A Framework for Continuous Quality Improvement in Health Care Organisations

• Abstract
• Introduction
• Quality means improving the system
• Leadership must believe in quality improvement
• There has to be a commitment to impart training in quality tools
• Developing a "quality culture" is essential
• There can be no quality improvement without measurement
• From quality assurance to continuous improvement
• Some ground rules for implementing a quality improvement programme
  • Management structure should support implementation of a quality-driven system
  • Concentrate on processes
  • Prepare for change
  • Consider role of customers
  • Be wary of the "best practice" syndrome
  • Quality is the responsibility of all staff
• Some practical strategies to achieve the goal of quality improvement
  • Ownership of vision, mission and critical factors for success
  • Finalising policies, procedures, guidelines, implementing core education and training modules and preparation of training packages
  • Quality improvement at "input"
  • Quality improvement at the point of service delivery
  • Improving methods of delivery of care
  • Developing customer advocacy
  • Culturally appropriate services
• Conclusions
• References

Abstract

At last, quality improvement as a concept as well as a process is becoming popular in New Zealand health care delivery. Even though "quality" is difficult to define, it can lead, if understood, to substantial gains for an organisation. This article discusses this concept and suggests some rules for implementing a quality improvement programme within health care service organisations. Practical strategies for organisations wishing to improve the quality of their services are also identified.

Introduction

Everybody is a customer of one sort or another. As providers as well as customers, members of health care services are concerned about quality in every aspect of their lives. When shopping we are all concerned about quality of product we are buying. When eating we want to make sure the products we eat are of high quality.

It is difficult to define quality. The reason for this may be that it is a concept or an approach and not a tangible object and there is no agreed definition. Moreover, the level of quality of anything may be assessed quite differently by different people.

For example, in a health care environment, a health care professional may be more concerned about delivering the best clinical treatment, an administrator may be concerned about making sure that the service is delivered efficiently, a receptionist may be concerned about making sure that the service delivered is co-ordinated. However, the consumer will assess the quality of service delivery according to their own perceptions as a patient rather than on any criteria important to the service providers. The expertise of a health care professional, the efficiency with which the service is delivered and how well it is co-ordinated may be overshadowed by difficulties the consumer may have experienced getting a car park! Two things should be clear from this.

First, providers cannot concentrate on one aspect of service delivery to improve quality of the service; everything matters. To improve quality the whole system has to improve. Secondly, as far as the consumer is concerned quality is determined by how it is perceived.

This article considers what quality should mean to health care organisations.

Quality means improving the system

The goal of an organisation to improve quality has to be "system improvement". The "system" includes employees and the environment in which it operates as well as its customers.

The system must be improved in such a way that all requirements for high quality are met and the system operates more efficiently. If the system is unsound, deficiencies are inevitable. For example, if a member of staff has failed to provide adequate supervision to a patient, the cause may lie in system failure. This staff member may have a high work load; he or she may be under pressure to complete jobs that he or she may not have training or expertise in; his or her supervisor may not have provided supervision or inspected his or her work; the supervisor may be unclear about what to inspect and supervise; the work standards expected may be inadequate; communication may be inadequate; the process of review may be inadequate; and the list goes on. Even though the incident may have come to light with regard to one patient and one staff member, a "systems inquiry" may reveal several underlying problems.

Leadership must believe in quality improvement

Leaders of health care organisations must show clear commitment to quality improvement. It is acknowledged that a strong and consistent commitment from the top over a sustained period is crucial for an organisation to achieve its goal of quality improvement. In New Zealand’s public health care organisations, commitment must be shown by the CEOs, clinical directors (clinical leaders) and business managers to embrace quality improvement. This can be demonstrated by the leaders of each clinical service personally leading quality improvement committees and initiatives within their services as well as spearheading the development of a quality improvement plan. Once a quality improvement plan is in place, middle level managers (and process improvement leaders) must ensure the quality improvement plan is "owned" by their staff and that clinicians are fully involved in the implementation of the plan.

There has to be a commitment to impart training in quality tools

To achieve quality improvement emphasis on the technical dimension is important. This includes a commitment that training in quality tools will be made available to all staff, quality tools will be used to measure quality and quality tools will be utilised to monitor improvements. The implementation plan must contain a strategy to ensure that all staff, beginning with the leaders of the service, have an opportunity to learn the use of quality tools and examine their clinical or medical practice on the basis of factual quantitative information and perceived deficits. Tools commonly used for quality control include data collection, histograms, pareto charts, Ishikawa diagrams, stratification, scatter plots and control charts.

Developing a "quality culture" is essential

The existence of a quality improvement plan is, in itself, meaningless if the organisational culture will not allow it to be implemented. For real development to take place, "people have to be developed". Quality circles, described as "the most exciting and profound approach to management since the advent of scientific management" ^{[ 1 ]}failed because they were tools of development which organisations used without developing either the people or the organisational infrastructure to support them ^{[ 2 ]}.

The cultural dimension of a quality improvement programme has been defined as the underlying beliefs, values, norms and behaviours of the organisation that support or serve as a barrier to organisation-wide improvement. Successful quality improvement requires a supportive organisation, culture that emphasises empowerment, flexibility and teamwork, rather than a culture that reflects a hierarchical and bureaucratic management structure.

Not paying adequate attention to an organisation’s internal customers or to the cultural factors necessary to support quality improvement initiatives will result in failure. On the other hand, an empowered workforce and a culture that encourages continuous learning will create in their turn greater improvements in the quality of service delivery. The obvious question is how does one foster the development of such a culture? This is something that must be addressed on an ongoing and continuous basis over the duration of a quality improvement plan.

There can be no quality improvement without measurement

Reliable, valid information is necessary for decision-making at all levels. This is true for any type of service business. In a high quality health care delivery system, it is not possible to determine the sources of systemic instability without information on customer satisfaction, customer expectations and patient outcomes.

Lack of objective measurement allows the illusion that "things are done well", and can encourage people within the system to make subjective judgements and criticise others for not doing things well. Since no one has any information to confront or contradict criticism, it becomes easy for people involved to deflect responsibility entirely or to shift blame without accepting responsibility to remedy the system’s flaws.

Measurement of quality-related activities can help to assist with evaluating improvement. They are not intended to be used to reflect an individual’s performance.

All staff of a health care organisation should be encouraged to get involved in performance measurement and analysis. A method of feeding back results of any measurement to all personnel is an essential part of a quality improvement system. This ensures that systemic deficiencies are identified, performances measured and processes and procedures improved.

From quality assurance to continuous improvement

The quality improvement plan should have a customer focus, incorporate good practice concepts and reflect principles of continuous improvement. The process should not stop at the point at which "inspection" occurs. Therefore, the method of quality assurance that ensures that certain aspects of care meet pre-set standards (without allowing the continuous quality improvement cycle to continue) is flawed and unsatisfactory.

Monitoring and evaluation of performance on a continuous basis is an essential part of a health care organisation’s quality improvement plan. Monitoring helps in recognising problems, deficits and gaps. However, a health care organisation’s intention should be to make sure that any identification of problems, deficits and gaps leads to improvement of the system. Adoption of the principle of continuous improvement will create a culture that fosters learning and change and places emphasis on developing the capacity to measure. A climate that encourages experimentation, change, empowerment and teamwork will thus be fostered and the service will learn continuously how to improve itself, how to meet the needs and expectations of its customers and how to overcome barriers to meeting those needs.

Some ground rules for implementing a quality improvement programme

It is acknowledged that the introduction of a continuous quality improvement programme in a health care organisation is dependent upon several factors. Health care organisations should be particularly concerned about the following factors:

Management structure should support implementation of a quality-driven system
A change in structure and functions of management may be required. For example, a vertically hierarchical system is unlikely to work effectively as it is important for the leaders in a quality-driven system to function both vertically and horizontally. In addition to focusing on work practices within their own sphere of influence, they must focus horizontally, on work processes across various teams. In addition to relevant clinical skills, which most people in the system will possess, this may require a common sense of mission and vision as well as training in quality improvement techniques.

Vertically, leaders should be less involved in decision-making and focus on developing a supportive environment and facilitating re-allocation of resources and personnel. However, they must retain direct responsibility for training and skills development. The decision-making authority should be located at the ground level of the organisational structure, where consensual rather than directive process should guide decision-making.

Concentrate on processes

In addition to performance, attention must be given to the processes that influence decision-making. Processes determine how well a system is functioning and determine the actions of people working in it.

Prepare for change

Quality improvement cannot be a one-off thing, which therefore becomes static. Its philosophy is one of incessant change. It involves working with high expectations and with what is available, including resources and, more importantly, people. Quality improvement requires developing a quality culture within the service which will support continuous quality improvement and encourage people within it to strive beyond just meeting pre-set targets and standards. This almost always means changing from "how things have always been done".

Consider role of customers

A health care organisation has a variety of customers. The models of care have to be based on customers’ perceptions of their needs and the customers should be able to provide feedback so that the organisational processes can be improved. However, designing services according to customers’ perceptions does not necessarily mean that the organisation has to "ask" its customers how to do things. It is the job of the organisation (and its staff) to "find out" about the customers’ perceived needs and expectations to ensure the development of innovative models of care and delivery. The customers’ role is to provide oversight and possibly regulation.

Be wary of the "best practice" syndrome

Best can always be made still better. Moreover, "best practice" in a service organisation cannot exist independently of clients’ needs and expectations, the strategic direction of the organisation and the limits of the available resources. Health care organisations must develop innovative ways of meeting customers’ needs, however, this can only be done within the resource constraints placed on the service. Best practice, whether in management or clinical processes, should never be panaceas to be applied indiscriminately.

Quality is the responsibility of all staff

All staff must participate in quality improvement activities and ensure that they contribute towards accomplishing the goals and targets in the organisation’s quality improvement plan. In fact, one key initial task for the leaders of health care organisations should be to ensure that structures involving all staff in quality improvement programmes are in place; all members of staff have a quality improvement plan of their own; and the service supports the participation of all staff in quality improvement-related activities.

Some practical strategies to achieve the goal of quality improvement

Ownership of vision, mission and critical factors for success

Developing a vision and a mission for the organisation is an essential, foundation ingredient in putting a quality improvement plan in place. To effectively organise a system and to meet the needs of both employees and patients, it is important that managers, staff and patients are all clear about what the organisation is trying to accomplish.

Once a vision has been created, it is essential that it is communicated to all staff. Further development and review of an organisation’s vision and mission should occur frequently and regularly with the involvement of as many of its stakeholders as possible. It is important that an organisation take into consideration the views and expectations of all its external and internal customers.

Finalising policies, procedures, guidelines, implementing core education and training modules and preparation of training packages

It will be difficult to find a health care organisation uncommitted to becoming a service provider delivering the highest quality of care. To achieve this aim, it is essential that all the necessary tasks are undertaken efficiently, effectively and consistently. This requires policies, procedures, pathways and guidelines that employees of an organisation can refer to. Once policies, procedures in place and documented, all such policies and procedures must be systematically reviewed on an ongoing and regular basis.

In addition, the organisation must also ensure that all staff have access to training and education to ensure they have the competencies to achieve the expected standards outlined in the organisation’s documentation.

Quality improvement at "input"

To improve quality at the level of input, health care organisations must not only provide effective and efficient care to its catchment population but also have the capacity to attract those people who are in need of health care but do not seek it because of stigma (or other barriers) related to the health care organisation. Obviously, funding and contractual arrangements restrict many organisations’ ability to influence these barriers, but all health care organisations can play a part in general health promotion and prevention in a variety of ways.

Quality improvement at the point of service delivery

Patients can require a wide range of services administered by several different sectors within the health care service. Many patients are often not able to negotiate services they need. Service delivery is further complicated because, currently, there is much fragmentation in the provision of services within the whole health care sector as well as within individual organisations.

Service delivery has to be in line with customer expectations. Therefore, health care organisations must solicit feedback and it is important to first define exactly what aspects the organisation wants data about. In any feedback exercise, it must be kept in mind that customers may not always tell the truth; replies may be biased; and questions and answers may be interpreted incorrectly. Moreover, customers will all give feedback from their own perspective. Therefore, considerations that are important to external customers may differ from customer to customer and also from what the organisation’s internal customers expect, which may again differ from the expectations of "funders" and the government.

The service delivered must be monitored on a regular basis and inspection is important. However, inspection must not be a disciplinary mechanism, rather it should be a process of problem identification, problem prevention, problem elimination and improvement of the service delivery system.

Improving methods of delivery of care

Both over-utilisation as well as under-utilisation of health care services creates dissatisfaction in the mind of customers and staff. There is often a tendency for organisations to blame staff for both over- and under-utilisation, whereas the cause of the particular problem may actually lie in "the system".

The short-sighted view of blaming staff for keeping a patient in hospital for too long and causing fiscal deficit, or for too short a time, thus placing too much stress on the community, might obscure the real causes of problems and, therefore, the possibilities for improvement.

The process under discussion requires improvement to be refined. The development of clinical pathways, clinical guidelines and triage protocols are examples of some processes that aid improvement.

Developing customer advocacy

The customers of a health care organisation include the patients and their significant others, referrers (eg, GPs and hospital specialists), the organisation’s staff and other health care providers. It is essential that health care organisations listen to all their customers.

Patient advocacy has great potential to affect and improve patient care. However, it is also important for organisations to clearly understand that patients are not the only customers of a health care organisation and it must pay adequate attention to the needs of these "other" customers as well.

Examining customer complaints and investigating adverse incidents is the preferred way for many organisations to get feedback from its customers. One major drawback of this is that these reports often highlight an individual’s performance but do little to highlight the system’s contribution to a problem. On receipt of a complaint or an incident report, the organisation has no option but to become defensive and try to justify their own practices and to prove that the concerns expressed were unjustified or exaggerated. If the allegations cannot be refuted, the staff involved directly in patient care are often blamed for the "incident" whereas the cause may be the system, eg, over work, inadequate staff numbers, lack of resources, lack of training or even lack of time. These issues need never be addressed under this approach and administrators can remain immune from taking any responsibility or having to try and institute system-wide changes.

Culturally appropriate services

It is important for health care organisations to consider the cultural needs and expectations of all cultural groups with which it may come into contact, whether it is with regard to food, building, other personal requirements or cultural and religious practices. For the organisation to be responsive to these needs it is important, first, that these needs and expectations are ascertained and, secondly, they are fulfilled.

The Ministry of Health has released an elaborate programme for evaluating whether health services are being delivered effectively to Maori. There is no reason why a similar programme should not, and can not, be developed and applied to individual services and population groups. In fact, there does not seem to be anything in this programme which non-Maori cultural groups would not value. The programme developed to deliver services to the Maori people can be used as a frame of reference to develop programmes of effective service delivery for other cultural and ethnic groups.

To develop a high quality service health care organisations have to develop in such a way that they meet the needs of their catchment population and, therefore, of all population groups.

Conclusions

It must be acknowledged that having a plan for service quality improvement does not automatically lead to improvements in quality. However, not having a clearly stated plan of action allows people to escape criticisms and deflect responsibilities.

Having a plan in place can some times delude the organisation into believing that a system is in place that guarantees improvement.

A good plan will help communicate an organisation’s vision and mission but it will only be useful if systems are then designed whereby the ideas in the plan are implemented or there is a commitment from leaders of the organisation that these will be implemented.

References

1. Hutchins D. Quality circles handbook, London: Pitman; 1985. p3
2. Hill S. Why quality circles failed but total quality might succeed. BJ Ind Rel 1991:29