Topic 7: Introduction to quality improvement methods

1 165 Why students need to know aboutquality improvement methods Students will be familiar with the termevidence-based medicine and the randomizedcontrolled trial, which has enabled medicine toestablish if a particular treatment is validated byevidence or merely one that rests on belief of thepractitioners. Research methods such as therandomized controlled trial measure clinicaleffectiveness. But such methods do not measurecontextual components or the process of problems in health systems are significantlyaffected by the processes of care and arandomized controlled trial will not measure theproblems nor fix them. Students need to be awarethat process measures require different science of improvement is new to medicineand as a result there has been debate aboutwhether the measures of quality improvement arerigorous enough.

2 Berwick has captured thisdebate in a paper published in 2008 where heargued that both research methods are necessaryto improve health-care research for improvingclinical evidence and research for improvingprocesses of care [1]. quality improvement methods are designed tostudy processes and have been successfully usedfor decades in other industries. In health care,students will be familiar with the goal of scientificresearch, which is to discover new knowledge butthey will be less familiar with quality improvement ,which is to change performance [2]. Students areencouraged to observe or join a team undertakingan improvement activity. Medical students canbegin to understand the role of qualityimprovement methods by: asking about measures that improve qualityand safety ; recognizing that good ideas can come fromanyone; being aware that the situation in the localenvironment is a key factor in trying tomake improvements; being aware that the way people think andreact is as important as the structures andprocesses in place.

3 Realizing that the spread of innovativepractices is a result of people adopting newprocesses and not the other way quality improvement methods are based onthe application of continuous quality improvementtheory developed by the manufacturing principle underpinning quality improvementwas that quality was not something controlled atthe end of the line, but rather throughout theentire work process. This Topic explains some ofthe underlying attempts to persuade and influenceclinicians to change behaviour, such ascompliance with a protocol or vigilance in regardto drug interactions in the interest of improving thequality of patient care, have by and large have been thousands of recommendationsby hundreds of committees and peer groups forimproving the safety and quality of patient careover decades, yet there is little evidence thatclinicians have changed their practice because ofthem.

4 The publication of evidence in peerreviewed journals, does not necessarily lead in ofitself , to clinicians' changing their practice. Manyarticles outline best practice and make urgentrecommendations for changes as a result of newinformation [3]. quality improvement methods have successfullyaddressed this gap and provide clinicians with thetools to: (i) identify a problem; (ii) measure theproblem; (iii) develop a range of interventionsdesigned to fix the problem; and (iv) test whetherthe interventions worked. Tom Nolan, Brent James, Don Berwick and othershave applied quality improvement principles in1 Topic 7: Introduction to quality improvement methods 166 Topic 7: Introduction to quality improvement methods developing quality improvement methods forhealth clinicians and managers.

5 The identificationand examination of each step in the process ofhealth-care delivery is the bedrock of thismethodology. When students examine each stepin the process of care they begin to see how thepieces of care are connected and is critical for safety improvement . A range of quality improvement methods havebeen designed. Below are some more commonexamples: clinical practice improvement (CPI); root cause analysis to retrospectively examinewhat went wrong; failure modes and effects analysis toprospectively consider what might go wrong. KeywordsQuality improvement methods , PDSA cycle,change concepts, continuous improvementmethods, variation, CPI, root cause analysis,flowcharts, Cause and effect diagrams(Ishikawa/fishbone), Pareto charts, histograms,run objective The objectives of this Topic are to describe theprinciples of quality improvement and to introducestudents to the basic methods and tools forimproving the quality of health outcomes: knowledge andperformanceThis Topic is an important one for students tounderstand because improvement will only beachieved and sustained through continuousmeasurement.

6 However, it will also be one of themost difficult because many hospitals and clinicsdo not measure the processes of their care. Aneffective way for students to understand thebenefits of using quality improvement methods isto apply the principles and use the tools toundertake their own improvement project. What students need to know (knowledgerequirements): the science of improvement ; the quality improvement model; change concepts; two examples of continuous improvementmethods; methods for providing information on clinical students need to do (performancerequirement): know how to perform a range ofimprovement activities and tools. WHAT STUDENTS NEED TO KNOW(KNOWLEDGE REQUIREMENTS)The science of improvement W Edwards Deming, the father ofimprovement theory, described the following fourcomponents of knowledge that underpinimprovement: [4] appreciation of a system; understanding of variation; theory of knowledge; stated that we do not need to understandthese components in depth to apply theknowledge.

7 An analogy used by improvementleaders ( Langley; Nolan [4,5]) is that we candrive a car without understanding how it beginning their medical careers onlyneed a basic understanding of the science ofimprovement. It is more important to be familiarwith the methods used to improve the processesof of a systemIn applying Deming s concepts to the health care,we need to remember that most patient careoutcomes or services result from a complexsystem of interaction between health-careprofessionals, treatment procedures and medicalequipment. Therefore, it is important that medicalstudents understand the interdependencies andrelationships among all of these components(doctors, nurses, patients, treatments, equipment,procedures, theatres and so on) therebyincreasing the accuracy of predictions about anyimpact that changes may have on the of variationVariation is the differences between two or moresimilar things such as different rates of successfor appendectomies in two different parts of thecountry.

8 There is extensive variation in health careand patient outcomes can differ from one ward toanother, from one hospital to another and oneregion to another. Variation, though, is a feature ofmost systems. Shortages of personnel, drugs orbeds can lead to variations of care. Deming urgespeople to ask questions about variation. Studentscan get into the habit of asking their clinicalsupervisors what their outcomes are for aparticular treatment or procedure. Do the threepatients returned to theatres after surgery indicatea problem with surgery? Did the extra nurse onduty make a difference with patient care or was ita coincidence? The ability to answer suchquestions and others like them is part of thereason for undertaking improvement activities.

9 Theory of knowledgeDeming says that the theory of knowledgerequires us to make predictions that any changeswe make will lead to an improvement . Predictingthe results of a change is a necessary step toenable a plan to be made even though the futureis certain. Many students will have experience ofsuch predictions, having written study planspredicting what is necessary to pass with specific experiences may be better atfocused predictions. For example, healthprofessionals who work in particular health-caresettings such as a rural clinic may be better atpredicting the results of a change in thisenvironment. Because they have more knowledgeabout these clinics and the way they function orshould function and the way the change willimpact on the patients and their families.

10 Whenhealth professionals have experience andknowledge of the area they wish to change it ismore likely that the change will result in animprovement. Comparing the results with thepredictions is important learning. Deming saysthat building knowledge by making changes andmeasuring the results or observing the differencesis the foundation of the science of improvement . PsychologyThe last component is the importance ofunderstanding the psychology of how peopleinteract with each other and the system. Making achange whether it is small or large will have animpact and knowledge of psychology helps tounderstand how people might react, and why theymight resist change. A medical ward, for example,includes a number of people who will varyenormously in their reactions to a similar eventsuch as introducing an incident monitoringsystem.