A Systematic Narrative Review of Quality Improvement Models in Health Care

Dr Alison PowellDr Rosemary Rushmer Professor Huw Davies Feb 2009 http://www.nhshealthquality.org/nhsqis/5658.html

Presentation outline• Preamble: “quality”; quality improvement

“interventions”; and organisational challenges

• Five common QI approaches: alphabet soup of TQM, CQI, BPR, PDSAs and OWAs

• Making sense of the evidence…• Differences & similarities in the models• Drawing conclusions:

– some necessary but not sufficient conditions– strategies for over-arching support

“Quality of care” is contested and complexTacit

understandings differ across various professional groups…

Common dimensions:

• Safety• Effectiveness• Patient-centredness• Timeliness• Efficiency• Equity IoM, 2001But these

dimensions can conflict…

Levels of QI interventions• Macro policy choices:

e.g. Commissioning (World-Class?); Finance (Payment by Results?); “Choice”; Appraisal, oversight, inspection and regulation…

• A (micro) focus on individuals:e.g. continuing professional development;

(re)accredidation; encouragement to adopt evidence-based practice…

• Meso-level (organisational) change:– improvement and redesign at service

level…

Organisational challenges (1)• Organisational & service complexity• Multiple stakeholders &

multiple/conflicting missions• Multiple – but poorly integrated –

standards and targets • Strong professional identities,

boundaries and autonomy… …limited professional engagement• Limited management control

Organisational challenges (2)• Disconnect between resource decisions

and quality considerations• Patchy data/analytic capacity• Patchy / contested evidence-base• Education/socialisation focus on

individuals• Ongoing impacts of reorganisations,

organisational histories and major macro-level policy choices…CHURN

• Models imported from industry• Some – diverse, but limited – evidence

(limited quantitative data, no cost-effectiveness data)

• Lack of clarity over “intervention”…indeed, growing hybridisation

• Complex interventions in ‘social worlds’• (Pawson & Tilley’s) “Realistic

Evaluation”:Context + mechanism influences outcomes “discerning what works, for whom, in what circumstances,

in what respects - and how”

Making sense of the evidence

The approach…• Systematic searching (in health care)• Review within each ‘model’ – nature

of approach, evidence, experience…• Integration across the models –

– observations on similarity and difference– learning from system-wide experiences– identification of “necessary but not

sufficient” conditions– lessons learned from evidence to-date.

Alphabet soup: common QI approaches

• Total Quality Management (TQM) &Continuous Quality Improvement (CQI)

• Business Process Reengineering (BPR)

• Practitioner-led rapid-cycle change (e.g. IHI’s PDSAs)

• LEAN thinking (Toyota)• Six Sigma

TQM/CQI

• TQM/CQI approaches take as a focus the internal and external customers’ definitions of quality; see quality improvement as an ongoing activity that is part of everyday work rather than an isolated project; and focuses attention on systems rather than on individuals.

“Getting it right first time…”

BPR

• BPR entails radical rethinking to design core processes from scratch; and emphasises the need for organisations to be designed around key processes and not around specialist functions.

• Less radical offshoots emphasise the importance of processes and pathways.“Why are we doing this at

all…?”

Rapid-cycle change

• Rapid cycle change (e.g. the Plan-Do-Study-Act cycle) entails short-cycle small-scale tests of change followed by reflection on the results; emphasises close involvement of health care teams in defining the problem, suggesting potential solutions, and testing and refining these possible solutions.

“Practitioners are doing it for themselves…”

BPR

• BPR entails radical rethinking to design core processes from scratch; and emphasises the need for organisations to be designed around key processes and not around specialist functions.

• Less radical offshoots emphasise the importance of processes and pathways.“Why are we doing this at

all…?”

Lean thinking

• Lean thinking approaches emphasise examining the organisation’s processes to ensure that they are providing what the customer wants with minimal wasted time, effort and cost.

“Just-in-Time; Lean (and mean?)…”

Six Sigma

• Six Sigma aims to increase the reliability of a process or system of care by using statistical tools and analysis to identify (and hence be able to address) the root cause of variation in the process or system (common cause vs. special cause variations).

“Define; Measure; Analyse; Improve; Control”

System-wide experience

• Jonkoping County, Sweden

• Kaiser Permanente• The VA and QUERI• The “Organising for

Quality” cases• IHI’s 100,000 lives

campaign

Difference & Similarity in Approach

• Differences (often) in: – Pace, place and scope of change– focus of change activities:

- processes or systems?- specific aspect(s) of quality?- (whose) perspective on quality?

- enabling or mandating improvement?• Similarities (often) in: objectives, tools

(esp. measurement – SPC), implementation

Clear-cut taxonomy neither feasible nor useful

Conclusions

• Evidence limited, but not absent…• Although models vary in principle, in

practice much overlap, borrowing and hybridisation – no one model emerges as ‘best’

• Policing vs. enabling balance (i.e. data for judgment vs. data for learning)

• Context/model interactions are crucial…

Necessary, but not sufficient…

• Active engagement of health professionals…(with training)

• Tailored, multi-faceted approaches to suit local need

• Sustained action at multiple levels…• Board-level support and follow-

through…• AND Active participation of managers

(organisational leaders) to…

Vital but do not guarantee success

…managerial attention especially to…

• Communicate alignment with wider objectives (and protect from overload)…

• Provide local resourcing/tools, including external linkage…

• Help address local system consequences and barriers…

• Embed new practices into routine service.

Consider over-arching support• Identify useful tools – provide training

in their use• Help local organisations identify their

quality improvement needs (data/analysis)

• Provide central support/training for local data gathering/analysis

• Support Boards to develop as quality champions

Sharing the Findings

• Downloadable PDF from QIS website A Systematic Narrative Review of Quality Improvement

Models in Health Care. Powell, Rushmer and Davies http://www.nhshealthquality.org/nhsqis/5658.html

• Series of papers in Br J Healthcare Management(monthly: January – August 2009)

• See also: Quality Improvement: Theory and Practice in Healthcare

Boaden, Harvey, Moxham, Proudlove and Bevan http://www.institute.nhs.uk