Utah took steps to improve its rate of adverse drug occurrences.

Some of these steps included providing timely feedback to physicians, tracking patient drug allergies in a more effective way, monitoring kidney functions while administering antibiotics with toxic effects to patients as well as managing antibiotic use through a computerized disease management program.

All these led to a decline in adverse drug reaction caused by antibiotics by 75%. This was an astonishing achievement and it is among the best quality improvement examples today.

Quality Improvement definition in Nursing

Generally, nurses are directly involved in almost all aspects of quality improvement, including patient care, data collection and so on. In addition to this, nurses are responsible for performing immediate interventions to reduce medical complications, monitoring and assessing patients. They also oversee other care providers, as well as educate patients and their family members about hospital care. Therefore, nurses are pivotal in quality improvements because hospitals are largely reliant on them to help address improvement demands.

However, quality improvement definition in nursing is not much different from the overall definition of QI in health care. It encompasses everything you do to ensure that the care provided to patients is beneficial, does not cause harm and based on the best evidence available.

Consequently, as hospitals face increasing demands to participate in various quality improvement activities, the roles of nurses also increase. Nurses are the largest providers of healthcare and are well positioned to serve on the frontlines of quality improvements. Since they spend most of their time with patients, they are most likely to be at the fore of noticing medical errors, recognize when a patient needs something, avoid failure to rescue and are in the best position to positively impact patient’s experiences and outcomes.

Magnet recognition

The most relevant program for nurses, as pertains hospital quality improvement, is the Magnet Recognition. This program was developed by the American Nurses Credentialing Centre (ANCC), a subsidiary of the American Nurses Association (ANA) to recognize hospitals that provide nursing excellence. The Magnet Recognition program empowers nurses to have a voice in the hospital processes. This intervention has led to higher nurse retention, lower mortality rates and higher hospital quality care.

Nevertheless, several challenges are associated with nurse’s involvement in quality improvement such as scarcity of nurses, growing demands, high administrative burden among others. And so, there is a limit to how much work, including quality improvements, that can be added to the nurses who are already short-staffed and so it is difficult to keep quality improvement efforts on track. As a result, hospitals will face trade-offs and tensions when allocating nursing resources among many competing priorities of quality improvements and direct patient care among others.

In as much as quality improvement is not solely the responsibility of nurses, they are an integral part of these activities because of their day-to-day responsibilities with patients. Hence, hospitals should guard against reducing the involvement of nurses in quality improvement activities when in the actual fact, they are likely to have the greatest impact and influence.

Conclusion

In conclusion, although leaders should set the tone for quality improvement, it is the responsibility of everyone and so everyone should be held accountable for its success and failure.

The quality improvement framework emphasises on quality, safety and improvements in patient’s experiences. It provides individualized care across all services and uses leadership, patient and staff engagement, methods of improvement, measurement and information as well as governance to drive positive improvements.

In addition, quality improvements should centre on safety, efficiency, effectiveness and equity and for a successful improvement to be achieved, the right methods, approach and tools should be used.

As a result, quality improvement makes use of various methodologies to achieve its aim. They include system thinking, the psychology of change, theory of knowledge, variations, the theory of constraints, lean and total quality management among others.

Employing these methods have helped to improve quality in healthcare. For example, in the USA, by employing the method of measurement and reporting, the use of beta-blockers to stop heart attack increased, thereby reducing the mortality rate drastically. Also, a decline in caesarean section births, as well as preventable adverse drug reaction, were recorded.

Finally, the role of nurses in improving the quality of health care cannot be overemphasized. They play a vital role in influencing patient’s experiences and outcomes, either positively or negatively. They also inevitably influence patient’s health-seeking behaviour. Thus, to understand quality improvement definition in nursing, one needs to understand quality improvement in healthcare in general.

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