Why upcoming initiatives seeking to deliver long term sustainable improvement in healthcare could just succeed
The next 10 years will be the decade of quality improvement in healthcare, according to the health secretary Jeremy Hunt.
Hopefully he will be right. However, a recent King’s Fund report on quality improvement over the past 10 years makes sober reading.
The authors cite the “the establishment and later disbandment” of the National Patient Safety Agency, the NHS Modernisation Agency, the NHS Institute for Innovation and Improvement and NHS Improving Quality.
There have been no shortages of quality improvement initiatives – but not all innovations that start with a fanfare stand the test of time.
‘Not all innovations that start with a fanfare stand the test of time’
Should we launch another national body, or is it time to take a breath and reflect on what works in quality improvement and what we could do in the future that will last?
A common thread that runs through quality improvement initiatives that succeed (and that is often missing from those that fail) is integration.
For quality improvement projects to succeed and to be sustainable, they need to meet the needs of multiple stakeholders and to align clinical, managerial and financial outcomes.
This might seem to be aiming high – but it is achievable. Quality improvement is a science, and sometimes a complex one – however, it can be made accessible to all.
‘Quality improvement is a science – however it can be made accessible to all’
As always, starting with the patient is a good idea. It is worthwhile thinking about what quality improvement projects would make the greatest difference to patients and populations in your organisation.
This might be improved access to care, fewer medication errors, or pressure ulcers.
It involves doing more than just involving patients as advisers on certain projects; it is also ensuring that they are continuously involved at a strategic level in making important decisions on what quality improvement projects matter to patients and therefore should be pursued (and what ones do not matter as much and can be put on hold).
Another group of key stakeholders is doctors (and especially junior doctors), nurses and allied healthcare professionals.
Here, it is a matter of finding out what motivating factors might get these groups involved in quality improvement.
Many junior doctors have to do a quality improvement project to satisfy curricular needs.
If they can eventually get the quality improvement project report published, and have something for their CV, then so much the better.
Senior doctors in primary or secondary care might need to do a quality improvement project to help them jump the hurdles of appraisal and revalidation.
Nearly all will want to do quality improvement if it will help their patients and make their everyday working lives easier.
Lastly, there is the issue of ensuring that senior management and the clinical leadership teams are involved. They will likely be interested in issues such as productivity, avoidance of error and cost control.
And there is also an element to which leadership development and quality improvement could be better integrated.
‘Success involves breaking down silos that exist’
Leadership skills cannot be learned in isolation – they need to be learned in context and there is no better context than that of a quality improvement project, where a team works to further improve a service that is already working well, or to rescue a service that is failing.
Is it possible to satisfy all these stakeholders?
The short answer is yes. But success involves breaking down silos that exist between different stakeholders in healthcare.
It does not always happen as it should. Some hospitals might have institutional problems in falls and pressure ulcers, but the quality improvement projects being carried out there might be in waiting times and medication errors.
However, others do things differently – and better.
At BMJ Quality Improvement we have a growing experience of supporting (and publishing) projects that help institutions to achieve these outcomes.
There are a range of examples. They include a quality improvement project to reduce missed dose mental healthcare medication errors on older people wards.
Another example is a project to improve low cost generic medication prescription rates in primary care pediatric practice.
They are both associated with cost savings and quality improvement.
‘If we adopt new approaches, then the next 10 years really will be different’
There are a variety of other examples and a wide range of support tools available – such as those of the Institute for Healthcare Improvement and those on the websites of the medical royal colleges and the Department of Health.
There are other ways to do quality improvement and they go by different names including, but not limited to, top down, command and control, and carrot and stick.
However they could have another epithet – methods that do not work in the long term.
There are other ways of doing quality improvement – they just involve us thinking about and doing things differently.
If we adopt new approaches, then the next 10 years really will be different.
Dr Kieran Walsh is clinical director of clinical improvement at BMJ.