PEPs - Clinical Quality and Evidence

Module 4 - Quality Improvement


The theory behind change and quality improvement is well outlined by Dr John Øvretveit ¹ who, in a report supported by the Health Foundation ², identifies two types of approach: extrinsic, and intrinsic. The extrinsic approaches include centralised government initiatives, economic drivers and professional requirements, while the intrinsic approaches incorporate a range of models and methods that can be put in place by individual organisations. These are known as organisational or industrial approaches because they were originally developed within an organisational or industrial context.

The Health Foundation believes that a combination of extrinsic and intrinsic approaches is needed to ensure sustained improvement. External reward and incentive systems, such as the CQUIN (Commissioning Quality and Innovation) ³ framework (NHS Institute for Innovation and Improvement), are important, but individual organisations can usefully complement these by adopting internal approaches, which involve developing and setting their own goals, with full staff engagement.

Once the goals are set, quality improvement approaches offer organisations a systematic way of implementing change and monitoring progress. Actually initiating change so that services improve can be difficult. There are many reasons for this. One of the important figures, who have worked, both in the USA and worldwide, in analysing the reasons for this, is Don Berwick ⁴, who founded the Institute for Health Improvement (IHI ⁵), in Boston. He has highlighted the failure of audit to make the important impact that we had hoped for. He and others have suggested a different approach termed Total Quality Management (TQM) (among other names, including Six Sigma ⁶) which integrates quality, efficiency and leadership. They have fallen back on work done in industry, particularly by the father of this science, W Edwards Deming ⁷ ⁸, to improve quality, which is based on organisational change.

The tenants of these, among others, are:

1. Culture

This is vitally important. Having a culture in an organisation where every member of staff understands that their goal is to deliver high quality (including safe) care every time is vital.

2. Aims  

Having all the team understand what the aim of the organisation/team is and that the customer (i.e. patient and relatives) is paramount.

3. Collaboration

The team/organisation understands and works to this one goal (as above) and all personal agenda are subordinate to this goal.

4. Training

The differing requirements of the team to deliver its goals are identified and appropriate training given. The belief that, if one is at a certain position one automatically has the competencies required is not accepted and only the demonstration of such competencies accepted.

5. Anti-perfectionism

Very philosophical concept that, in healthcare, reflects that quality is a continuum and changes with

time and, possibly with changes in culture. So what is high quality at one time will no longer be so in a subsequent era but that merely means that those of us in healthcare must realise that nothing stands still and we must adjust our goals accordingly.

6. Measurement

Vitally important that we understand how to measure quality (see section below) usually in the three

domains of patient reported outcomes, effectiveness and safety and we use this to identify areas that need improving and the impact of the changes that we have made.

7. Small steps

This is the concept of making a small change and assessing the impact of the delivery of care. This

approach has been used extensively in the NHS modernisation agenda. It has many manifestations such as the PDSA (Plan, Do, Study, Act) cycle ⁹. With this approach a small change is made and its impact assessed. If positive it applied widely.

8. Standardisation

We are generally faced, in healthcare, with very similar problems. Thus having a standardised approach to such problems appears logical so that we do not all have to “learn how to develop the wheel”. It also allows for comparisons to be made between healthcare provides which is an approach called “benchmarking”.   This affords clinicians, patients, managers and commissioners to compare provider’s performance feed in known variables and use this process to allow colleagues to reflect on their performance and work on ways of improving it so that variation is minimised. Never the less 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 enroll in such improvements are clinicians. The factors are complex and have been summarised by Davies et al ¹¹ 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  Plan, Do Study, Act cycle which originates with IHI ¹⁰ but can be found in most service improvement plans. In fact it was W Edwards Deming who introduced the concept to industry first. The NHS Institute uses it, among other tools. A schematic diagram is as follows:

The four stages of the PDSA cycle:

Plan - the change to be tested or implemented

Do - carry out the test or change

Study - data before and after the change and reflect on what was learned

Act - plan the next change cycle or full implementation

When does it work best?

When making changes to processes, it is safer, and more effective to test out improvements on a small scale before implementing them across the board.

Using PDSA cycles enables you to test out changes before wholesale implementation and gives others, including patients, the opportunity to see if the proposed change will work.

Using the PDSA cycle involves testing new change ideas on a small scale?

For example:

  • Trying out a new way to make appointments for a GP or one clinic
  • Trying out a new patient information sheet with a selected group of patients before introducing the change to all patient groups
  • By building on the learning from these test cycles in a structured way, you can put a new idea in place with greater chances of success

As with any change, ownership is key to implementing the improvement successfully. If a range of colleagues are involved in trying something out on a small scale before it is fully operational, the barriers to change will be reduced.

Why test change before implementing it?

  • It involves less time, money and risk
  • The process is a powerful tool for learning; from both ideas that work and those that don't
  • It is safer and less disruptive for patients and staff
  • Because people have been involved in testing and developing the ideas, there is often less resistance

Attachment: Howtochangepractice1.pdf

NICE - How to change practice (PDF)

  1. Øvretveit J. Does improving quality save money? A review of the evidence of which improvements to quality reduce costs to health service providers. London: Health Foundation, 2009 (PDF Document)
  2. The Health Foundation
  3. Commissioning for Quality and Innovation (CQUIN) payment framework
  4. Don Berwick's Top Ten Tips (PDF Document)
  5. Institute for Healthcare Improvement
  6. Six Sigma in Healthcare Industry: Some Common Barriers, Challenges and Critical Success Factors (PDF Document)
  7. Dr. W. Edwards Deming
  8. Toyota’s approach to quality (PDF Document)
  9. Plan, Do, Study, Act (PDSA)
  10. Science of Improvement: How to Improve - Institute for Healthcare Improvement