Quality improvement (QI) in healthcare is as important now as it has ever been. Moreover, there’s plenty of advice available on the “best” way to go about it. Indeed, if you search online with the phrase “ways to drive improvement in healthcare,“ you will get about 365 million results. This is literally one million things to read every day for the next year.
Many of these articles will contain similar pieces of advice: collect and analyse data and patient outcomes; set improvement goals/targets; use Plan-Do-Study-Act (PDSA) cycles to test improvement ideas; communicate with staff about goals and progress towards those goals; connect with other organisations to collaborate and/or learn from them. These are all excellent ideas that health services would do well to adopt.
If you are already implementing some – or all – of these ideas, and yet, for all that effort, you still aren’t achieving the kind of QI outcomes you were expecting, then this article is for you. Read on as we examine five fresh ideas on how to drive quality improvement in the healthcare sector. These are ideas you may not find elsewhere.
- 1. Engage frontline staff in both issue diagnosis and identifying possible solutions
- 2. Re-imagine the role of Quality Teams within hospitals
- 3. Stop thinking about quality improvement as a remedial activity for problems that have already happened
- 4. Schedule time for QI-related activities into every staff member’s weekly work plan
- 5. Focus a bit less on compliance and a bit more on improvement
1. Engage frontline staff in both issue diagnosis and identifying possible solutions
When things go wrong in patient care, they almost always go wrong at the clinical frontline. This is because the clinical frontline is where all the pathways converge. It’s where the health service systems, processes, protocols, and facilities intersect with healthcare workers’ knowledge, experience, and skill. Also, with the patient-specific circumstances of the moment.
The most informed group in terms of identifying where that convergence works and where it doesn’t is the frontline staff. Others can observe what’s happening, but they don’t really understand what they’re observing in the same way as those who are part of the action. Importantly, the people in the middle of the action usually also have a good idea about how things could be improved.
Engaging frontline staff in QI is not a new idea. The Godfather of Quality Improvement, W. Edwards Deming, proposed this around 70 years ago and implemented it to great effect in several sectors. But in the decades since, the healthcare sector has favoured a more “scientific” approach to QI. This has sidelined people who are experts in their own job simply because they are not also experts in the science of improvement.
Meaningful engagement of frontline staff certainly requires some effort. However, to NOT engage this group with issue diagnosis and solution identification is to cut your organisation off from the most important information source for QI.
Fortunately, engaging frontline staff is actually not all that difficult to do. Frontline workers generally like to talk about their work. Moreover, if the engagement activities are meaningful and not simply tokenistic, staff will be more than willing to participate.
There are two keys to the good engagement of frontline staff. The first is to make the engagement a regular, structured activity. The second is to remember that engagement is a two-way process. It requires commitment and effort from both frontline staff and their managers.
2. Re-imagine the role of Quality Teams within hospitals
Most people would agree it was a great step forward when healthcare organisations started establishing Quality Units and hiring managers and other staff with specific responsibility for quality. This brought the concept of “quality” front and centre in hospitals. It also made a statement about the importance of quality to the organisation.
Unfortunately, the establishment of Quality Units also had the unintended consequence of disengaging the rest of the hospital’s staff from the idea that “quality” is an integral part of their own work.
But there’s an even more important problem.
If the Quality Unit is responsible for identifying where QI efforts are needed, the only basis on which they can make such a determination is when an adverse incident or poor patient outcome raises a flag. That is when something has already gone wrong. This means the Quality Unit will see QI as a remedial reaction to existing problems rather than a proactive approach to preventing problems.
Fortunately, we don’t need to do away with Quality Units to solve this issue. We need to re-imagine the role of the Quality Unit within the hospital.
Rather than making Quality Units responsible for originating QI projects within the hospital, we should consider their primary function to be facilitating regular, structured dialogue with frontline staff about routine practices. The purpose of these conversations is to help staff identify latent safety threats and sources of protocol variance that could result in patient harm before they actually do.
By having such conversations with staff across the whole organisation, the Quality Unit can determine which are “local” issues requiring local solutions and which issues represent more widespread problems that might require hospital-wide solutions. Above all, the Quality Unit should seek the input of frontline staff in identifying possible solutions.
“The people who do the work often have very good ideas about how best to solve the problems they face in their daily practice.”
Following on from this, the Quality Unit should then be responsible for prioritising and implementing the solutions. Sometimes this might involve investigating successful solutions from other hospitals. Other times, this might involve devising a solution from scratch, based on ideas put forward by frontline staff. Importantly, the Quality Unit would have a major role in ensuring tasks on the local and hospital-wide action plans actually get done.
As is currently the case, Quality Unit staff should be responsible for analysing the data collected through audits, incident reporting, and other systems. However, instead of primarily reporting these data to senior management, the Quality Unit should regularly feed the results back to the hospital’s individual work units. Ideally, the Quality Unit would present the data in the context of regular structured conversations with frontline staff. This way, the staff can reflect collectively on how the data relate to routine practice.
The main benefit of re-imagining the role of the Quality Unit in this way is that this approach enables more of a partnership between the Quality Unit and the frontline workforce. The collective ownership of the resulting quality initiatives significantly increases the likelihood of sustained improvements in quality.
3. Stop thinking about quality improvement as a remedial activity for problems that have already happened
The adage “if it ain’t broke, don’t try to fix it” is probably the single worst approach to QI that it is possible to have. This is particularly the case in the healthcare sector. Just because something doesn’t appear to be broken doesn’t mean it can’t be improved. And it also doesn’t mean it isn’t about to break, with potentially catastrophic consequences.
Waiting for things to break before we pay them any attention is antithetical to the concept of QI. Moreover, it also means that harm may have already occurred. When our QI conversations in healthcare start from harm that has already occurred, it changes the nature of the conversation. It almost guarantees that people are defensive about their role in the incident rather than positively seeking ways to improve.
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It is obviously very important for healthcare organisations to be able to address harm that has already occurred and identify the underlying issues. However, the objective of the quality and safety movement in the healthcare sector is for hospitals to get better at preventing avoidable harm, not simply to get better at responding to bad outcomes.
A preventative approach to QI means focussing on routine practice rather than focussing on adverse incidents or poor indicator results. It means changing our thinking from “how can we prevent this bad situation from happening again?” to “how can we do this better?” and applying that lens to everything we do, not just to the things that are obviously not working.
Most importantly, the “how can we do this better” conversations should involve both the Quality Unit and the frontline staff. They need to work in partnership to drive genuine – proactive – QI.
One consequence of establishing Quality Units in hospitals has been that most frontline staff see quality as someone else’s business. They often don’t look at quality-related activities as something integral to their own business. This unfortunate and unintended outcome has been exacerbated by staff workloads that make little or no allowance for meaningful contributions to quality-related activities.
To turn this situation around, healthcare organisations have to recognise that genuine QI takes time. Moreover, everyone needs to have the time to participate properly. Staff shouldn’t have to request time to reflect on their contribution to work activities. They should regularly be required to do so by their managers. And in this sense, managers should be required to do so by the organisation’s senior management.
Of course, this means scheduling “quality time” into every staff member’s weekly work plan. It also means that quality assurance should be integral to every role. Also, participation in QI activities should be explicitly stated in every position description.
“Quality assurance should be integral to every role”
To prepare all health professionals for more quality-oriented roles, education and training programs should include assessable topics on quality. This way, graduates can emerge from their courses with knowledge and skills in QI alongside their other professional/vocational skills.
Factoring an hour or two of quality-related time into every staff member’s work plan each week may appear to be an added cost to healthcare organisations. However, the reality is that the additional staff time focussed on QI will quickly more than pay for itself. Frontline health professionals currently spend a great deal of “unmetered” time every week completing incident reports, repeating procedures, working through inefficient processes and remedying mistakes that result from a historical lack of focus on continuous quality improvement.
✅ Spending less time fixing errors and more time on improving quality will improve the budget bottom line. It will also improve staff morale, with important benefits for staff retention and teamwork.
5. Focus a bit less on compliance and a bit more on improvement
In the healthcare sector, the combination of accreditation (to benchmark systems and protocols) and indicator monitoring (to benchmark outcomes) was supposed to guarantee quality. Unfortunately, the reality has been that this approach to quality and safety has engendered a compliance focus amongst managers and staff that is antithetical to the concept of quality.
Quality is now something organisations “do” periodically to prepare for accreditation or collect and analyse data to report against indicators. Staff see the activities as burdensome and unrelated to their “real” jobs. Quality-related projects are treated as “special” and, once they are completed, things soon drift back to “normal” practice.
Once organisations start to see quality as a compliance issue, they are far more likely to frame their approach to QI in terms of the minimum effort required to meet requirements. This all but guarantees that quality never really improves. This also encourages staff to stop looking to improve things once a minimum standard has been met.
There is a better alternative.
When healthcare organisations focus on the question “how can we do this better?” for everything they do, this prompts the workforce – managers and staff alike – to deliberately reflect on practice, which is the basis of learning. As the American philosopher, psychologist and educational reformer John Dewey noted about 90 years ago, “We do not learn from experience. We learn from reflecting on experience.”
Just as reflection is the basis of learning, learning is the starting point for improvement.
When organisations don’t limit themselves to meeting minimum standards and focus instead on continuous improvement, the added benefit is that they meet the compliance requirements as a matter of course.
And learning organisations are great places to work. They find it easier to attract and retain staff, at the same time ensuring a positive workplace that delivers the highest possible quality care for patients.
Learn more about how MEERQAT can help you improve quality in your organisation.