Tools & Resources

Quality Improvement in Health Care

Quality Improvement (QI) can be defined as all activities that contribute to defining, designing, assessing, monitoring, and improving the quality of healthcare. These activities can be performed as part of the accreditation of facilities, supervision of health workers, or other efforts to improve the performance of health workers and the quality of health services.

Since 1990, the Quality Assurance Project, now the Health Care Improvement Project (HCI), has developed tools and methods based on quality management principles used in industry and applied them in the context of developing country health systems. Four core principles have emerged out of this experience to guide quality assurance in health care:

• Focus on the client: services should be designed so as to meet the needs and expectations of clients and communities
• Focus on systems and processes: providers must understand the service delivery system and its key service processes in order to improve them
• Focus on measurement: data are needed to analyze processes, identify problems, and measure performance
• Focus on teamwork: quality is best achieved through a team approach to problem solving and quality improvement.

Focus on the Client

Health services exist to meet the health needs of clients, so the delivery of health services should be designed to meet those needs. A focus on the client examines how and whether each step in a process is relevant to meeting client needs and eliminates steps that do not ultimately lead to client satisfaction or desired client outcomes. This focus on the client can be achieved by gathering information about clients and then designing services to cater to the needs that are discovered. Client-focused organizations meet client needs and expectations, thereby providing higher quality care. This encourages clients to return when they need additional care and to recommend the services to others.

A focus on clients not only involves people that come to a facility to receive services (referred to as external customers), but also addresses the work-related needs of personnel (referred to as internal customers) involved in the delivery of care. External customers include the people receiving the end product, or output, of a system. For example, patients are external customers of health care in a hospital. Internal customers are organizational members involved in the processes necessary to produce the output. Doctors, nurses, administrative personnel, and cleaning staff are all examples of internal customers in a hospital, and each is important in achieving the overall goal of quality care. Internal customers benefit from system efficiency by being able to perform their jobs better, thereby better meeting the needs of external customers.

Focus on Systems and Processes

Quality management views all work in the form of processes and systems. Systems are arrangements of organizations, people, materials, and procedures that together are associated with a particular function or outcome. As shown in the figure below, a system consists of inputs, processes, and outputs/outcomes. A process is defined as "a sequence of steps through which inputs from suppliers are converted into outputs for customers." All processes are directed at achieving one goal or output from the system that encompasses the processes.

Conceptual Model of a System

• Clinical algorithms: The processes by which clinical decisions are made
• Information flow processes: The processes by which information is shared across the different persons involved in the care
• Material flow processes: The processes by which materials (e.g., drugs, supplies) are passed through the system
• Patient flow processes: The processes by which patients move through the medical facility as they seek and receive care
• Multiple flow processes: Most processes are actually multiple flow processes, whereby patients, materials, information, and others are involved simultaneously in the same process of care.

In routine health care delivery, many processes occur simultaneously and involve many professional functions in the organization. Processes can cause inefficiencies due to problems that occur in the execution or the transition of one step to the next. Inefficiency in a process often results from unnecessary steps that add complexity, waste, and extra work to a system, ultimately reducing the overall quality of care.

Tools such as a flowchart help people understand the steps in a process. Processes also may be unclear and/or missing steps, and therefore in need of clarification. By increasing understanding of the processes and systems of care, QI activities can identify weaknesses and change processes in ways that make them produce better results.

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Focus on Measurement

In quality improvement, data are used to analyze processes, identify problems, test solutions, and measure performance. Data are important because they ensure objectivity. For example, the collection and analysis of data allow us to develop and test hypotheses. Comparing data from before and after a change can allow us to verify that the changes have actually led to improvements.

Specifically, measurement and data are used in qualilty improvement to:

• Identify opportunities for improvement to initiate QI efforts
• Detect and assess problems
• Verify possible causes of problems
• Inform decision making
• Show if a quality intervention yielded improvement and by how much
• Monitor processes over time to see if the change or improvement is maintained

Data may be quantitative in nature, such as service statistics, or qualitative, such as customer feedback or comments of health workers.

Focus on Teamwork

A team is "a high-performing task group whose members are interdependent and share a common performance objective" (Francis and Young 1992). Experience has shown that teams are important to QI for several reasons. First, processes consist of interdependent steps that are executed by different people, so the group working within a process will understand it better than any one person. Including key people in the improvement of a process often involves clarifying and incorporating the insights and needs of clients into health care delivery. The participation of major stakeholders improves the ideas generated, builds consensus about changes, and reduces resistance to change. Moreover, mutual support and cooperation arise from working together on an activity and can lead to increased commitment to improvement. Such an atmosphere of support discourages blaming others for problems. Finally, the accomplishments of a team often increase the members’ self-confidence. This empowers staff to work towards the goal of quality by motivating them to contribute their knowledge and skills to improve organizational and individual performance.

Additional Resources

A Modern Paradigm for Improving Healthcare Quality sets out the methodologies for four approaches to quality improvement (QI). The four approaches, which vary in the intensity of resources and time they require, are individual problem solving, rapid team problem solving, systematic team problem solving, and performance improvement. Activities/tools: systems view, evidence-based medicine, hierarchy of evidence, hypothesis testing, interpreting data variation, four steps to QI, continuous QI, Shewart's Cycle for Learning and Improvement (Plan, Do, Study, Act), matrix of QI tools, descriptions of 21 QI tools and activities with advice on when and how to use each.
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Russian
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Un Paradigme Moderne de l’Amélioration de la Qualité des Soins de Santé

Monitoring the Quality of Primary Care: Written for midlevel managers seeking to improve primary care at the facility level, this guide details one of the core activities of quality assurance: quality monitoring. The three-step approach to measuring quality is described and a running case example highlights the description of the approach. Activities/tools: Dimension of quality of care, systems view, steps and substeps of quality monitoring, prioritization matrix, flowchart, identifying standards that staff could appropriately monitor, selecting indicators, data collection methods and how to choose the most appropriate one(s), sample data collection tools, scoring provider performance and tabulating results, interpreting and using results from quality monitoring, and disseminating results.
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Le Monitorage de la Qualité des Soins de Santé Primaires
Vigilancia de la calidad de la atención primaria

Monitoring the Quality of Hospital Care: This guide looks at a hospital as having a series of interactive systems, each with inputs, processes, and outcomes. It explains how to determine which processes or outcomes to monitor and then outlines two quality monitoring approaches: the "Quick Start" for monitoring a few indicators for a short period and "Implementing a Monitoring System" for developing an ongoing, multi-indicator method. Both approaches are highlighted with a running case example. Activities/tools: Systems view, taxonomy of health system standards, defining an indicator and its data source(s), presenting data with a line or bar chart or tables, flowcharts, fishbone diagram, dimensions of quality, steering committee action plan, vision statement and organizational structure, prioritization matrix, communications plan, analysis and action plan, and monitoring tool. Appendices include "Use of Specific Standard Formats," Infection Control Administrative Policies," "Pharmacy Department: Medication Errors," "Standing Operating Procedures: Medication Errors," "Five Processes of Care That Affect the Risk of Surgical Site Infection," and others.
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Helping Healthcare Providers Perform According to Standards: This work examines the principles for designing interventions to increase adherence to standards. It describes the main approaches and interventions that have helped providers meet clinical and administrative standards and summarizes the findings of studies evaluating the effectiveness of those interventions.
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How Can Self-Assessment Improve the Quality of Healthcare?: Many healthcare providers in developing countries work without supervision. While self-assessment can be a lost-cost alternative to certain methods of supervision, any alternative must be effective as well as inexpensive. This paper reviews several studies of various kinds of self-assessment interventions and can help policy makers decide what kind of self-assessment program to implement and how to do so.
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Measuring the Competence of Healthcare Providers: This paper reviews studies that examine the link between competence and performance. It explains how competence is acquired, discusses issues underlying behavior change, and describes several assessment methods.
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The Use of Manual Job Aids by Health Care Providers: What Do We Know?: This literature review summarizes quantitative and qualitative research on difference healthcare job aid formats (excluding those used for counseling patients) and their effect on provider performance.
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