Contemporary Themes in

Healthcare Policy and Practice

Quality Improvement
Week 6 session 2
Contemporary Themes in
Healthcare Policy and Practice
Module Leader- Martin McCracken-Joyce
Martin.Joyce@london.aru.ac.uk
By the end of this session
LO 4 – Analyse and critique themes and best practice in Healthcare
Management
• Identify and analyse the
nature of quality of
healthcare and quality
improvement
What is quality improvement?
Quality improvement is a
systematic approach to
improving health services and
the quality of care and
outcomes for patients based
on iterative change,
continuous testing and
measurement, and
empowerment of frontline
teams (Kings Fund, 2017).
Defining quality
• Quality is often difficult to define as it is subjective and
individuals have their own interpretation of its meaning. High
quality care provision is care delivery that meets a certain
standard of excellence that is acceptable to everyone.
• A clear definition is dependant on two sets of factors: intrinsic
and extrinsic –
• Intrinsic relates to values, beliefs, attitudes and self-knowledge
• Extrinsic relates to time, money, people and other resources
(Gopee & Galloway 2017)
Defining quality
• ‘the measurement of actual level of service provided plus the
efforts to modify when necessary the provision of these
services in the light of the results of the measurement’
(Williamson 1979)
• ‘all activities undertaken to predict and prevent poor quality’
(Øvretveit 1992)
• In nursing: ‘purpose of is to assure the consumer of nursing of
a specified degree of excellence through continuous
measurement and evaluation’
(Schmadl 1979)
Maxwell’s elements of quality theory
• Acceptability
• Accessibility
• Appropriateness
• Effectiveness
• Efficiency
• Equity
Donabedian’s theory
• Donabedian’s (2005) three components approach for
evaluating the quality of care underpins measurement for
improvement. The three components are structure, process
and outcomes. Measurement for improvement has an
additional component – balancing measures.
• Donabedian believed that structure measures have an effect
on process measures, which in turn affect outcome
measures. Together these form the basis of what is required
for an effective suite of measures. The reality is that cause
and effect are more complex, particularly within the NHS
with so much variability in individual patients. The selection of
relevant measures can be developed using driver diagrams.
The Donabedian model for quality of care

Structure Process Outcome

• Physical and • Focus on the • Effect of
organisational care delivered healthcare on
characteristics to patients the status of
where e.g. services, patients and
healthcare diagnostics or populations
occurs treatments
Drivers of quality in healthcare
• Cost
• Error/Patient Safety (To Err Is Human: Building
a Safer Health System)
• Effectiveness
• Consumerism
(Wakefield 2008)
asserts that the problem is not bad people in health care--it is that good
people are working in bad systems that need to be made safer
Quality at different levels

International (WHO)

National (CQC)

Organisational (NHS
Improvement)

Local
Why is quality improvement important?
• Quality improvement tools
can play a key role in
improving health care,
including improvements in
time-savings, timeliness of
service provision, cost
reductions and a decrease in
the number of errors or
mistakes.
• At a time of severe financial
restraint, rising demand for
services and significant
workforce pressure, quality
improvement approaches
offer opportunities to
improve the quality of care
and increase productivity.
Activity – What high
quality care means to Clinical effectiveness
me
If a close family member
became a patient what
type of service would Patient safety
you like them to
achieve? Focus your
thoughts around the
three domains of Patient experience
quality as outlined in
the 5YFV (NHSE, 2014):
Break
CQC 5 key questions
• Safe: you are protected from abuse and avoidable harm.
• Effective: your care, treatment and support achieves good
outcomes, helps you to maintain quality of life and is based on the
best available evidence.
• Caring: staff involve and treat you with compassion, kindness,
dignity and respect.
• Responsive: services are organised so that they meet your needs.
• Well-led: the leadership, management and governance of the
organisation make sure it's providing high-quality care that's
based around your individual needs, that it encourages learning
and innovation, and that it promotes an open and fair culture.
• (CQC, 2018)
NHS 5 key domains
• Domain 1 - Preventing people from dying prematurely
• This domain captures how successful the NHS is in reducing
the number of avoidable deaths.
• Domain 2 - Enhancing quality of life for people with long-
term conditions
• This domain captures how successful the NHS is
in supporting people with long-term conditions to live as
normal a life as possible.

(NHS England, 2013)

NHS 5 key domains
• Domain 3 -Helping people to recover from episodes of ill health
or following injury
• This domain captures how people recover from ill health or injury
and wherever possible how it can be prevented.
• Domain 4 - Ensuring that people have a positive experience of
care
• This domain looks at the importance of providing a positive
experience of care for patients, service users and carers.
• Domain 5 - Treating and caring for people in a safe environment
and protecting them from avoidable harm
• This domain explores patients safety and its importance in terms
of quality of care to deliver better health outcomes.
(NHS England, 2013)
Activity – In groups compare and contrast the CQC key
questions with the NHS 5 key domains.

1. Note the similarities and differences

2. Do they complement each other?
3. Think of a healthcare setting; how would you include the
CQC and NHS requirements in internal policy?
Quality frameworks
• A framework for evaluating and continuously
improving the quality of services. It shows key
concepts and the relations between them to
guide analysis or other actions”
• Puts structures on the processes that go to
ensure quality

Standards Audit Certification

Examples of frameworks

A Systems Framework for Healthy Policy

Plan-Do-Study-Act Cycle
The PDSA cycle, also known
as the Deming Cycle, is a
continuous quality
improvement model based on
sequences of four steps .
Deming’s (1986) four principles

APPRECIATION OF A UNDERSTANDING THE PSYCHOLOGY OF KNOWLEDGE ABOUT

SYSTEM THEORY OF CHANGE VARIATION
KNOWLEDGE
Deming’s (1986) four principles
• Deming described how the principles of profound knowledge are used
in practice to improve quality through the Shewhart Plan, Do, Check,
Act (PDCA) cycle (Dale 2003) of continuous improvement consisting of:

• Planning based on external evidence and internal performance data

that are used to predict how an intervention will make an improvement
• Doing the implementation, using the psychology of change
• Checking resulting effects on the system, whether the desired results
occur
• Taking action to fully implement the changes or plan a new
intervention

(Baillie & Maxwell, 2017)

PDSA Cycle
Step 4 : Act
• Adopt if solution has worked
• Adapt if some benefits realised
• Abandon if it hasn’t worked
Step 1 : Plan
• Describe the issue?
• What outcome do you want?
• How will you measure any improvement?
• Plan what you are going to do differently
• ‘who, what, where, when and how’

Act Plan

Study Do
Step 2 : Do
Step 3 : Study • Carry out the plan and collect
• Observe the results information on what worked well and
• Analyse the data what issues need tackling
• Compare to predictions
• Summarise learning
PDSA Video
PDSA Activity
GROUP ACTIVITY 6.1

• Go to
http://www.ihi.org/education/IHIOpenSchool/Courses/Doc
uments/QI102_exercise.pdf and practice planning an
improvement project.
• Ask a partner to review your work, using the reviewer
questions as a helpful guide. Refine your worksheet based on
peer feedback.
Discussion
• How did you select your aim, measures, and changes?
• What is your level of confidence you will be able to make this
change?
• How do you think having this written plan will help you?
• What did you learn during this activity?
References
• CQC, 2018 https://www.cqc.org.uk/what-we-do/how-we-do-our-job/five-key-questions-we-ask
• Langley, K, Nolan, K and Nolan, T et al. (1996) The Improvement Guide: A Practical Approach to Enhancing
Organisational Performance, San Francisco: Jossey-Bass
• NHS England, 2013 https://www.england.nhs.uk/wp-content/uploads/2013/12/stra-op-how-to-
guide1.pdf
• Hudson P. (2003) Applying the lessons of high risk industries to health care Qual Saf Health Care 12(1)
• Irvine D., Leatt P., Evans M.G. & Baker R.G. (1999) Measurement of staff empowerment within health service
organisations. Journal of Nursing Measurement, 7(1), 79–95.
• Kanter, R. M. (1993) Men and Women of the Corporation. NY: Basic Books.
• Kanter, R. M. (1993). Men and women of the corporation. New York, NY: Basic Books, Inc.
• Northouse, P.G. (2007) Leadership: Theory and practice, 4th ed.
• The Institute for Healthcare Improvement has lots of information on improvement models and PDSA cycles
(www.ihi.org).
• Øvretveit, J & Gustafson D. (2002) Quality improvement research: Evaluation of quality improvement
programmes. Qual Saf Health Care 2002;11:3 270-275 doi:10.1136/qhc.11.3.270.
• Images from unslaph.com