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which sets out a theory of change about howan intervention is supposed to work, is anotherhelpful tool.When identifying an intervention, it is useful tolook at how other teams have addressed similarimprovement challenges. As well as providinginsights about what has and has not worked in othercontexts, it can help to avoid the risk of ‘reinventingthe wheel’ by repeating work that has already beencarried out elsewhere.Data and measurementfor improvementMeasurement and gathering data are vital elementsof any attempt to improve performance or qualityand are needed to assess the impact against setobjectives.12 When trying to assess the impactof a change to a complex system, a combinationof measures is often used, such as process andoutcomes measures. Measuring for improvementaims to identify the changes that occur while theintervention is being tested so that the interventioncan be refined over time in response to these data.16Quality improvement made simple

To measure change it is important to capturea baseline and then carry out measurement atregular intervals to gauge whether the impact ofthe intervention represents an improvement ordeterioration compared to the expected level ofperformance variation.It is also important to measure ‘what would havebeen’ without the intervention, bearing in mindany potential external causes of change seen inmeasurement. This can be done using statisticalprocess control (SPC), a method that examines thedifference between natural variation (commoncause variation) and variation that can be controlled(special cause variation). SPC uses control charts thatdisplay boundaries (control limits) for acceptablevariation in a process.Improving reliabilityA key focus of quality improvement is to improvethe reliability of the system and clinical processes.Ensuring reliability mitigates against waste anddefects in the system and reduces error and harm.Analysis of high reliability organisations, manyof which can be found in industries that havedeveloped and sustained high levels of safety, such ascommercial aviation and nuclear power industries,Underlying principles17

has identified a number of common attributes andbehaviours. These include a culture of ‘collectivemindfulness’ in which staff routinely look for andreport minor safety problems and share a willingnessto invest time and resources in identifying andlearning from errors.13In health care, systematic quality improvementapproaches such as Lean (see Section 4) have beenused to: redesign system and clinical pathways create more standardised working procedures develop error-free processes that deliver highquality, consistent care and use resourcesefficiently.Other health care organisations have taken aproactive approach to safety by developing thecapacity to detect and assess system-level weaknesses(hazards and their associated risks) and introducinginterventions to address them (risk controls).14Demand, capacity and flowSome backlogs and delays in health care servicesare attributable to resource shortages or increasesin demand. A case in point is the backlog of18Quality improvement made simple

appointments and procedures created by theCOVID-19 pandemic. However, not all delaysare the result of capacity problems. It may be thatthe capacity is in the wrong place or is providedat the wrong time. To understand whether thereis a capacity shortfall in a service, it is necessaryto measure the demand (the number of patientsrequiring access to the service) and the flow (howand when a need for a service is met).For a process improvement to be made, there needsto be a detailed understanding of the variation andrelationship between demand, capacity and flow.For example, demand is often relatively stable andflow can be predicted in terms of peaks and troughs.In this case, it may be the variation in the capacityavailable that causes the problem (for example, howwork plans are scheduled, staff sickness, and plannedor unplanned leave).The relational aspectsof improvementWhen planning, designing and testing animprovement intervention it is important to focusnot just on the technical aspects of improvement,such as how to apply quality improvement methodsUnderlying principles19

and tools and to measure change, but also on therelational aspects of improvement. The way in whichthe team of people leading the intervention worktogether and how they communicate with otherswhose support they need, is likely to have a profoundinfluence on the success of the intervention. Theserelational issues are discussed in the remaining partof this section.Involving and engaging staffEvidence about successful quality improvementindicates that the method or approach used is notthe sole predictor of success, but rather it is theway in which the change is introduced.15 Factorsthat contribute to this include leadership, effectivecommunication,16 staff engagement and patientparticipation, as well as training and education.Engaging the people closest to the issue beingaddressed is especially important, but it can bechallenging. For example, many clinicians will bekeen to improve the quality of the service they offerand may already have done so through methodssuch as clinical audit, peer review and adoptionof best practice. However, they may be unfamiliarwith quality improvement approaches. For this20Quality improvement made simple

reason, capability building and facilitated supportare key elements of building clinical commitment toimprovement. Other important aspects include: involving the clinical team early on whensetting aspirations and goals ensuring senior clinical involvement andpeer influence obtaining credible endorsement – forexample, from the royal colleges involving clinical networks acrossorganisational boundaries providing evidence that the change has beensuccessful elsewhere embedding an understanding of qualityimprovement into training and education ofhealth care professionals.Clinicians are more likely to engage with the processif the motivation and reasons focus on improvingthe quality of patient care rather than on cost-cuttingmeasures.Nonetheless, it is important to ensure that allrelevant staff are engaged, not just clinicians.Managers, for example, can help to ensure thatUnderlying principles21

improvement is embedded into standard practice17and non-clinical staff, who are often the first pointof contact for patients, play a key role in improvingcare. Breaking down traditional hierarchies for thismultidisciplinary approach is essential to ensure thatall perspectives and ideas are considered.Co-producing improvementAt its best, quality improvement in health care isbuilt on an equal partnership between staff, patients,carers and the wider public. These partnerships arepart of a desire to move away from a staff-drivenapproach to improving care, in which patients aresometimes invited to participate, to a model wherestaff and patients make decisions that relate directlyto the patient’s care together.18Underpinning these partnerships is a sharedpurpose, which is informed by discussions on whatmatters most to patients19 and where they thinkimprovement efforts should be focused.20 Trust,openness and an ability to listen respectfully are keyto the success of these discussions.21 A willingness toconfront any power imbalances among participants,making it difficult for some participants to contributeequally, is also important.2222Quality improvement made simple

Creating such an environment is not alwaysstraightforward: patients may need support andtraining to make the transition to being ‘makersand shapers’23 of services, while professionals mayneed guidance on addressing certain issues, such asunconscious bias.It is important that organisations invest resourcesinto patient and public involvement in improvementand build up the necessary skills and knowledge tomaximise the time, expertise and commitment ofpatients, carers and the wider public.Building effective teamsHow improvement team members relate to eachother and work together has a critical bearing on thesuccess of the intervention. Treating each other withrespect and courtesy, listening carefully to the viewsof others and valuing their ideas, regardless of theirhierarchical position, are all behaviours that can helpthe team to work together more effectively.24Equally important are a willingness to learntogether and a sense of humility, founded on anawareness that no single person has the skills andexperience to solve a problem on their own. AnyUnderlying principles23

team disagreements should be resolved throughopen discussion, rather than by personal orpositional power.25Other vital attributes are the ability to ask questionsclearly and frequently, and to share knowledge andthoughts in a focused and timely fashion. These‘teaming’ skills26 help team participants to interacteffectively and efficiently.CollaborationCollaboration is an essential component of effectivelearning and improvement. Working collaborativelyand outside of traditional organisational boundariesoften provides the basis for understanding andaddressing improvement challenges. Networksand partnerships such as clinical audit networks,academic health science networks, primary carenetworks, the Q community (see Section 6)or other similar groups enable the sharing ofexperiences, knowledge and expertise within localhealth systems.Collaboration also provides opportunities forscaling up of techniques, learning and discussionand can drive continued developments in qualityimprovement.27 Health care quality improvement24Quality improvement made simple

strategies developed through collaborative networkscan be shared and adopted at regional or nationallevels and therefore have a wider uptake than thosedeveloped locally. This raises the standard of qualityand consistency of care across a broader landscape.28Underlying principles25

Approachesand methods4

Many of today’s quality improvement approaches andmethods were originally developed in industry and havebeen adapted for use in other sectors, such as health care.These industrial approaches have been used extensivelywithin health care for the past 30 years to improve specificcare processes and pathways, but their use has only beenembedded throughout a few large health care providerorganisations (see Section 5). Perhaps because of this, theevidence base for their effectiveness is relatively limited,although it is expanding with the increasing levels ofresearch into the implementation and impact of qualityimprovement interventions.The roots of many quality improvement approachesand methods can be traced back to the thinking aboutproduction quality control that emerged in the early1920s. During the 1940s and 1950s, quality improvementtechniques were further developed in Japan, pioneeredthere by the American experts W Edwards Deming,Joseph Juran and the Japanese expert Kaoru Ishikawa. Morerecently, Don Berwick has become known for his work inthe US, leading the pioneering work of the Institute forHealthcare Improvement (see Section 6). Several qualityimprovement approaches and methods draw from the workof these pioneers.Approaches and methods27

This section describes some of the most popularquality improvement approaches and methods. Theevidence has not yet evolved to the point where oneapproach can be recommended above another. Thechoice of approach or method is likely to dependto some extent on the nature of the problem beingaddressed and its context. Whatever approach ormethod is used, discipline is important, particularlyin terms of fidelity to the underlying principlesdescribed in Section 3.29,30Model for improvementThis is an approach to continuous improvementwhere changes are tested in small cycles that involveplanning, doing, studying, acting (PDSA), beforereturning to planning, and so on.31,32 These cycles arelinked with three key questions. ‘What are we trying to accomplish?’ ‘How will we know that a change is animprovement?’ ‘What changes can we make that will resultin improvement?’28Quality improvement made simple

Each cycle starts with hunches, theories and ideasand helps them evolve into knowledge that caninform action and, ultimately, produce positiveoutcomes. To measure the impact of each change,tools such as control charts are used (see Section 3).LeanThis approach has its origins in Japan’s car industry.It is a quality management philosophy based ontwo core values – to make customer value flow andrespect for people.33 In health care, Lean emphasisesthe patient’s central position to all activities and aimsto eliminate or reduce activities that do not add valueto the patient. This is achieved by applying Lean’soperational principles, which involve five steps forcontinuous improvement.1.Defining what is value-adding to patients.2.Mapping value streams (pathways thatdeliver care).3.Making value streams flow by removingwaste, delay and duplication from them.Approaches and methods29

4.Allowing patients to ‘pull’ value, such asresources and staff, towards them, so thattheir care meets their needs.5.Pursuing perfection as an ongoing goal.Clinical microsystemsThese are small groups of people who work togetherregularly to provide care to a specific group ofpatients.34–36 This approach is based on the principlethat the quality, safety and person-centredness of anentire health care system is largely determined bywhat happens in its constituent microsystems.A systematic approach has been developed toimprove microsystems focused on the 5Ps:patients, people, patterns, processes and purpose.Assessing the 5Ps helps to identify opportunities forimprovement, which are then addressed using themodel for improvement approach.Experience-based co-designThis is an approach that was designed in the UK –for and with the NHS. It aims to improve patients’experience of services, through patients and staffworking in partnership to design services or30Quality improvement made simple

pathways.37,38 Data are gathered through in-depthinterviews, observations and group discussionsand analysed to identify ‘touch points’ – aspects ofthe service that are emotionally significant. Staff areshown an edited film of patients’ views about theirexperiences, before staff and patients come togetherin small groups to develop service improvements.Approaches and methods31

Key questionsfor planning anddelivering qualityimprovement5

Q.A.What are the challenges to delivering qualityimprovement?In a review of 14 quality improvementprogramme evaluations funded by theHealth Foundation, 10 key challengeswere consistently identified from theprogrammes.39 These were:1.convincing peers that there is a problem2.convincing peers that the solutionchosen is the right one3.getting data collection and monitoringsystems right4.excess ambitions and ‘projectness’ –treating the intervention as a discrete,time-limited project, rather than assomething that will be sustained as partof standard practice5.the organisational context, culture andcapacities6.tribalism and lack of staff engagement7.leadershipKey questions for planning and delivering quality improvement33

8.balancing carrots and sticks – harnessingcommitment through incentives andpotential sanctions9.securing sustainability10. considering the side effects of change.However, the review also showed that if you takethe time to get an intervention’s theory of change,measurement and stakeholder engagement right, thiswill deliver the enthusiasm, momentum and resultsthat characterise improvement at its best.Q.A.34Can quality improvement have unintendedconsequences?Quality improvement does not always workand can have the unintended consequenceof diverting resource and attention withoutproducing benefit. Sometimes, change in onearea can cause a negative effect in another, forexample, improved early discharge might leadto increased readmission. In other instances,the overall impact of a quality improvementeffort may be negative. Leaders need toanticipate and monitor for these potentialunintended consequences using a set ofQuality improvement made simple

balancing measures and may need to makedecisions about scheduling or sequencingof initiatives.The scale of a quality improvementintervention, and the extent to which itis coordinated with other improvementefforts, also matters.40 An isolated small-scaleintervention to solve a problem in a specificteam or service may end up duplicatingwork carried out elsewhere or, by adopting asolution that varies from standard practice, itcould create a potential safety risk.Quality improvement is likely to be moreeffective if it is undertaken as a healthcare organisation or system-wide effort.Improvements to care processes andpathways need to be considered holistically,rather than as disconnected interventions,and then approached as a long-term,sustained change effort. An integrated,system-level approach also allows a broadrange of skills and expertise to be deployed tosolve improvement challenges.Key questions for planning and delivering quality improvement35

Q.A.What skills do improvers need?Quality improvement requires bothtechnical and relational skills.41,42 As wellas understanding how to plan, implement,measure and refine improvementinterventions using recognised methods,such as PDSA cycles, improvers need to beable, among other things, to describe theirintervention effectively and convince othersto work with them. Negotiation skills,the ability to read people and situationseffectively and work well in a team are vital togetting an intervention up and running.Practical skills, such as the capacity to managetime effectively, identify the right priorities,and keep a project delivery plan on schedule,are also essential. Equally important arelearning skills, particularly the ability toreflect, both individually and as a group,on the lessons learned from each step of anintervention – and to use these learnings torefine the improvement approach. Successfulimprovers have often developed certain‘improvement habits’, which help them to36Quality improvement made simple

get their ideas off the ground and ensure thattheir intervention is sustained.43 These habitsare summarised in Figure 1.Figure 1: The habits of improversQuestioningORESOMMCAU N I C ATCRETeamplayingCIA LIOAT I V I T YCriticalthinkingNComfortablewith conflictOptimisticIEN C ERGINCFacilitativeSILLECO-PTHALDNKAcceptingof changeINFLUENUNICAT IOMMNCOCING HUDEOANHIT EMS RNEmpatheticREProblem findingCalculatedrisk takingToleratinguncertaintyGeneratingideasSource: The habits of an improver: Thinking about learning forimprovement in health care. The Health Foundation; 2015.Key questions for planning and deliverin

Quality improvement made simple ISPUBLISHEDBYTHE(EALTH&OUNDATION 3ALISBURY3QUARE ,ONDON%# 9 !0 ISBN: 978-1-911615-56-9 4HE(EALTH&OUNDATION Written by Bryan Jones, Esther Kwong and Will Warburton Acknowledgements The authors would like to thank Joanna Bircher, Nick B