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Background to quality in UK healthcare
“Safety, effectiveness, patient centeredness, timeliness, efficiency & equity”1 are words which combine to form a comprehensive definition of quality in healthcare. It is only in recent years that there has been a concerted push towards truly improving quality in the National Health Service (NHS). A drive towards quality improvement (QI) is usually driven by an industry ‘wake up call’. In the NHS, this call came from the exposure of significant failings in patient care in certain trusts and departments across the UK.2–4 Since then, there has been huge progress in improving the care for our patients, with greater clinical governance and standards,5 ,6 regulation7 and focus on safety.8–10 However, we are yet to become a healthcare system which truly learns from its mistakes, shares its learning and is dedicated to continual improvement.11 ,12
Audit alone cannot bring about continual improvement. True QI methodology is poorly understood and poorly used. In this article, we discuss how to undertake QI and suggest how it might be integrated into GUM and HIV services.
Understanding the quality of care we provide is the lever to delivering improvement work in our services. Four deceptively simple questions, which encompass audit and QI, can be used to comprehensively assess care delivered. These questions will be further explored throughout the article:13
Do you know how good you are?
Do you know how good you are relative to the best?
Do you understand your variation?
Can you demonstrate your rate of improvement over time?
Audit as branch of QI
Since 1989, when systematic use of clinical audit was strongly supported by the White Paper ‘Working for Patients’,14 audit has been applied as a methodology to improve healthcare service. At national and local levels, audit has raised both excellence and discrepancies in care in sexual health15 ,16 and HIV services and it remains an annual requirement of all GUM trainees.17
Audit is a branch of QI and helps answer the first two of the four questions. It establishes the baseline from which to improve (‘Do you know how good you are?’) and national audits allow us to benchmark our local services (‘Do you know how good you are relative to the best?’). Audit is also a useful quality assurance tool, for example, checking a service's compliance with National Institute for Health and Care Excellence (NICE) guidelines.
However, audit leads to only modest change in practice18 ,19 and is not enough to improve the quality of care. Audit usually relies on only two data collection points (pre and post an intervention) and this approach to measurement cannot provide evidence to answer the third question (‘Do you understand your variation?’). In fact, one study showed that only 22% of audits led to reaudit.20 Even when reaudit occurs, audit cannot demonstrate improvement. One data point after an intervention does not provide evidence of sustained improvement (‘Can you demonstrate your rate of improvement over time?’), but instead may lead to false reassurance that improvements have occurred.
What is QI?
More than audit, successful QI is a team-driven exercise, making the most of the skills and intricate service knowledge of the multidisciplinary workforce. There should be an understanding of team dynamics and behaviours in the same way we analyse human factors following a resuscitation.
Formally, QI is defined as a change (improvement) combined with a method to deliver better outcomes.21 Effective QI results in better patient (and population) health, better system performance and professional development.22 The process, through real-time continuous measurement, provides evidence of sustained improvement.23
QI methodology was initially developed to quality control production in industry. The recent diffusion to healthcare has been led by the Institute of Healthcare Improvement (IHI).24 Rapid spread is being actively encouraged and facilitated by organisations such as The Health Foundation21 as well as early organisational adopters, such as Salford Royal Hospital.25 However, the methodology still remains an unknown concept to many healthcare services.
There are several recognised improvement methodologies.26 ,27 However, in this article, we will show how the IHI's Model for Improvement28 can be used as a framework for accelerating and embedding improvement.
QI methodology
The Model for Improvement
The Model for Improvement28 (figure 1) was developed by the Associates in Process Improvement and has been adopted by the IHI. The framework has three questions which act as pathway through the improvement work.
The Model for Improvement.
“What are we trying to accomplish?” The aim of any improvement work is the starting point. Aims should be explicitly defined at the outset. The acronym SMART29 (specific, measureable, achievable, relevant, time bound) is a useful structure to aid aim setting. An aim should provide clarity, guide measurement, engage stakeholders and build accountability. The aim should not be achievable in a week or month but be an aspiration which promotes enthusiasm for the work.
“How will we know change is an improvement?” Batalden stated “All improvement will require change, but not all change will result in improvement.”22 Measurement is needed to understand whether a change (intervention) leads to improvement. QI measurement is rigorous, frequent and contemporaneous. The measurements should paint a picture of the system's normal variation and demonstrate sustained improvement only when serial data points reach the aim. QI is not research and large sample sizes are not required. Samples sizes should be just good enough to demonstrate if a problem exists in the system.
“What change can we make that will result in an improvement?” Changes need to be made to a system in order to bring about improvement. Rarely will one single change result in improvement. The Plan, Do, Study, Act (PDSA) cycle30 (figure 2) is a method through which the effect of a given change can be tested. The planning stage (P) requires the user to predict the consequences of the change and consider how they will evidence that this change has led to an improvement. This evidence (usually measurement) is then studied and used to evaluate whether to adopt the idea and change the system accordingly. Tests of change are small and build up over time continually using measurement to guide the scaling up. The concept of ‘pilot’ and then ‘roll out’ is at odds with a QI approach, which recognises that ideas and improvement strategies need to be thoroughly tested in all different environments.
The Plan, Do, Study, Act (PDSA) cycle.
Figure 3 shows a simple worked example of an aim, PDSA cycle and run chart for a QI project within HIV medicine.
A worked example of a quality improvement project. PDSA, Plan, Do, Study, Act.
How can QI methodology be integrated into GUM and HIV services?
A literature search has demonstrated that QI projects have rarely been undertaken within sexual health and HIV services. One exception is work undertaken at Chelsea and Westminster to improve HIV testing within their emergency department.31 This work used real-time, continuous measurement to increase HIV testing.
Lack of QI knowledge and its methodologies hinders its application across the NHS. However, most junior doctors now need to undertake QI as part of their curriculum.32 Many consultants are equally unaware of QI methodologies, rendering them unable to supervise. To aid the integration of QI into sexual health and HIV services, it needs to be a requirement of specialist registrar training and consultants need to upskill and advocate its methodology, with courses33 and online resources to aid this.34 QI is a team exercise and uses the expert resources of the wider multidisciplinary team. Teaching, training and inclusion of the multidisciplinary team are vital.
Following training, there needs to be local support for the application of QI. Most trusts will have clinicians or non-clinicians with QI experience available to support services. Some hospitals have used the IHI's Breakthrough Series Collaborative (BTS),35 which is “a short term learning system that brings together a large number of teams from hospitals or clinics to seek improvement in a focused topic area.” This may be hard although not impossible to achieve across sexual health and HIV services, or where BTS exists within current organisations, sexual health and HIV services should strive to be involved.
However, ultimately services need to have the confidence to start using QI where audit previously existed. Only by getting started and consistently using QI, will its benefits be seen and true improvements realised. Training alone is not enough. Other critical success factors to consider if QI is going to be successful include stable leadership, executive support, robust governance structures and some existing QI capabilities.36 Without these, QI runs the risk of not delivering its potential impact. Successful QI includes team work, creativity and enthusiasm. It should neither be regarded as dull, a chore nor an ‘after work job’ but be given time within our daily work, becoming our core business for improving quality.22
Conclusion
Berwick stated that “The NHS in England can become the safest health care system in the world” but the “most important single change in the NHS would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”12
QI can deliver greater and more sustained improvement. Its methodologies are not complex but remain a relatively new concept in a healthcare system where audit is ingrained. Seeking teaching, training and then application of this methodology at local and national levels will start the spread of QI within our specialty.
Footnotes
Contributors Both authors contributed to the writing of this article.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
▸ References to this paper are available online at http://sextrans.bmj.com