Question: What has been learnt through the application of quality improvement

methodologies, sourced from other industry sectors, but applied in a health care

setting?
Introduction

Background of Quality Improvement in Healthcare

Around 200 years have passed since the beginning of quality improvement in health care

(Marjoua and Bozic, 2012). Dr. Ignaz Semmelweis, for example, campaigned for handwashing

as a means of reducing disease transmission and other healthcare-associated diseases as early as

1846 (Davis, 2015). The American College of Surgeons established a second hospital

standardization program a year later, in 1918, to guarantee that minimum quality standards were

maintained during surgical operations (James, 2017).

Definition of Quality Improvement in Healthcare

To enhance patient care, quality improvement (QI) is a framework that utilize in the health-care

industry. Measurement, analysis, and improvement of processes made possible the quality

improvement in healthcare.

Importance of Quality Improvement in Healthcare

When healthcare providers have dependable, cost-effective, and long-lasting processes, they can

accomplish their goals for improving care delivery and patient outcomes through increasing

quality and performance overall (iPatientCare, 2016). First and foremost, it is important for

healthcare professionals to adapt to a new environment in which quality improvement is

prioritized above the process results.

Characteristics of Quality Improvement in Healthcare

According to Don Berwick (Donald Berwick, 2015), there are six dimensions of quality in

healthcare i.e., safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

Quality Improvement Methodologies in other Industries
Simulation training (David et al., 2001), patient handover (Catchpole et al., 2010), structured

communication (Lee et al., 2012), and even quality improvement itself (Julie, 2015) have all

been adopted from industrial contexts, patient safety and satisfaction are being improved in

industries such as civil aviation, nuclear power, and the automobile industry. Anyone hoping to

improve healthcare quality may take a quick cut by studying other businesses. What if we took

use of other industries have invested decades in research and development to enhance the overall

quality and safety of healthcare delivery?

It is not as easy as it looks. Implementing healthcare improvement strategies has proven difficult,

with mixed results. Some interventions, including event reporting systems, have proved popular

and successful in reducing CVC infections, have failed to accomplish their objectives and have

been met with discontent and frustration (Dixon-Woods et al., 2011). If people use a new

improvement method too broadly and simplistically at first (Peerally et al., 2017), they will

likely to encounter a great deal of confusion and criticism from their colleagues (Catchpole and

Russ, 2015). But despite the challenges, turning to other sectors for inspiration and new ideas is

still essential, just as other companies increasingly look to healthcare for inspiration and advice

on how to operate (Carl and Kevin, 2019).

Lean production system is mostly adopted by other industry sectors. The lean system, which is

employed in the production of Toyota automobiles (Vinod, 2015), led to the development of the

Lean Production System or Lean methodology, as it is currently called. While Lean and Six

Sigma are similar, and seeks to optimize processes by eliminating non-value-added tasks from

the process (a.k.a. waste). Using the Lean approach, steps include optimizing value-added tasks
in the greatest feasible order to allow for continuous operations (Endsley et al., 2006). A root-

cause analysis is used in this technique to analyze mistakes and then enhance quality and avoid

similar errors from occurring again. Doctors, nurses, technicians, and managers are using the

concepts of the lean systems in pathology laboratories (Printezis and Gopalakrishnan, 2007),

pharmacies (Spear, 2005), and blood banks (Johnstone et al., 2003), resulting in improved patient

care while reducing operating costs. According to the results, root-cause analysis may help

health care companies enhance patient safety and quality., then establishing objectives,

eliminating ambiguity and workarounds, and clarifying duties (Hughes, 2008). Following their

efforts in this area, members of the project teams developed action plans to simplify and

reorganize work processes because of their collaboration.

Quality Improvement Methodologies in Healthcare

Plan-Do-Study-Act (PDSA)

Planning, doing, studying, and acting (PDSA) is a process that is utilized in quality improvement

initiatives and studies that are aimed at bringing about beneficial changes in health-care systems

and achieving positive outcomes. The Institute for Healthcare Improvement uses a fast cycle

improvement methodology, when it comes to improving processes quickly (Berwick, 1998). One

of the model's most distinguishing characteristics when it comes to change is the cyclical nature

of effecting and evaluating it. Before systemwide changes are implemented, it is most efficiently

done via modest and frequent PDSAs rather than large and slower ones(Langley and Moen,

2009).
Six Sigma

It was originally developed as a business strategy, and it is the process of developing, planning,

and monitoring procedures for waste reduction or elimination while improving customer cost and

satisfaction safety. Six Sigma is the process of reducing or eliminating waste while increasing

customer satisfaction and financial security (Pande et al., 2000). When evaluating improvement,

Process performance, or its capacity, is used to compare basic process capacity (before

improvement) with process capabilities after piloting possible quality improvement solutions, or

vice versa (Barry et al., 2002). Six Sigma employs two main techniques, which are as follows:

Using one approach, people may examine the process result and count the problems, then use a

statistical table to convert the defect rate per million to sigma (sigma). This technique may be

used in both the preanalytical and post analytic phases of the process. Rather than using

observable variance in the process to forecast process performance, in the second approach,

estimations of process variation are used to calculate the process variation., which are derived by

subtracting the set tolerance limits from the observed variance in the process. Experimental

techniques may be used to determine the precision and correctness of the findings in analytic

processes where precision and correctness can be determined by using this methodology.

FMEA

The occurrence of errors is difficult to predict when they would occur at what specific periods.

FMEA is a risk assessment method that identifies and eliminates known and/or future defects,

issues, and mistakes from a system, design, process, or service before they fail (Spath, 2011)

(Knutzen et al., 2003). Aims of FMEA include trying to discover all predicting how a process

may fail, predicting the likelihood and consequences of each failure, and taking steps to avoid
them. FMEA is a method used in health care that employs a multidisciplinary team to assess a

process from the viewpoint of quality improvement.

These procedures and processes may be used to compare different processes or procedures and to

track changes over time. To track changes over time, it is necessary to use measurements that are

well-defined and can offer objective information on the efficacy of a procedure. The Joint

Commission requires trained health care providers to engage in proactive risk management each

year to identify system vulnerabilities and make adjustments to minimize the risk of patient

suffering (Adachi and Lodolce, 2005).

Effectiveness of Methodologies in delivering the safety and

quality improvement in healthcare

Quality methods used to identify and evaluate problems in health care were shown to be

beneficial in prioritizing quality and safety issues (Singh et al., 2007) and concentrating on

systems (Horbar et al., 2003) rather than individuals, according to the research (Jimmerson et al.,

2005). The different tools were used to address mistakes and rising costs, as well as to alter

provider behavior (Horner et al., 2005). More than one quality improvement technique was

utilized in many projects, such as starting with root-cause analysis and then implementing

change in processes using Six Sigma, Toyota Production System/Lean, or Plan-Do-Study-Act

methodologies.

Six Sigma

Many health care settings and procedures, including hospitals, have reported that Six Sigma has

been utilized effectively to reduce defects/variations and operating costs (Guinane and Davis,
2004), as well as to enhance outcomes in a range of processes (Peter, 2003). Six Sigma was

found to be a thorough method that differentiated between causes of variation and process

metrics (Peter, 2003). Since the fundamental causes of pre-implementation processes were

recognized and addressed Six Sigma made workarounds and rework more complex (Printezis

and Gopalakrishnan, 2007). Furthermore, researchers discovered that the more teams used this

approach, the better they were at executing it and, as a consequence, the more successful their

outcomes were (Thompson et al., 2003). This method was shown to improve patient safety,

decrease expenses, and increase work satisfaction, despite the fact that it requires a significant

investment of leadership time and resources. (Thompson et al., 2003) A key approach for

problem-solving and continuous improvement, Six Sigma was also essential for communicating

effectively about the issue, directing the implementation process, and generating findings that

were clear, succinct, and objective (Printezis and Gopalakrishnan, 2007).

Plan-Do-Study-Act

The overwhelming majority of initiatives used the PDSA method (progressive implementation

and improvement) to progressively deploy initiatives while improving them as needed. Then

came the analysis and response to what was learnt through problem-solving and process

adjustments, followed by the next PDSA cycle, and so on. Most PDSA quality improvement

initiatives were shown to be more successful when executed in several short and fast cycles to

accomplish the intervention's objectives. This happened as a result of the initiative's gradual

rollout allowing the team to make adjustments early on (Buhr and White, 2006) and resist

becoming diverted by every detail and uncertainty (Wojciechowski and Cichowski, 2007). It was

possible to improve the team's ability delivering PDSA cycle education and training, utilizing

feedback from baseline measurements to effectively implement the PDSA method, and using
additional techniques in addition to those described above. It is part of the job description to have

frequent team meetings and to improve the effectiveness of the team to accomplish a shared

objective with others, particularly patients and their families (Warburton et al., 2004). The use of

fast cycle change, data collection, and the construction of run charts were all challenging for

some teams to master, PDSA cycles based on fundamental principles one research found that in a

complicated system (Erdek and Pronovost, 2004).

FMEA

FMEA was utilized to avoid incidents and improve treatment quality (Gering et al., 2005).

FMEA was used to predict failure modes and consequences. If the process is safe, it may be

evaluated experimentally at the appropriate rate of change. Retrospective evaluation may also be

carried out by identifying potential areas of failure and gaining an understanding of the process

from the viewpoint of people who were directly engaged in it (Burgmeier, 2002). It was helpful

for the team to focus on a single document from the beginning of the analysis by creating a flow

map of the procedure prior to beginning the study (Burgmeier, 2002). Prioritizing improvement

methods was done with the use of FMEA data, which was utilized as a standard for future

improvement efforts (Kim et al., 2006), to educate the public and offer a justification for the

spread of these practice modifications to other contexts (Apkon et al., 2004), improve the team's

capacity to enable change across all hospital services and departments (Suzanne, 2006). Because

of the application of FMEA, systematic error control was made possible, which was essential for

delivering excellent clinical care in complicated processes and in complex environments. In

order to achieve this, among other things, integrated event reporting and error reporting, decision

support, standardized language, and education of caregivers were required (Apkon et al., 2004).
Appropriate Methodology to use for Quality Improvement in

Health Care
PDSA cycles, have been utilized to promote quality improvement in recent years to drive such

changes. There is widespread usage of the technique in healthcare improvement; nevertheless,

there has been no comprehensive assessment of how the method has been implemented.

However, despite increasing investment in research into healthcare quality improvement (Walshe

and Freeman, 2002), the evidence for successful quality improvement treatments remains

inconsistent (Marlies and Loes, 2008), in light of many studies demonstrating that such measures

are only effective when used in certain situations (Nicolay et al., 2012).

To provide high-quality and high-value care while staying within a tight budget, it is necessary to

create quality improvement methods that allow for iterative creation and testing of care

interventions. This also applies to the broad provision of high-quality and high-value health care.

PDSA are an example of a technique for organizing iterative change development that is

effective. TQM, CQI, and Lean are all examples of methods for continuous quality

improvement, quality improvement techniques that may be utilized as stand-alone methods or as

components of larger quality improvement approaches (Walshe, 2007).

Figure 1 Source: Langley GL

The evidentiary basis for the efficacy of quality improvement techniques is weak and under-

theorized, despite the increasing usage of these methods (Auerbach et al., 2007). Despite this,

PDSA cycles' efficacy and applicability have received few objective assessments (Ting et al.,

2009). It has been shown that certain PDSA methods result in substantial increases in patient

outcomes (Benning et al., 2011), whereas others have shown no change at all (Landon et al.,

2004).

The PDSA cycle, as opposed to more traditional healthcare research techniques, is a pragmatic

scientific methodology for assessing changes in complex systems (Moen and Norman, 2009).

The PDSA cycle is a scientific and practical method for assessing complex system changes.

The PDSA cycle's pragmatic principles encourage intervention testing on a small scale and in

iterations because it enables quick evaluation and flexibility in modifying the modification in
response to input, resulting in the creation of solutions that are appropriate for their intended

purpose (Rushmer, 2009).

The ability to experiment on a small scale allows users to act and learn with greater freedom,

while also reducing risk to patients and resources. As the public's trust in the intervention

increases, so does the potential to gather evidence for change and involve stakeholders.

Also, there are some issues using PDSA for improvement quality in health care. One of the most

common difficulties faced while utilizing PDSA is the mistaken belief that it may be utilized as a

stand-alone procedure. A full suite of quality improvement techniques is required for PDSA to

be successful.

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