Methods and Tools of Quality Improvement

Quality in Health

METHODS AND TOOLS OF QUALITY IMPROVEMENT

Pawan Kumar Gupta*, R.S.Uberoi** and Anupam Sibal****Quality Team member, **Chief Quality Head, ***Group Medical Director & Senior Consultant, Pediatric Gastroenterologist

and Hepatologist, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.

Correspondence to: Dr. Pawan Kumar Gupta, Assistant Manager, Department of Quality,Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.

e-mail: [email protected]

QUALITY ASSURANCE IN HEALTHCARE

THE most comprehensive and perhaps the simplestdefinition of quality is that used by advocates of totalquality management (W. Edwards Deming, 1982): “Doingthe right thing right, right away.” In quality assurance, dataare used to analyze processes, identify problems, testsolutions, and measure performance.

Healthcare professionals naturally seek improvementand evaluate alternate ways to provide appropriate andoptimal care for the patients. Many healthcareorganizations have adopted TQM (total qualitymanagement), Six Sigma, PDSA (Plan, Do, Study, Act),and other data-driven methodologies to conduct, achieve,and sustain quality improvement (QI) and performanceimprovement (PI) projects. In quality assurance, data areused to analyze processes, identify problems, testsolutions, and measure performance.

The application of Web-based information technology(IT) and data analysis tools to the QI process enhancesthe capability and capacity of leading healthcareorganizations to conduct QI/PI projects and gainactionable knowledge for informed decision-makingfrom them faster and without additional resourceexpenditure.

INTRODUCTION TO QUALITY IMPROVEMENT

Quality improvement is about ensuring that our focusis on improving, not just maintaining. Qualityimprovement focuses on the safety, effectiveness,efficiency, acceptability, accessibility andappropriateness of services for consumers (who might bepatients, health care professionals, or the hospital).

Quality improvement is a continuous cycle of planning,implementing strategies, evaluating the effectiveness ofthese strategies and reflection to see what furtherimprovements can be made. There are many methodsavailable that support quality evaluation andimprovement in health care. Some of these are presentedbelow including the Plan-Do-Study-Act cycle for qualityimprovement (Fig.1).

PLAN-DO-STUDY-ACT: PDSA APPROACH

This is the beginning of a continuous cycle whichallows for the initiation of changes for improvementthrough a process that requires evaluation to prove thatthe desired outcome is achieved.

Strategies for Quality Evaluation andImprovement (Fig. 2)

• Plan: Examine the current situation

• Find areas for improvement

• Define and quantify the problem and aims

• Look for possible solutionsFig.1 PDSA cycle

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243 Apollo Medicine, Vol. 5, No. 3, September 2008

• Do: Implement a plan for change

• Strategies that target knowledge, attitude andbehaviour

• Other strategies

• Study: Evaluate your success

• Act: Take action based on the results

EXAMINE THE CURRENT SITUATION (PLAN)

Choose and define the area of service or departmentthat needs improvement. Not all change is improvement:resources should be utilised wisely in trying to improvequality. At the planning stage some data need to becollected to quantify exactly how bad the problem is, andso that improvement can be shown later.

Ask the 5 W-questions and the 1-H question: Who,What, Where, Why, When and How often- about yourproblem. This helps you clearly define your problem andaims.

Identify the barriers to change: There is often morethan one thing that stops change from happening.Identifying barriers helps to identify the best strategies tosupport change. Areas to consider include:

• personal barriers- for example, a person’s attitudetoward change, or their knowledge/skill in relation tothe new behaviour

• social barriers- for example, poor leadership orsupport from peers for new behaviours

• process barriers- for example, lack of clarity aboutthe actual process, or competing processes that arehigher priority

• environmental barriers- for example, a lack of somephysical resource needed to carry out the newbehaviour

Implement a plan for change (Do)

Once the most appropriate area that needs change hasbeen identified, what is the strategy for making changeand improving practice?

The most important factor in choosing a strategy isensuring that it matches the goal/aims and provides anadequate solution to the identified problem. For example,if a lack of knowledge is identified as a key problem, thenenvironmental modification is not an appropriatesolution.

Effectiveness of strategies that target personal/ groupknowledge, attitudes and behaviours is summarisedbelow.

(a) Strategies that target knowledge, behavior, attitudes

(b) Disseminating information / recommendations tostaff in an accessible form: Requires staff to take theinitiative to read, assimilate and apply the newinformation in their practice.

(c) Posters/ visual reminders: It is going to have moreimpact if it is placed immediately in the area in whichit is relevant and make sure that the poster is in linewith hospital policy.

(d) Tailored approaches: Addressing the specificbarriers to change that have been identified.

(e) Monitoring (audit) and feedback: Its evident thatmonitoring and feedback combined are effective, andthis is more likely where the strategy is usedintensively. However, the two must go hand in hand;monitoring of practice alone does not improvepractice.

(f) Interactive workshops: Both interactive workshopsand traditional teaching approaches target knowledgeand skills of staff, which is important if these areas

Fig.2 Plan-Do-Study-Act Cycle for Quality improvement

What changes are still to be made?Should this improvement be expanded(e.g. other units, hospital wide)?What is the objective of the next cycle?

Analyse your data• Have you made the changes you expected?• Have you achieved all of the objectives in

you plan?• What else have you learned?

What is you topic for improvement?What are your objectives?What are your predictions?What data will you need to measure progress?When, who, how and where will you make yourimprovement?

Carry out you planDocument your progressCollect data along the wayNote problems and solutions

ACT

STUDY DO

PLAN


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have been identified as barriers to change.

(g) Environmental ‘modification’

(h) System or process redesign

Evaluate the success (Study)

Evaluating the success or otherwise of your QI project isan essential step.Some important steps for effectivemeasurement are:

(i) Examine data at more than one time point.

(ii) Aim for useful data, not perfect data.Measurement is not the goal; improvement is thegoal.

(iii) Sample, don’t measure everyone. Sampling cansave time and resources while accurately trackingperformance.

(iv) Make measurement simple. Useful data are ofteneasy to obtain from existing information systems. Asimple data collection form can get the data that isneeded to measure improvement.

(v) Target measurement: Ensure that what ismeasured is what is set to be achieved - this meanslooking back at the aims and targeting the datatoward those aims. For example, to improve patientID bands (e.g., make them more durable), countingthe number of patients wearing an ID band at anygiven time is NOT a best measure. If the aim is amore durable ID band, durability should bemeasured (e.g., get nurses to note the number ofbroken ID bands).

(vi) Consider qualitative and quantitative aspects.Quantifying change is important. However, it isimportant to also consider qualitative information,such as how staff feel about the new process, whatthe impressions of patients are about the newprocess, and how both groups feel further changescould be made.

Take action based on the results (Act)

The last phase in the PDCA cycle means looking indepth at what has been learned and how the knowledgeshould be applied.

If the change worked, look at expanding the project-e.g., across the department, into other departments, intoother problem areas.

If the change did not work, look at what has been learnedand start the cycle again, with a different plan.

In either case, use what has been learned to plan newimprovements, beginning the cycle again.

DMAIC

DMAIC refers to a data-driven quality strategy forimproving processes, and is an integral part of the SixSigma Quality Initiative. DMAIC is an acronym for fiveinterconnected phases: Define, Measure, Analyze,Improve, and Control.

Each step in the cyclical DMAIC Process is required toensure the best possible results. The process steps:

Define the Customer, their Critical to Quality (CTQ)issues, and the Core Business Process involved.

• Define who customers are, what theirrequirements are for products and services, andwhat their expectations are

• Define project boundaries the stop and start of theprocess

• Define the process to be improved by mappingthe process flow.

Measure the performance of the Core Business Processinvolved.

• Develop a data collection plan for the process

• Collect data from many sources to determine typesof defects and metrics

• Compare to customer survey results to determineshortfall .

Analyze the data collected and process map to determineroot causes of defects and

• opportunities for improvement.

• Identify gaps between current performance andgoal performance

• Prioritize opportunities to improve

• Identify sources of variation

Improve the target process by designing creativesolutions to fix and prevent problems.

• Create innovate solutions using technology anddiscipline

• Develop and deploy implementation plan

Control the improvements to keep the process on thenew course.

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• Prevent reverting back to the “old way”

• Require the development, documentation andimplementation of an ongoing monitoring plan

• Institutionalize the improvements through themodification of systems and structures (staffing,training, incentives)

THE QUALITY ASSURANCE MODEL

The QA approach to improving health services andindividual performance incorporates three core qualityassurance activities (Fig.3):

• Measuring quality

• Defining quality

• Improving quality

The Quality Assurance Triangle effectively illustratesthe synergy between these three core QA functions oractivities. The greatest impact on quality of care can beachieved only when all three activities are implemented ina coordinated fashion. The triangle shape appropriatelysuggests that there is no “correct” or even optimalsequence to initiate QA activities. The order will dependon the capacity of the healthcare system or facility and theinterest of the providers. In practice, QA is a cyclical,iterative process that must be applied flexibly to meet theneeds of a specific program.

Measuring Quality

In the QA Triangle, Measuring Quality is thesystematic identification of the current level of quality thefacility or system is achieving. The QA approach toMeasuring Quality is inextricably linked with DefiningQuality. Quality cannot be measured without a clear

definition or standard. Likewise, Measuring Quality leadsdirectly to the identification of areas for improvement orenhancement—the first step in Improving Quality.Successful improvement ultimately contributes toattaining quality care, the goal of quality assurance.

QA activities that are part of Measuring Qualityinclude:

• Quality Assessment

• Quality Monitoring

• External Evaluation of Quality

Specifically, measurement and data are used in QA to:

• Identify opportunities for improvement to initiateQA efforts

• Detect and assess problems

• Verify possible causes of problems

• Inform decision making

• Show if a quality intervention yieldedimprovement and by how much

• Monitor processes over time to see if the changeor improvement is maintained

Data may be quantitative in nature, such as servicestatistics, or qualitative, such as customer feedback orcomments of healthcare workers.

Quality Assessment

Quality assessment is the measurement of the qualityof healthcare services. A quality assessment measures thedifference between expected and actual performance toidentify opportunities for improvement.

A quality assessment frequently combines various datacollection methods to overcome the intrinsic biases ofeach method alone. Examples of such methods mayinclude:

• Observation of service delivery (by expertobservers, peers, supervisors)

• Mystery client method

• Audit of individual patient records

• Review of data from automated informationsystem

• Health worker interview

• Patient exit interviewFig.3. Three core quality assurance activities.


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Quality assessment is often an initial step in a largerQA process which may include providing feedback tohealth workers on performance, training and motivatingstaff to undertake quality improvements, and designingsolutions to bridge quality gaps.

IMPROVING QUALITY

Improving quality involves application of appropriatemethods to close the gap between current and expectedlevels of quality as defined by standards. Qualityimprovement approaches may include individual problemsolving, rapid team problem solving, and systematic teamproblem solving, process improvement and redesign andorganizational restructuring/reengineering.

The Four-Step Approach to Quality Improvement

Quality improvement (QI) methodology has evolvedover the years. People working to improve quality learnedthat increasing resources does not always ensure theirefficient use and, consequently, may not lead toimprovements in quality. In fact, a key lesson is that inmany cases quality can be improved by making changes tohealthcare systems without necessarily increasingresources. By improving the processes of healthcare notonly better outcomes can be created, but also the cost ofdelivering services can be reduced by eliminating waste,unnecessary work, and rework. Current QI approachesexamine how activities can be changed so employees cando their work better. For example, poor employeeperformance may stem from a lack of supplies, inefficientprocesses, or the lack of training or coaching rather thanworker performance. The philosophy behind approach toQI recognizes that both the resources (inputs) andactivities carried out (processes) must be addressedtogether to ensure or improve the quality of care. Qualityimprovement is defined as consisting of four key steps.

(i) Step one: Identify – Determine what to improve

(ii) Step two: Analyze – Understand the problem

(iii) Step three: Develop – Hypothesize about whatchanges will improve the problem and developsolution strategy based on these changes

(iv) Step four: Test and implement – Test thehypothesized solution

QI is not limited to carrying out these four steps, butrather emphasizes on ways to further improve qualitycontinuously. When improvements in quality areachieved, teams can continue to strive for furtherimprovements.

Core principles to guide quality assurance inhealthcare:

• Client focused: services should be designed so asto meet the needs and expectations of clients andcommunities. This, in turn, encourages clients toreturn and to recommend the services to others.

• Systems and processes: understanding theservice delivery system and its key serviceprocesses is very important in order to improvethem. Quality management views all work in theform of processes and systems. Systems arearrangements of organizations, people, materials,and procedures that together are associated with aparticular function or outcome. A system consistsof inputs, processes, and outputs/outcomes. Aprocess is defined as “a sequence of steps throughwhich inputs from suppliers are converted intooutputs for customers.” All processes are directedat achieving one goal or output from the systemthat encompasses the processes.

• Measurement: data is needed to analyzeprocesses, identify problems, and measureperformance

Fig.4. Determining the Next Step after Solution Testing

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• Teamwork: a team approach to problem solvingand quality improvement is the best way toachieve quality. A team is “a high-performing taskgroup whose members are interdependent andshare a common performance objective”. Mutualsupport and cooperation arise from workingtogether on a project, leading to increasedcommitment to improvement. Such anatmosphere of support discourages blamingothers for problems. Finally, theaccomplishments of a team often increase themembers’ self-confidence.

DIMENSIONS OF QUALITY

The following nine dimensions of quality have beendeveloped from the technical literature on quality andsynthesize ideas from various QA experts.

Technical performance: The degree to which thetasks carried out by health workers and facilities meetexpectations of technical quality (i.e., adhere tostandards)

Access to services: The degree to which healthcareservices are unrestricted by geographic, economic,social, organizational, or linguistic barriers

Effectiveness of care: The degree to which desiredresults (outcomes) of care are achieved

Efficiency of service delivery: The ratio of the outputsof services to the associated costs of producing thoseservices

Interpersonal relations: Trust, respect,confidentiality, courtesy, responsiveness, empathy,effective listening, and communication betweenproviders and clients

Continuity of services: Delivery of care by the samehealthcare provider throughout the course of care(when appropriate) and timely referral andcommunication between providers.

IMPROVEMENT COLLABORATIVES

The improvement collaborative is a major newapproach for rapidly improving the quality and efficiencyof healthcare. A collaborative focuses on a single technicalarea (for example, prevention of mother-to-childtransmission of HIV). A collaborative is a time-limitedimprovement strategy, usually lasting from 1 to 2 years.

Collaboratives are designed to achieve dramaticimprovements in the quality and outcomes of care in ashort period of time by fostering active learning among

improvement teams and by regularly tracking andcommunicating results of the improvement efforts. Thecollaborative facilitates active sharing of strategies andideas for improvement among participating teams. Thisway the teams can learn from each other and can quicklybenefit from successful changes that are implemented.

(i) Safety: The degree to which the risks of injury,infection, or other harmful side effect are minimized

(ii) Physical infrastructure and comfort: The physicalappearance of the facility, cleanliness, comfort,privacy, and other aspects that are very important toclients

(iii) Choice: As appropriate and feasible, client choice ofprovider, insurance plan, or treatment

INSTITUTIONALIZATION

Institutionalization is an ongoing process in which aset of activities, structures, and values becomes an integraland sustainable part of an organization (Fig. 5).

Quality assurance will be institutionalized when it isformally and philosophically incorporated into thestructure and functioning of a health system (ororganization), consistently implemented, and supportedby a culture of quality, as reflected in organizational valuesand policies that advocate quality care.

A conceptual model describing the fundamentalelements and components of an institutionalized qualityassurance is described as follows.

The core or center of the model is quality care, thedesired outcome. Technical approaches or activities forimproving quality of care are represented by the QAtriangle of: defining quality (QD), measuring quality(QM) and improving quality (QI). The QA Project has

Fig.5 Institutionalization of Quality Assurance


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found that these technical QA activities will have the mostimpact when all three are implemented in a coordinatedfashion. Success over the long term in achieving quality ofcare also depends on supporting technical activities withan enabling environment, a structure that delineates roles,responsibilities, and accountability for the implementationof QA activities, and support functions to sustain theirimplementation.

The Essential Elements of Institutionalizing QA

QA and improved quality of care require more than atechnical approach of tools and methods. Sustainedimprovements often require a change in attitude and senseof ownership for the quality of services provided by anorganization. Many supporting factors are required tointegrate QA into the structure and function of anorganization. These are the building blocks which we callthe essential elements of institutionalization.

There are eight essential elements that make up the QAinstitutionalization framework, and they can be dividedinto three categories:

(i) Internal enabling environment: Policy

Leadership

Core values

(ii) Structure

(iii) Support functions: Capacity building

Communications

Rewarding quality

The Internal Enabling Environment

An internal environment conducive to initiating,expanding, and sustaining QA is necessary toinstitutionalize QA. Such an enabling environmentincludes the following elements, each importantindividually, but also supportive of each other in asynergistic fashion:

• Policy: written policies that support quality throughclear, explicit, and communicated directions/directives and provide support, guidance, andreinforcement for QA as an integral part of theorganization

• Leadership: leaders who work directly and openly toimprove quality by setting priorities, modeling corevalues, promoting a learning atmosphere, acting onrecommendations, advocating for supportive policies,

and allocating resources for QA

• Core values: organizational values are articulated,promoted, and practiced. These values emphasizequality of care, ongoing learning, and continuousimprovement of services

• Resources: sufficient allocation of human andmaterial resources for conducting, supporting, andmaintaining QA activities

A Structure to Support QA Implementation

Whatever form the QA structure takes,institutionalization needs mechanisms to ensure oversight,coordination, delegation of roles and responsibilities, andaccountability:

• Oversight: The oversight includes both leadershipsupport and technical oversight for QA efforts.

• Coordination: As QA activities run across specificservice delivery and administrative programs,coordination with technical experts and with thoseimplementing specific programs is critical foreffective standards development, monitoring, andimprovement.

• Roles and responsibilities: The true structure for QAis manifested in how the roles and responsibilities forperforming QA activities are divided and/or delegatedwithin the organization. Eventually, responsibilitiesfor QA should appear in routine job descriptions forindividuals as well as in the scope of work fororganizational units.

• Accountability: With maturity of a QA program, everyindividual becomes accountable for results andresponsible for quality. As QA becomes moreintegrated into the job descriptions (roles andresponsibilities) of staff throughout the organization,the type of oversight required shifts, as does itslocation. Early QA activities may be coordinatedthrough a more umbrella-like structure as the programis taking shape. Accountability holds both for resultsachieved and for the resources used to achieve thoseresults.

Essential Support Functions

In addition to creating an internal environment thatsupports a culture of quality, provides resources andguidance for implementation, and has outlined clear rolesand responsibilities for QA, those doing the day-to-dayimplementation of QA require more specific types ofsupport. As the name implies, support functions provide

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“support” for the staff to undertake and sustain technicalQA activities. The development of ongoing systems toensure QA Capacity Building, Communication of QAEfforts, and Rewarding Quality Work are critical for anorganization to move beyond performing QA as isolatedactivities, to a state of continuously implemented QA,embedded in the organizational work ethic. There aremany other support functions, such as logistics andfinancial management, but these three have particularimportance in QA institutionalization.

Capacity Building

Capacity building refers to the ongoing process ofensuring that staff have the necessary knowledge andskills to carry out their QA responsibilities and that theyknow when and how to best use these skills. Essentialcapacity-building activities include:

• Provision of basic QA expertise: Developingbasic QA expertise should ultimately beintegrated into the training systems. Staff needswill evolve over time, and thus, training should betailored to these evolving QA responsibilities andrelated training needs.

• On-going coaching and mentoring: Coachingand mentoring provide ongoing technical andqualitative support to facilitate the behaviorchanges needed to undertake and sustain QAactivities, while simultaneously encouraging thedevelopment of a “culture of quality.”

• Supervision: Staff also need day-to-day supportand correction as they undertake QA activities.Supportive supervision requires enhancing thefacilitating role of the supervisor, assuring thatsupervisors have a foundation of QA expertise, aswell as teaching supervisors how to observe, givefeedback, and assess a situation.

“Doing QA” is really more than the simple applicationof technical methods. It often requires behavior change–learning to work differently.

Communication of QA Efforts

Communication is a two-way interaction, withinformation imparted from various parts of theorganization to staff within the organization, to thecommunities being served, and to other stakeholders,

including policy makers, and then received back fromthese sources. Communication reinforces the notion thatQA is everyone’s business, that successes should beshared, and that lessons can be learned (and shared) whenthings do not go as well as planned.

Successful communication support for QA includes:

• Recording improvements and changes, illustrated bydata to demonstrate results that have been achievedand by the stories behind these results.

• Sharing what has been achieved and how it was done,both with the organization’s staff and the communityit serves, as well as with others who might learn fromit and become motivated to improve their ownservices.

• Using the results for advocating policy changes.When activities are well documented with supportingdata, it is easier to convince decision makers.

Rewarding Quality Work

In addition to having the capacity to do QA and havinginformation available about what can be achieved, staffmembers also need to see that their efforts in QA areimportant to organizational leadership and the communityserved. Rewarding quality work (or efforts to improvequality) fosters a commitment to quality and motivation tostrive for excellence. Providing individual, group, or evenorganizational rewards reinforces interest in QAendeavors and assures that staff values are aligned withorganizational values. Not only should an organizationdevelop incentives (both material and intangible) thatbolster workers’ motivation to undertake QA activities andultimately improve quality of care, it should also examinewhat kind of disincentives or barriers to quality currentlyexist and identify ways to remove them.

CONCLUSION

In sum, experience with quality improvement hasrendered it a simpler, more robust methodology, and theapplication of QI methodology to a wide range of settingshas become clearer. The settings include both clinical andnonclinical environments, with the approaches rangingfrom individual problem solving to process improvementby permanent teams. In all of these approaches, themethodology and principles remain unchanged, thoughtheir specific methods may vary.

Methods and Tools of Quality Improvement

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