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Introducing healthcare improvement

Introduction

This OpenLearn course provides a sample of postgraduate study in Health and Social Care.

In this free course, Introducing healthcare improvement, you will be exploring what is meant by the terms ‘quality’ and ‘quality improvement’ in the context of healthcare. You will consider what constitutes the key dimensions of healthcare quality that improvement initiatives typically target. You will be introduced to some key ideas from the academic literature on healthcare improvement and encouraged to reflect on your own personal knowledge and experience of healthcare.

This OpenLearn course provides a sample of postgraduate study in Health and Social Care.

Learning outcomes

After studying this course, you should be able to:

define what is meant by quality improvement in healthcare

describe the different dimensions of quality improvement in healthcare.

1 Defining and evaluating quality improvement in healthcare

There are many different definitions of ‘quality’ in healthcare across the different health systems in the world. For example, NHS England considers high quality care to consist of care that is safe, clinically effective and has a positive experience for the patient (NHS England, n.d.a). Going beyond the definition of quality, it is important to note that the process of improving healthcare also involves defining the important aspects of quality improvement as well as evaluating the standards achieved currently. We shall examine both of these processes (defining and evaluating quality improvement). Firstly we will tackle the question of ‘what is quality improvement?’

1.1 Defining quality and quality improvement in healthcare

Definitions of ‘quality improvement’ tend to be broad to reflect the diverse range of stakeholders involved in healthcare (such as patients, carers, family members, healthcare staff, managers and educators). Batalden and Davidoff (2007) propose that quality improvement is:

…the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning…)

(Batalden & Davidoff, 2007, p.2)

Activity 1

This definition of quality improvement identifies three areas that may result in positive change after an improvement intervention:

patient outcomes (health)
system performance (care)
professional development (learning).

Thinking about what these three areas mean (in relation to the healthcare system with which you are most familiar), what do you consider to be important examples of each of these three areas? You may want to use an internet search to see what aspects of your healthcare system are being subject to quality improvement interventions.

Discussion

Your answers will inevitably reflect your healthcare system and context. Here are some examples from the UK NHS context.

Examples of patient outcomes (health): Essentially, this addresses how you would know whether the healthcare service is improving the health of the population. So you might want to record and monitor:

prevalence rates (the proportion of people in the population who have an illness or condition) for obesity, diabetes, hypertension, depression, asthma, dementia and many more conditions
survival rates of people with cancer and long-term or chronic conditions
average life expectancy for different groups in the population (females, males and ethnic minorities) may also provide useful information about the health outcomes of the population.

Examples of system performance (care): This addresses how you would know whether the healthcare service or system is doing its job effectively and efficiently. So you might consider:

waits and delays in the system, such as how long a patient has to wait until they can get an appointment with their GP, practice nurse or any other healthcare professional
the number of patients who get readmitted to hospital soon after discharge is also monitored to indicate whether people are being discharged safely from hospital
patient complaints about their healthcare service could indicate whether the system is performing well.

Examples of professional development (learning): This aspect addresses whether staff working in healthcare settings are continuing to learn, sharing knowledge, developing skills and training so that the care they offer is of high quality. So you might want to survey staff about:

whether they have access to resources (such as books, journals and conferences) to keep up-to-date with their field and any developments in patient care
whether they are satisfied with their training and their continuing professional development opportunities related to improving quality and safety.

1.2 Evaluating quality improvement in healthcare

Defining quality improvement is the first stage of improving healthcare. After we have defined what quality is, we then have to evaluate healthcare in line with this definition. Evaluating healthcare is about judging the standards that are achieved and whether they match the standards we expect or want. For example, we might assess whether our healthcare service is providing safe, clinically effective care that is a positive experience for the patient in line with the goals of NHS England. We use these definitions of healthcare quality to help us evaluate services and the results of these evaluations help us design ways to improve care in the future. Activity 2 invites you to evaluate the healthcare quality using a short case study.

Activity 2

Read this research brief from RAND Europe (Martin et al., 2013) about integrated care quality improvement pilots. Integrated care broadly means the capacity for different parts of an organisation (departments or staff groups) to work together to offer good quality care. It also includes the capacity for healthcare professionals to work with social care professionals to offer a joined-up service. This research brief looks at the set of 16 quality improvement pilot studies and determines if they were successful at improving healthcare quality on the whole. Look through the report and consider the three aspects of quality improvement interventions according to Batalden and Davidoff (2007).

What does this research brief indicate about how successful these integrated care pilots were for

the patients
healthcare system performance
the staff professional development/learning?

Note down what may have been a positive change and what may be a negative change.

Discussion

1. The patients
Positive changes	Negative changes
A greater number of patients received a care plan.	Patients reported that they were less likely to see the GP or nurse they preferred.
More patients understood their coordination arrangements.	Patients felt less involved in decisions about their care.
More patients understood their follow-up plan after they left the hospital.	There was a drop in the number of patients who felt that they were listened to by social services.

2. Healthcare system performance
Positive changes	Negative changes
Staff felt that they worked more closely with their team members.	There were no reported negative changes but 40 per cent of staff thought it was ‘too early to tell’.
Staff they had better communication with colleagues and with other organisations.
Staff reported that their teamwork and communication improved.

3. The staff professional development/learning
Positive changes	Negative changes
There was a 9 per cent reduction in hospital costs at some sites.	Emergency admissions increased.
	There was no overall cost saving to introducing the pilots.

2 Six aims of quality in healthcare

One of the most important definitions of high quality care was established in 2001 in the USA. The Institute of Medicine released a report entitled Crossing the Quality Chasm: A New Health System for the 21st Century (2001). This report outlined six dimensions of high quality care that should inform the development of quality improvement initiatives. As a result, these six dimensions of quality are sometimes also referred to as aims for improvement. The Institute of Medicine also stated in their report (2001) that healthcare providers should measure and monitor the quality of the care they offer in relation to these aims so that this information can help target quality improvements at the right aim. The six aims are that healthcare should be:

safe
effective
patient-centred
timely
efficient
equitable.

These aims have also been adopted as a framework by the World Health Organization (2006) and by healthcare providers around the world. For example, the Healthcare Quality Strategy for NHS Scotland (Scottish Government, 2010) is explicitly based on these aims for improvement.

The Institute of Medicine also stated in their report (2001) that healthcare providers should measure and monitor the quality of the care they offer in relation to these aims. Monitoring healthcare quality allows any quality improvement initiatives to focus on specific aims for improvement. We shall now consider each aim in turn and reflect on what they mean for quality improvement in practice.

2.1 Safety in healthcare

Safety in healthcare refers to the reduction of risks and the minimisation of harm to patients.

The following video outlines how a team working in hospital surgery responded to greater numbers of Never Events. A Never event is a preventable or avoidable event that did, or could have, caused a patient serious harm or death. For example, the current list of Never Events in the NHS (England and Wales) includes conducting surgery on the wrong part of the patient (wrong site surgery) and leaving instruments in the patient after surgery (retained instrument post operation; NHS England, n.d.b).

Activity 3

Watch this video about improving safety.

Download this video clip.Video player: Improving patient safety

Show transcript|Hide transcript

Transcript: Improving patient safety

[MUSIC PLAYING]

Iain Moppett:

So Change programme has been looking at improving the safety of patients in theatres. We had a run of a lot of never events a few years ago. And that really focused our mind on how to improve the care that we’re providing our patients.

Maria Shallow:

We basically asked the teams to see what ideas that they thought and that they could come up with and, obviously, also listened to staff on the ground floor. We also put in a patient safety lead. We’ve had different leads going through the last few years with our ideas.

Iain Moppett:

Well, a good example of that is the emergency laparoscopy project which we’ve been doing, where the idea of how to improve was taken from an evidence base but was very much driven by medical staff and by theatre staff saying, well, look, we know what the problems are with the way these patients come through theatres. We know that they get delayed. They’re not getting the scans as quickly as they might do. Let’s look at how we can make that better.

And they really got together, developed that, been supported by management. But they’ve very much driven that from the ground up. They’ve seen the problems, and they’ve tried to resolve those.

Yuliya Johnson:

Patient safety champions, they’ve been introduced in a Nottingham hospital for a few years now.

Maria Shallow:

We have 47 operating theatres. And each theatre has a champion assigned in that theatre that works for the team and is able to champion the safety agenda within each theatre, so looking at the safety WHO checklist, looking at the quality of what we’re doing in terms of the briefings and debriefings.

Alison Adkin:

My role is to oversee the patient safety champions, listen to what is happening on the ground floor within theatres. So I have the time to facilitate training, encourage staff to engage with the five steps, also organise the champions, and feed up to the governance programme within theatres.

Yuliya Johnson:

I think patient safety champion role makes it easier for governance team and for patient safety leads to communicate with every theatre and to cascade the messages of safety down to every member of the team.

Alison Adkin:

The introduction of the patient safety lead role has impacted not only the five steps but the engagement with the WHO checklist while the patient is in the anaesthetic room. And I think for patients, that gives them the assurance that everything is checked. And their operation is absolutely confirmed.

Iain Moppett:

The most innovative feature, I think, actually, is putting it all together. It’s not that any one thing is a magic bullet, which is sorting something out - but I think what we’ve done is said, actually, we’re going to do, it’s all of these bits together. We’re going to listen to our staff. We’re going to find out what the problems are. We’re going to focus on getting the mandatory training right. And we’re going to try to learn from our incidents.

Yuliya Johnson:

Currently, with the patient safety champions, we manage to access our incidents database quite quickly. We can share learning from our incidents between the floor staff.

Iain Moppett:

In terms of impact, I think there’s different ways to measure that. Clearly, we started off looking at never events in surgery. And those have dramatically reduced. And that’s a clear evidence of impact.

Yuliya Johnson:

People found their voices, and people found the places where they can voice their opinions about patient safety. And there are so many levels that it could be utilised there.

Maria Shallow:

Without the empowerments, I don’t feel that you get effective change. So as leaders, we can say about a change that we’d like to happen. But actually, the ground floor staff are the ones that are actually going to be able to embrace that change and go along with the change that you’re wanting to make. And everybody feels, that actually, in our theatre teams, that we deliver a high quality-led service. And that we do the best for our patients.

[MUSIC PLAYING]

End transcript: Improving patient safety

Download

Improving patient safety

Interactive feature not available in single page view (see it in standard view).

1. What are the key messages from this video?

2. Thinking about what you have learnt from this video, can you think of any ways to monitor the safety of healthcare?

Discussion

1. The video highlights the importance of patient safety ‘champions’ or ‘leads’. The practitioners featured emphasise the importance of listening to staff and empowering practitioners, of sharing learning in the team, and of collaboration between different professionals.

2. Investigating any instances of Never Events occurring in a hospital could give one indication of the safety of the healthcare.

The interactive guide ‘In Safe Hands’, produced by Health Education England (HEE), offers guidance and examples of how healthcare workers can adopt safe clinical practice and improve the safety of patients in the care sector.

2.2 Effective care

In the context of healthcare, effectiveness can be defined as selecting the appropriate methods and approaches to achieve the desired outcomes. Sometimes this facet of high quality care is also referred to as clinically effective care. Typically, effective or clinically effective healthcare adheres to an evidence base in which the treatment or care has shown proven benefits for patients or communities. Similarly, the use of treatments or care which have not shown evidence of working should be avoided.

Activity 4

The Health Foundation has created a quality improvement report on Dementia care. Read the Key findings (on pages 6-12) in the report summary (Health Foundation, 2011).

List all the treatments or care recommendations that have been cited in the key findings which would make dementia care more effective.

Discussion

Providing early diagnosis in memory clinics
better community support for people with dementia and carers (such as respite care)
psychosocial interventions to improve knowledge and reduce stress
staff training to address behavioural problems in people with dementia
GP training in diagnosing dementia
trying to minimise the risk of admission to hospitals
reducing the number of inappropriate drugs that people with dementia are prescribed.

2.3 Patient-centred care

Figure 1 Patient-centred care transcends the patient’s age.

Show description|Hide description

A lady in medical clothing is giving a young girl a high five on a hospital ward.

Figure 1 Patient-centred care transcends the patient’s age.

One of the most consistent dimensions featured in definitions of healthcare improvement is patient-centred care (this phrase is most typically used in the US literature). This takes into account the preferences and desires of patients and acknowledges and respects their cultural background. Person-centred care is a related term (commonly used in the UK) but generally refers to the whole person (going beyond the narrow focus on their symptoms and treatment) and advocates a holistic approach to care which requires acknowledgement of wider social, psychological, societal and cultural factors that may affect the individual and their healthcare journey.

Activity 5

Watch this video about person-centred care.

Download this video clip.Video player: Person-centred care

Show transcript|Hide transcript

Transcript: Person-centred care

[MUSIC PLAYING]

What is person-centered care? Person-centered care is where health and care professionals work collaboratively with people using their services and their communities.

What does that actually mean? It means that care is coordinated, tailored to the needs of the individual, underpinned by dignity, compassion, and respect and enables them to live a fulfilling life.

Seems like a no-brainer. Don’t we already do that? Actually, it’s not standard practice, but it should be. Is it worth it? In a word, yes.

Person-centered care can have lasting benefits. There is evidence that it improves health outcomes, care quality, and patient experience.

On the professional side, it enhances staff satisfaction. If we want to adopt it, fundamental changes to care are required.

How do we put it into practice? There are lots of things we can do to develop people’s roles in health services and to unlock that person-centered potential to get health and care services working better together and to help people to have the knowledge, the skills, and the confidence to work differently with their health and the NHS.

[MUSIC PLAYING]

End transcript: Person-centred care

Download

Person-centred care

Interactive feature not available in single page view (see it in standard view).

What are the main elements of person-centred care?
What are the benefits – for patients and staff?

Discussion

According to the video, person-centred care is coordinated, tailored to the needs of the individual, underpinned by dignity, compassion and respect, and enables the individual to lead a fulfilling life. It improves care quality, health outcomes and patient experience. It also enhances staff satisfaction.

2.4 Timely healthcare

Figure 2 Healthcare should take place promptly for the benefit of the patient, the healthcare provider and system.

Show description|Hide description

A pocket watch being held in someone’s hand.

Figure 2 Healthcare should take place promptly for the benefit of the patient, the healthcare provider and system.

Timeliness is a key component to high quality care. Timely care should minimise waits and delays in care or services, such as being admitted to hospital, receiving healthcare appointments, undergoing tests, and in receiving test results.

Activity 6

In the case of England, we can explore the timeliness of a number of healthcare services over time by looking at the data collected on these services to determine the healthcare quality. Take a look at these graphs showing the waiting time for diagnostic tests or procedures (Quality Watch, 2016). Diagnostic tests or procedures are often required before a patient can be referred to another service and so shorter waits on these tests or procedures are indicative of better quality care.

What does the first graph show about the timeliness of the service for diagnostic tests from January 2006 to January 2014 – does it appear to have improved or worsened over time and what are the reasons given for the changes?
In the second graph, what is the median waiting time for a diagnostic test in July 2014?
The third and final graph shows the number of people who are on the waiting list for a diagnostic test or procedure. What effect did the change that took place in 2008 appear to have on the waiting list?

Discussion

The proportion of people waiting more than 6 weeks and more than 13 weeks reduced sharply in 2008 and continued to remain at a similar level during this time period. This indicates waiting times decreased and therefore timeliness appears to have improved in this respect. A likely cause for this change is the introduction of a six-week diagnostic waiting time target by the Department of Health in 2008.
The median is approximately two weeks.
The size of the waiting list in England reduced from approximately 810,000 in January 2006 to 411,000 in March 2008. This indicates that the amount of people who received a diagnostic test or procedure according to this graph almost halved. From 2009, the number of people receiving diagnostic tests and procedures has increased.

2.5 Efficient care

Figure 3 Efficient healthcare includes getting the most benefits out of the budget available.

Show description|Hide description

A calculator with three stacks of coins next to it. A stack of 2ps, a stack of 20ps and a mixture of pennies, silver coins and a pound.

Figure 3 Efficient healthcare includes getting the most benefits out of the budget available.

Efficient care means that it should be cost effective and not wasteful. Healthcare providers always need to be concerned about costs and value for money, but increasing demand and pressure on resources has led to an even greater emphasis on improving efficiency in recent years. For example, a report on the funding pressures facing the NHS includes the following conclusion:

This analysis suggests that without unprecedented, sustained increases in health service productivity, funding for the NHS in England will need to increase in real terms between 2015/16 and 2021/22 to avoid cuts to the service or a fall in the quality of care patients receive. This could be avoided if the government were to return the NHS in England to funding growth at the historic (pre-2010/11) average rate of four per cent a year in real terms. However this is highly unlikely, with further cuts to total public spending already planned until 2017.

(Nuffield Trust, 2012)

Activity 7

Let’s consider this report by John Øvretveit for The Health Foundation entitled ‘Does improving quality save money?’ (2009). Turn to the abstract on pages ix and x.

Note down all of the points raised in this abstract about the link between improving quality and saving money.

Discussion

Poor quality care is common and is costly – there is a financial and human cost to poor quality care.
Interventions to improve quality have varying costs and some can be quite costly.
Not all interventions are effective and therefore, these will not be cost effective.
Much of the research Øvretveit examined did not include the cost of the quality improvement intervention and so the cost effectiveness is undetermined.
Managers and policy makers should be sceptical when the intervention costs are not outlined, but should seek to adopt interventions with evidence for effectiveness and savings.
More research should be provided about effective interventions, their cost and the support they need to be successful and result in savings.

Adapted from Øvretveit (2009)

2.6 Equitable care

Equitable care means delivering care that does not differ in quality according to characteristics of the patient or patient group such as their age, gender, geographical location, cultural background, ethnicity, religion and socioeconomic status.

Activity 8

Watch the first 3:39 minutes of this YouTube video about how effective communication contributes to healthcare equality in the United States. The video focuses on best practice in providing healthcare for a diverse population.

What are the two kinds of ‘competency’ referred to in the video and what do you think they mean?
What do you think is meant by ‘health literacy’?
What kinds of things come under the heading of ‘culture’, according to the video?
How relevant are these ideas to other countries outside the USA, including your own national context?

Discussion

The two kinds of competency mentioned in the video commentary are linguistic and cultural competency. Linguistic competence refers to knowledge and understanding of language. Cultural competence refers to awareness of the culture and cultural norms of others.
The term ‘health literacy’ seems to mean an individual’s understanding of health-related issues, and it is seen as being influenced by (among other things) education, income, country of origin and level of assimilation to the host culture.
The video commentary defines ‘culture’ quite broadly, including factors such as sexual orientation, gender identity, race and ethnicity, language and socio-economic status. But also physical and mental capacity, age, religion, housing status and regional differences fall under this heading.
The claim that the United States is becoming ever more linguistically and culturally diverse is also relevant to other countries, including those of Western Europe. This means that many of the issues raised in the video have a global relevance, even if the specific nature of each national context is different in some way to the American context.

Conclusion

This OpenLearn course provides a sample of postgraduate study in Health and Social Care.

You have now completed this exploration of quality improvement in healthcare. During the activities you have encountered examples of practical healthcare interventions and were encouraged to think about how each intervention intended to influence quality improvement.

You have also explored the different dimensions of quality in healthcare. Importantly, these six dimensions represent the aims of quality improvement initiatives in international healthcare contexts as well as in the UK. By learning about these goals of healthcare improvement, you will be better equipped to analyse how and why healthcare improvement initiatives may work.

This free course, Introducing healthcare improvement, has introduced you to the notion that healthcare improvement is complex because quality can change in many ways from a single quality improvement intervention. It is important to remember that a diverse range of stakeholders can influence healthcare quality and improvement including patients as well as healthcare staff.

References

Batalden, P. B. and Davidoff, F. (2007) ‘What is “quality improvement” and how can it transform healthcare’, Quality and Safety in Health Care, vol. 16, no. 1, pp. 2–3.

Health Foundation (2011) Spotlight on Dementia Care [Online], London, The Health Foundation. Available at http://www.health.org.uk/ publication/ spotlight-dementia-care (Accessed 4 June 2016).

Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st Century [Online], Washington, National Academy Press. Available at http://www.nap.edu/ read/ 10027/ chapter/ 2 (Accessed 4 June 2016).

Martin, R., Lewis, R., Steventon, A., Abel, G. A., Adams, J. L., Bardsley, M., Brereton, L., Chitnis, X., Conklin, A., Staetsky, L., Tunkel, S. and Newbould J. (2013) Does integrated care deliver the benefits expected? Findings from 16 integrated care pilot initiatives in England [Online], RAND Corporation. Available at http://www.rand.org/ pubs/ research_briefs/ RB9703.html (Accessed 4 June 2016).

NHS England (n.d.a) What Do We Mean by High Quality Care? [Online]. Available at https://www.england.nhs.uk/ about/ our-vision-and-purpose/ imp-our-mission/ high-quality-care/ (Accessed 14 January 2016).

NHS England (n.d.b) Never Events [Online]. Available at https://www.england.nhs.uk/ patientsafety/ never-events/(Accessed 19 January 2016).

Nuffield Trust (2012) A Decade of Austerity? The Funding Pressures Facing the NHS from 2010/11 to 2021/22 [Online]. Available at www.nuffieldtrust.org.uk/publications/decade-austerity-funding-pressures-facing-nhs (Accessed 14 January 2016).

Øvretveit, J. (2009) Does Improving Quality Save Money? A Review of Evidence of Which Improvements to Quality Reduce Costs to Health Service Providers [Online], London, The Health Foundation. Available at www.health.org.uk/ publication/ does-improving-quality-save-money (Accessed 4 June 2016).

Quality Watch (2016) Diagnostic test waiting times [Online]. Available at http://www.qualitywatch.org.uk/ indicator/ diagnostic-test-waiting-times (Accessed 4 June 2016).

Scottish Government (2010) The Healthcare Quality Strategy for NHS Scotland [Online]. Available at http://www.gov.scot/ Publications/ 2010/ 05/ 10102307/ 2 (Accessed 21 January 2016).

World Health Organization (2006) Quality of Care: A Process for Making Strategic Choices in Health Systems [Online]. Available at http://www.who.int/ management/ quality/ assurance/ QualityCare_B.Def.pdf?ua=1 (Accessed 21 January 2016).

Acknowledgements

This free course was written by Rajvinder Samra.

This free course is adapted from a former Open University course Leading healthcare improvements (K827 ). .

Except for third party materials and otherwise stated (see terms and conditions), this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 Licence.

The material acknowledged below is Proprietary and used under licence (not subject to Creative Commons Licence). Grateful acknowledgement is made to the following sources for permission to reproduce material in this free course:

Every effort has been made to contact copyright owners. If any have been inadvertently overlooked, the publishers will be pleased to make the necessary arrangements at the first opportunity.

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