Healthcare improvement for healthcare providers

Healthcare improvement is also called quality improvement

Key points about healthcare improvement

  • Healthcare improvement, also known as quality improvement, is vital to the sustainability of our health system.
  • If we are to make significant improvements to our health system, then every person needs to see quality as a core responsibility of their role.
  • In the following sections, you will find a range of resources to help you, your team and organisation on your quality journey. Help make it even better by contacting us and recommending key resources, reports, stories and ideas.
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Healthcare improvement, also known as quality improvement, is vital to the sustainability of our health system. Not only are healthcare costs escalating out of control, but the pressure on hospital beds, leads to "Code Red" for most of winter in many hospitals around the country.

If we are to make significant improvements to our health system, then every person needs to see quality as a core responsibility of their role, from the cleaners, kitchen staff and technicians through to the surgeons and managers.

Quality is everyone's responsibility

This is personal! Most people want the best healthcare possible for themselves,their family and loved ones. For that to occur, each one of us needs to prioritise quality in everything we do. By learning some basic skills, working more effectively as a team, applying quality improvement methods, reviewing, and refining, together we can make a real difference to the quality of service and care we will all receive.

Background

Quality improvement icons like W. Edwards Deming, Walter Shewhart, and J.M. Juran introduced the concepts of quality improvement to industry and the manufacturing sector during the 20th century. Over time other sectors grasped the importance of applying the general laws and truths of quality improvement through the scientific method, thereby reducing problems and wastage while significantly improving productivity and competitiveness.

Safety critical sectors such as aviation, space programmes, shipping, armed forces and engineering have further advanced quality improvement methodology and applied the key principles with impressive results. While some areas of health have made large improvements in the last 50 years, (such as post-surgical infection rates, maternal and neonatal mortality), some would suggest that overall, health has lagged behind and it is only in the last 10 years that quality improvement has gained much traction. While the reasons for this are complex, two factors that cannot be ignored are the medico-legal implications of acknowledging mistakes and the impact of clinician autonomy, variability and resistance to standardisation.

Two key reports that have stimulated significant improvement in healthcare are: To Err is Human (1999), and Crossing the Quality Chasm: A New Healthcare System for the 21st Century (2001), both from the Institute for Medicine. The first one highlighted the reality that we all can make mistakes, but do we have the systems in place to reduce these? The second report caused shockwaves through the USA as the ''chasm" between best care and usual care was emphasised and called for urgent fundamental change to  redesign  the American health care system and close the quality gap.

An illustrated look at quality improvement in health care

Dr Mike Evans presents a brief history of quality improvement, then touches on system design, the Model for Improvement, and the familiar challenge, "What can you do by next Tuesday?"

Video: Quality Improvement in Healthcare

(Dr Mike Evans, 2014)

This is personal! Most people want the best healthcare possible for themselves,their family and loved ones. For that to occur, each one of us needs to prioritise quality in everything we do. By learning some basic skills, working more effectively as a team, applying quality improvement methods, reviewing, and refining, together we can make a real difference to the quality of service and care we will all receive.

As a team, discuss what success would look like. What measures or changes would you like to see for yourselves and for your patients? Then think about what can you easily measure and choose 2 to 3 measures of change that are meaningful for you as a team. 

Measures

As stated by the Institute for Healthcare Improvement (IHI), measurement is a critical part of testing and implementing changes in your practice. "Measures, driven by evidence-based guidelines, tell a team whether the changes they are making actually lead to improvement."

There are three types of measures:

  1. Clinical outcome measures: patient-level disease measures (eg HbA1c, blood pressure, cholesterol levels, weight)
  2. Process measures: care delivery measures (clinical screenings and other processes that impact clinical outcomes such as cardiovascular risk assessment, mammography and cervical screening)
  3. Balancing measures: measures to ensure that as the first two types of measures are made, other aspects of the health systems aren’t interrupted (eg patient/provider satisfaction, wait times, cost of care, etc.)

Read more about measures from IHI website & University of Victoria:

Sources of data

The following are potential sources of data and measures you may wish to use. 

Decide on a frequency

Once you have identified some useful measures, decide how frequently you will review these. It can be useful to have some short-term measures that are monitored weekly or monthly that provide regular feedback on whether the changes you are putting in place are making a difference. Some measures are best done weekly, others monthly and some 3, 6 or 12 monthly. 

Other measures are best done 3, 6 or 12 monthly and give a longer-term view. 

Learn more

Science of improvement: Establishing measures(external link) Institute of Healthcare Improvement
Blog: Measurement of improvement or measurement for improvement?(external link) Institute of Healthcare Improvement
Patient self-management support programmes: An evaluation(external link) Agency for Healthcare Research & Quality

Primary Care Team Assessment (PCTA)

One of the key tools practices may wish to use is to repeat the Primary Care Team Assessment that was completed at the beginning of this process 6 to 12 months later. By comparing your collective team scores, you'll be able to see what areas have improved and then plan what areas you may wish to work on next. 

See PCTA tool

Action Plan PDSA results

Another valuable tool to inform changes and progress is to summarise and evaluate the PDSA cycles that were completed over the intervening period. Remember, at the start of this project, you were encouraged to create a Team Action Plan, then start doing regular PDSA cycles. 
Aspects of the PDSA cycles you can assess include: 

  • The number of PDSA cycles
  • Quality of PDSAs
  • How many were completed in a timely manner?
  • Key learnings from the PDSAs? Were they too big, too small, or the right size to be doable and stimulating, prompting further review and flow on to the next cycle? 
  • How many team members actively participated in PDSAs?
  • How effective would you rate each one?

Resources

PDSA template [DOCX, 51 KB] Model for Improvement

Peer feedback

In any project or improvement work, it is important to gather feedback from key participants; in this case, your team members to assess what worked well, what didn't work so well and lessons or learnings for the next project. 

Tools to assist with this range from a basic hard copy questionnaire handed around in a team meeting through to using an electronic survey tool such as QuestionPro or SurveyMonkey which can provide automatic results collation report generation in a range of formats (pdf, excel, powerpoint and more.)

Project retrospective

A more formal method for gathering feedback and reviewing a project is to conduct what's called a project retrospective. Through the experiences of a project, the team gains experience,

"Through the experiences of a project, the team gains experience, wisdom and perspectives that they may not have possessed at project initiation. The retrospective is an important mechanism for harvesting this newly gained wisdom and seeking to apply it to future endeavours."  

  • "Team members come together, each with their own perspective and insights, to understand one another's view of the project and identify improvement actions.  It's not a session to create an explanation for management about a project failure - that would be a typical project post-mortem.  Nor is a retrospective merely completing a questionnaire so some project manager can figure out how to run the next project - that would be a typical lesson learned activity.  It's not a complaint or blaming session either."   (Pinnacle Projects website(external link))

    Template examples & articles - Lucidmeetings(external link) 

  • How to lead a successful project retrospective meeting(external link) Lucidmeetings

Learn more

Resources

PDSA template [DOCX, 51 KB] Model for Improvement

The following links will take you to websites for some of the key international and national groups focusing on quality and healthcare improvement. Let us know of others to include.

  • Institute for Healthcare Improvement(external link) – the Institute for Healthcare Improvement (IHI) is a non-profit organisation and leading international centre of excellence. Led by CEO Dr Don Berwick, (recently nominated for Administrator of the Centers for Medicare & Medicaid Services, USA), their website contains an impressive array of programmes, resources, tools and examples of healthcare improvement from around the world.

Video: Leapfrog programme – Robyn Whittaker

The Leapfrog programme includes a number of organisation-wide projects contributing towards improving health outcomes and experience of patients and families/whānau within the healthcare services.

Combining the projects under one programme provides greater visibility, attention and support from senior management and allows projects to move at a faster pace.

An ability to network and share resources when the projects interlink is also an advantage.

(Mobile Health, NZ, 2016)

Current Leapfrog projects include the following: 

  • mobility strategy
  • enhancing data capture
  • electronic ordering systems
  • clinical decision support tools
  • better outpatient follow-up
  • patient experience reporting
  • best facilities planning using a set of core design principles
  • improving primary care connections.

Further reading

Innovation & improvement(external link) Waitematā DHB

The Annual IHI National Forum on Quality Improvement in Health Care has shaped the course of health care quality in profound, enduring ways and played a part in effecting real change in health care quality and safety. It is one of the world's largest gatherings of healthcare professionals (nearly 6,000) committed to improving patient care and their safety. 

Quality patient information through portals

Dr Bycroft presents at the Partners in Care Show & Tell symposium in Wellington. She talks about how to improve the quality of available healthcare information and about how to make this information more accessible for both the public and health professionals.

Video: Janine Bycroft presents on quality patient information through portals

(Health Quality & Safety Commission, NZ, 2014)

Video: AND is the new OR - Maureen Bisognano and Derek Feeley

Energizing. Inspiring. Engaging. Attendees use these kinds of words to describe the 2014 Institute for Healthcare Improvement (IHI). An event that has shaped the course of health care quality in profound, enduring ways. (Keynote presentation by IHI President and CEO Maureen Bisognano and IHI Executive Vice President Derek Feeley).

 (Institute for Healthcare Improvement, US, 2014

Video: "My Hopes for Health and Health Care: A Pecha Kucha Style Workshop" by Helen Bevan

Pecha Kucha is one of the fastest-growing new ways to spread learning quickly and effectively. Eleven QI champions from around the world presented their personal hopes for health and health care in this innovative format.

(Institute for Healthcare Improvement, US, 2015)

Videos from 2017 annual conference (The Health Foundation, UK)

Sessions 1 and 2

Welcome and introduction – Dr Jennifer Dixon, Chief Executive. Learning health care systems at a macro level – concepts and ingredients.

(The Health Foundation, UK, 2017)

Session 4

Moving to improvement at scale.

(The Health Foundation, UK, 2017)

Session 7

Next steps towards faster progress.

(The Health Foundation, UK, 2017)

Video: Matthew Johnstone, Keynote Address

Matthew Johnstone, experience-based health consumer, international speaker, author and illustrator, gives the keynote address at the Health Quality & Safety Commission's Partners in Care Show & Tell symposium in Wellington. He discusses mental health, providing those in the mental health field with the right tools to ensure the best possible outcome for the consumer and his role at the Black Dog Institute.

(Health Quality & Safety Commission, NZ, 2014)

Video: Richard Hamblin presents on the Health Quality & Safety Commission's patient experience indicators

Richard Hamblin gives a presentation on patient experience indicators at the Health Quality & Safety Commission's Partners in Care Show & Tell symposium in Wellington. He talks about the importance of a system that enables the voice of the patient/healthcare consumer to be heard.

(The Health Quality & Safety Commission, NZ, 2014)

NZ Telehealth Resource Centre

The New Zealand Telehealth Resource Centre provides resources and advice to clinicians and practices who are considering or planning to implement a telehealth service. The services are provided entirely free of charge. The aim is to encourage the uptake of telehealth by health professionals across the country. It includes case studies of where telehealth is already providing benefits. Site visits, workshops and demonstrations are also offered by the resource centre team.

“Telehealth is changing the way we deliver healthcare and is a good example of how the sector is harnessing IT to provide better services to patients closer to home,” says Dr Coleman. “It means people living in rural or remote areas can access the same specialist care as those living in urban areas without having to travel great distances. Equally, telehealth is useful in busy urban environments or where a patient is not easily able to travel." (Source: Beehive.govt.nz – New online telehealth resource to encourage uptake(external link)). To learn more visit The NZ Telehealth Resource Centre homepage.(external link)

Model for Improvement

The Model for Improvement developed by Associates in Process Improvement (API) is the most well-known model for providing a simple, yet effective tool for accelerating improvement in small through to large organisations.

Learn more about the fundamentals of the Model for Improvement from the Institute of Healthcare Improvement website

Credits: Healthify editorial team. Healthify is brought to you by Health Navigator Charitable Trust.

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