PEPs - Clinical Quality and Evidence

Module 4 - Quality Improvement


A number of prominent clinicians have challenged traditional ways of thinking and pioneered developments in medical quality evaluation and improvement.  An excellent review (Kenney 2008) highlights the role of a number of key individuals:

As early as 1916, Ernest Codman, a US surgeon, used and published the ‘ends results’ system of auditing surgical care (Codman 1916). He is acknowledged by many as the founder of outcomes-based patient care. He believed that such information should be made public so that it could guide patient choice of hospital and physician. In the 1960s and 70s, Avedis Donabedian went further, presenting quality as a multidimensional concept, influenced not just by the technical quality of care, but also by features of the interpersonal relationship between doctor and patient and by the physical amenities of care (Donabedian 1966). Don Berwick has been interested in quality improvement throughout his career as a doctor, but he spent time in the 1980s studying and working on the application of industrial models of quality improvement in healthcare.

Influences on the development of clinical quality Improvement

Developments emanating from the evidence-based medicine movement and from public inquiries into major healthcare failures have introduced a number of new concepts to the field of clinical quality, which may have the potential to create better integration with wider organisational quality initiatives. Examples of organisational quality initiatives include:

Clinical Guidelines - They should be based on available research evidence.  

Care Pathways - Care pathways are used in healthcare in an attempt to standardise processes of care delivery. Pathways have been used in different ways, for example as a way of translating national guidelines into local practice or as a way of mapping ideal processes for specific care groups.

Clinical Governance - “Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care and creating an environment in which excellence in clinical care will flourish” ¹ (Royal College of Nursing).

Defining Quality

Developments in healthcare quality have been professionally led and reflect the different traditions and ways of working within the profession. As a consequence, a range of healthcare definitions and dimensions of quality have developed (see Table below) ².

  1. Royal College of Nursing website
  2. Quality Improvement: Theory and Practice in Healthcare. NHS Institute for Innovation and Improvement. Aug 2008 pp 31