PEPs - Clinical Quality and Evidence

Module 4 - Quality Improvement

Quality improvement

Quality Improvement ¹ ² is a concept that has grown up in healthcare over the past two decades although it has been in existence in industry for many years. In healthcare it developed as a response to a complex mixture relating to frustration with high profile failures in healthcare, the somewhat tardy approach in the NHS to the adaption of different and better ways of providing care and spiralling costs. In addition there is a gap that has developed between the evidence as to what should be done clinically and what actually is done ³. We need to be able to keep on top of changes in what constitutes clinical quality, which changes with astounding rapidity. Further the consumers of healthcare are becoming increasingly sophisticated with high expectations ⁴.

In the United Kingdom, at the beginning of this century, several movements developed as the Government’s response.  These were also in response to several healthcare scandals such as the high mortality in babies following heart surgery and more recently the failure of care of patients presenting as emergencies to the Mid Staffordshire Hospital ⁵. The Bristol inquiry ⁶ led the then government to form the Commission for Health Improvement  (CHI, as a regulator  of healthcare),  the

Modernisation Agency (now the NHS Institute for Innovation and Improvement 1) and NICE (National Institute for Clinical Excellence) now called the National Institute for Health and Clinical Excellence ⁷.

All subsequent Governments have had “modernisation” and “improvement” approaches. The current improvement agenda is the “QIPP” agenda (Quality, Improvement, Productivity and Prevention) ⁸.  In addition the regulator of healthcare has changed with the Healthcare Commission taking over from CHI (Commission for Healthcare Improvement) and then merging with the social care regulator CSCI (Commission for Social Care Inspection) and the MHA (Mental Health Act Commission) to form the CQC (Care Quality Commission) ⁹.  However service improvement has had a chequered history. Whilst it might appear simple that all clinicians (in the widest sense of this term) would be interested in improving services, the reality is that it is hard to improve services and the groups that may be hardest to enrol in such improvements are clinicians.

The factors are complex and have been summarised by Davies et al ¹⁰ as follows:

  • Limited knowledge and understanding of current concepts and methods of quality improvement
  • Differing definitions between health professions about what constitutes high quality care
  • The widespread belief that high quality care is already being provided, at least locally
  • Who is actually responsible for quality improvement
  • Concerns about potentially deleterious impacts arising from the measurement of health care quality.

Many health professionals are concerned that quality initiatives will be at best ineffective and a waste of scarce personal and organisational resources, and at worst actually detrimental to patient care. The best and most comprehensive review of the theory and methodology in relation to improving services and processes is provided in a monograph by Powell et al ¹¹ . Here the main techniques, which have nearly all been taken from industry, are regarded as:

  • Total Quality Management (TQM)/ Continuous Quality Improvement (CQI)
  • Business Process Reengineering (BPR)
  • The Institute for Healthcare Improvement (IHI)’s rapid cycle change
  • Lean thinking
  • Six Sigma

Quality: using measurement to effect change (30 Minutes)

Please visit The University of Manchester Library for instructions on how to access BMJ modules both on-campus and off-campus.

After completing this learning package you should know:

  • How transparency and indicators can drive quality improvement on a national level
  • On an institutional level, how measurement is used to produce better outcomes
  • How the right targets can motivate managers and frontline staff.
  1. NHS Institute for Innovation and Improvement
  2. Healthcare Improvement Scotland
  3. Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England. BMJ
  4. Dr Foster Intelligence
  5. Investigation into Mid Staffordshire NHS Foundation Trust (2009)
  6. The Bristol Royal Infirmary Inquiry
  7. National Institute for Health and Clinical Excellence (NICE)
  8. Cost and quality - NHS Institute for Innovation and Improvement
  9. Care Quality Commission
  10. Davies, H., Powell, A. and Rushmer, R. (2007) Why don't clinicians engage with quality improvement?
  11. Poweel, A, Rushmer, R. and Davies, H. (2009) A systematic narrative review of quality improvement models in health care