This website has been developed to provide some key literature, a gateway to tools that will help and various short reads on the topic of Quality Improvement. We have included the reasons for the adoption of a more systematic approach to bottom-up change alongside wider best practice advice and guidance. We have added a section to help you find projects in the topic that you want to improve and a library of resources and on line courses if you have time to delve deeper. Lastly are sections on local advice and support in your Trust and Royal College links to ensure you make the most of what is on offer and what is recommended during your training.
If you have any QI queries, please do not hesitate to contact our team at HEE SW via QualityImprovement.firstname.lastname@example.org
Quality Improvement in the South West
To get you started, the following video on the Measurement for Improvement by Mike Davidge is very informative on this topic of clinical learning.
First Do No Harm:
One of the core principles that underpins clinical and medical practice and has done for centuries is the idea of ‘first do no harm’ (Hippocrates in 5th Century BC).
This core purpose inevitably requires individuals who are practising medicine to learn from when things don’t work out quite as they intended. This may happen because the symptoms were poorly understood when described by the patient, the investigations were not done in a sufficient manner to identify the real problem or the speed of the changing symptomatology and signs were not observed. in some circumstances it is a combination of all of these is contributory to harm.. In addition, with increased complexity in the timing of and combinations of monitoring technologies and treatments a simple oversight or mis communication can lead to the wrong effects and outcomes for the patient.
The Challenge of Making Change Happen:
Change is hard. Semmelweis in 1846 postulated that doctors were taking an infection from patient to patient without washing their hands. He demonstrated with data that by hand washing after each patient the amount of infection that was transmitted was reduced. We know this was not readily accepted then and even more recently handwashing has remained a challenge to universally and consistently provide infection protection. Doing things differently requires more than evidence it requires intention, understanding, self and system discipline and that the environment makes it easy to do the right thing every time.
In the years since Semmelweis many actions and systems have been introduced to try and improve the quality of care and therefore the quality of the outcome for people with illness whether it be acute or long-standing. This has covered better and more structured oversight of professional practice, the development of more enhanced and in some cases ongoing examination and testing of competence, the requirement to undertake a certain amount of professional development in a respected and appropriate way each year and more recently of course appraisal and revalidation. The intention is to ensure individual knowledge, competence and capability is of a safe and high standard.
In addition, the hospital and healthcare systems in which care is provided and within which professionals work have developed their own approaches to ensuring they provide and deliver what is effective, efficient care. In the last half-century, we have moved from looking at simply the utilisation of hospital beds, staff, admissions, bed days, length of stay. We have added clinical coding and looked at the outcomes for patients with certain categories of diseases. NHS programs commenced in 1999 to early 2000s in coronary heart disease in cancer care and in other specific areas of are importance have ensured the whole systems knows what should be done and is organised to deliver it. You may well have contributed to the data collection for national clinical audits and become familiar with the importance of the standards that those audits describe and develop over time. Within the NHS, the Institute for Clinical Effectiveness and Excellence, NICE, reviews constantly new research evidence and information and proposes how best to improve the outcomes for patients. It is then up to us as clinicians to put this into practice.
How Quality Improvement Methods enable Change:
This is where Quality Improvement methods come in. In the last few years a lot more effort has been put into sharing best practices across the wider system in order to raise everybody’s standards of care through peer review, through inspection and through the collaboration of teams and individuals to come together. The objective being to share their individual experiences and improve the practice and delivery of healthcare widely across a region or a specialty across the country. There has been added value in using a small but well understood selection of approaches, each making sure we assess the current situation before embarking on change or new ideas and each focused on measuring impact and ensuring systems wide thinking and engagement in the design and testing of change ideas. Such an approach keeps the system safer for patients, involves the best of everyone and ensures that we design more resilient systems of working.
The Importance of Systems and Processes in determining the Outcome of Care:
One of the less known champions of quality, a US physician called Avedis Donbedien started writing in 1966 about the relationship between the way healthcare was organised, the activities that we all participated in to deliver health care and the outcomes for patients. His equation; Systems plus Processes = Outcomes, has and is a fundamental way to think about complex healthcare. It isn’t just what we do, it is the way it is done and all the additional and often peripheral components that build a quality experience when a person is ill and getting better under our care.
How do we define Quality?
Quality has several strands that must be equally attended to so as to ensure the optimal outcome for a person who is ill. It must be safe, timely, effective, efficient, equitable and centre on the person/ patient, their needs and where possible their preferences. This is often recalled via the acronym STEEEP so as to make sure all aspects of quality are considered so there are no unintended consequences of improving one and worsening another.
Quality Improvement Methods add structure and organisation to change:
Some of the methodologies that have been used commonly have developed outside of healthcare but that that does not make them inappropriate. With some adaptations and modifications Lean, Six Sigma and Failure Mode Analysis are just as valuable as the Model for Improvement, Clinical Microsystems or Co-designing with patients. The principles that underpin each of these is the importance of first discovering the work as it is actually done now, defining and sharing together the purpose of the work, harvesting ideas from everyone involved, test them out as agreed and in a way that addresses the main issues and most critically, measure to see the impact before embedding a new idea into the working day.
This means that we can more widely discuss the change needed across all the professionals and experts involved in the delivery of care however complex. By using a common framework that enables us to work together clinicians of different professional backgrounds, managers, community teams can all use the same approaches to identify the problem. We should always ensure we reflect on how that impact on patients as well as ourselves and on the system in which we work. We start with an investigation into what we actually do at the moment and then to come up with ideas and innovations that we can test out and put into practice once we are confident that they do in fact resolve the problems that we’ve identified in the first place.
QI is something we have always done, now the systems needs improving not simply our own ability:
Although quality improvement sounds like an add-on really quality improvement is something that we’ve all been involved with from the very commencement of our professional careers. However, as healthcare delivery has become more complex, more wide-ranging and over a longer period of time for many patients with a complex arrangement of systems of people and teams it is no longer just about me or you. My professional competence and my professional understanding and my knowledge base are important but so is my approach to change and participation in improvement with the wider team in practice day in day.
Using quality improvement methods can transform both the effectiveness of a team and the effectiveness of the care provided by that team.
Quality Improvement methods provide an approach to change in a complex system which manages and controls the inevitable risks that there are in what we do. The evolution of ideas and steady step by step changing our work is better than having a revolution that we are not involved in choosing or designing.
We are offering QI Development courses for ES/CS. These are run by our expert trainer Tricia Woodhead. The dates available in 2022/23 are:
- 20th September 2022
- 11th October 2022
- 16th November 2022
- 11th January 2023
- 2nd February 2023
Courses are available for booking via Max Course. Please register an account to access the course booking facilities.
Quality Improvement and Sustainability
To learn more about sustainable quality improvement concepts, education and courses; please visit the SusQI website. This is an expansive area of work which we encourage all those interested in QI to get involved with.
SusQI's highly developed website offers information on starting a sustainable QIP and links you with key contacts within this area of QI.