QUALITY IMPROVEMENT: THEORY AND PRACTICE IN …

1 Ruth BoadenGill HarveyClaire MoxhamNathan ProudloveForeword by Helen Bevan,Director of Service Transformation,NHS Institute for Innovation andImprovementQUALITY improvement : THEORY AND PRACTICE IN HEALTHCARERuth Boaden, Gill Harvey, Claire Moxham, Nathan ProudloveThis report, written in conjunction with the Manchester Business School, focuses on qualityimprovement in healthcare, and summarises the evidence about how it has beenimplemented and the results of this process. It has a focus on the role of various industrial QUALITY improvement approaches in thisprocess: the Plan-Do-Study-Act (PDSA) cycle, Statistical Process Control, Six Sigma, Lean, THEORY of Constraints and Mass Customisation. It also outlines the development of qualityfrom a clinical perspective and the way in which industrial approaches are now beingapplied in healthcare. The purpose of this report is: to provide a guide to the main approaches being used, in terms of their context aswell as their impact.

2 This shows the emphasis and focus of these approaches, sothat guidance on the situations where they might be most effective can bedeveloped to enable links to be made between aspects of QUALITY improvementwhich are often regarded as separate; specifically improvementfrom clinical and organisational improvement : THEORY and PRACTICE in Healthcare willbe of use to all healthcare leaders who are interested inquality improvement , and will also be very relevant toclinical staff across a range of : 978-1-906535-33-9 NHS Institute for Innovation and improvement 2008. All rights improvement : THEORY and PRACTICE in HealthcareNHS Insitute for Innovation and ImporvementIf you work within NHS England youcan order additional copies by calling 0870 066 2071 or Email: quoting NHSISERTRANQUALTYNon-NHS England and International customers canorder copies of this publication by going or by calling +44 (0)8453 008 027 QUALITY improvement : THEORY and PRACTICE in Healthcareis published by the NHS Institute for Innovation andImprovement, Coventry House, University of WarwickCampus, Coventry, CV4 find out more about the NHS Institute, email: Tel: 0800 555 550 You can also visit our website at you require further copies either:Tel: 0870 066 2071 Email: NHSISERTRANQUALTYNon-NHS England and International customers can order copies of this publication by calling +44 (0)8453 008 027.

3 QUALITY improvement : THEORY and PRACTICE in Healthcare is published by the NHS Institute for Innovation andImprovement, Coventry House, University of Warwick Campus, Coventry, CV4 publication may be reproduced and circulated by and between NHS England staff, related networks and officiallycontracted third parties only, this includes transmission in any form or by any means, including email, photocopying,microfilming, and recording. This publication is copyright under the Copyright, Designs and Patents Act 1988. All rightsreserved. Outside of NHS England staff, related networks and officially contracted third parties, no part of thispublication may be reproduced or transmitted in any form or by any means, including email, photocopying,microfilming, and recording, without the written permission of the copyright holder,application for which should be inwriting and addressed to the Marketing Department (and marked 're permissions').

4 Such written permission must always be obtained before any part of this publication isstored in a retrieval system of any nature, or : 978-1-906535-33-9 NHS Institute for Innovation and improvement 2008. All rights INFORMATION READER BOXsetatsEyciloPgninoissimmoCecrofkroW / RHManagementIM & TecnaniFecnamrofreP / gninnalPgnikroW pihsrentraP / eraC laicoSlacinilCDocument PurposeFor InformationROCR Ref:0 Gateway Ref: 103030 TitleAuthorPublication DateTarget AudienceCirculation ListDescriptionCross RefSuperseded DocsAction RequiredTimingContact Details0 Please review and approve in accordance with yourguidelinesBy 07 Aug 2008 NHS Institute for Innovation and Improvement00N/A07 Aug 2008 PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs , Medical Directors, Directors of PH, Directors of Nursing, Local Authority CEs, Directors of Adult SSs, PCT PEC Chairs, NHS Trust Board Chairs, Special HA CEs, GPs, Emergency Care Leads, Directors of Children's SSsProvides a review and guide to the main concepts and tools behind QUALITY improvement .

5 It also reviews the latest literature available and illustrates the impact of QUALITY improvement through case studies in Healthcare and some useful scenarios from Recipient's UseQuality improvement : THEORY and PRACTICE in HEALTHCARECV4 7AL0024 7647 5000 National Library for HealthNHS Institute for Innovation and ImprovementCoventry HouseUniversity of Warwick Campus, report has had a long genesis. It began life in 2004 as a supplementary report to theManchester Business School (MBS) evaluation of the Six Sigma training programme run bythe NHS Modernisation report was never formally published, but versions of it emerged whenever there werediscussions about the nature and role of QUALITY in the NHS. The NHS leaders who got accessto it enthused about it. There was no other publication available that set out the principlesand approaches to QUALITY in healthcare so comprehensively or effectively.

6 Word , there was such a groundswell of interest in this clandestine, unofficial paper thatthe NHS Institute asked Manchester Business School to review and update the paper forpublication and widespread timing of publication is fortuitous, just after Lord Darzi s report from the Next StageReview of the NHS, High QUALITY Care for All. The Next Stage Review gives a significant andwelcome prominence to QUALITY improvement in the next stage of NHS reform. It also setsout, in chapter five, the core elements of any approach to leadership . These includemethod: the management method (leaders) will use for implementation, continuousimprovement and measuring success . QUALITY healthcare is dependent on method. Each of us, whether commissioner orprovider, needs to develop skills and knowledge in methods for improvement . Theauthors of this report have summarised the improvement approaches and methods thathave been successfully utilised by industry over the past 50 years.

7 They have evaluatedall the approaches from a healthcare perspective. They have assessed the full spectrum,from the previous favourites such as Total QUALITY Management and Re-engineering, tocurrent preferences like Lean and Six Sigma to concepts such as Mass Customisationthat are newly emerging from the international healthcare improvement are some key messages for NHS leaders in this report. Firstly, when we treat clinically-led improvement (audit, clinical governance, etc) as a separate entity from managerially-ledperformance improvement , we do so at our peril. Leading organisations in healthcare qualityhave aligned improvement objectives and operate with a definition of QUALITY that coversboth clinical and managerial domains. Secondly, from a research evidence viewpoint, none ofthe approaches stands out as being more successful in healthcare than any of the an improvement method or model can make a significant difference to achievingoutcomes but it does not seem to matter which approach it is.

8 The authors conclude that theprocess of improvement is more important than the specific approach or method. Whenquality improvement efforts fail to deliver, it is rarely an approach problem or a tool problem. Rather, it is a human dynamics or leadership problem. Thirdly, for healthcareleaders, seriously adopting and committing to the method for as long as it takes to deliverthe results for patients is as important as selecting the specific method of improvement : THEORY and PRACTICE in HealthcareForewordFourthly, there are many paths (and many method options) to successful, sustainedquality improvement . The most important factor is the leadership ability to address manysimultaneous challenges and to adapt solutions and strategies to the organisation s welcome this report as an important contribution to the body of evidence on QUALITY inhealthcare at a time when QUALITY improvement is rightfully gaining a high strategic priority inthe NHS.

9 And I am delighted that, after four years, a report that has so much to teach thoseof us who want to provide safe, effective care and a great patient experience has finally seenthe light of day!Helen BevanDirector of Service TransformationNHS Institute for Innovation and Improvement2 QUALITY improvement : THEORY and PRACTICE in HealthcareGLOSSARY8 EXECUTIVE SUMMARY9 Where did the information come from?9 How robust is the information?9 Clinical QUALITY improvement10 What is QUALITY ?10 Industrial approaches to QUALITY improvement10 QUALITY improvement approaches11 Plan-Do-Study-Act (PDSA) cycle11 Statistical Process Control (SPC)12 Six Sigma12 Lean13 THEORY of Constraints14 Mass Customisation15 Underlying concepts15 Systems and processes15 The role of the customer16 Balancing supply and demand16 Translating improvement approaches to the healthcare context17 Does QUALITY improvement work?

10 Should read the report? parts of the report are most relevant? SOURCES AND did the information come from? Database Grey Prior : how robust is this information? The relevance of controlled QUALITY improvement is a complex social Is more than one methodology needed? this a new field of research? IN history of clinical QUALITY The role of other clinical professions293 QUALITY improvement : THEORY and PRACTICE in HealthcareTable Of on the development of clinical QUALITY Clinical Care Clinical and assessing healthcare Defining Process and Assessing Balancing elements of QUALITY improvement in QUALITY Differences and QUALITY approaches from manufacturing in the service awards and business Process improvement Plan-Do-Study-Act Outline of the How the approach fits with Where the approach has been used in healthcare.