What Does a Systems Approach to Quality Improvement Look Like in Practice?
Abstract
:1. Introduction
- What challenges have been addressed to improve their performance?
- Are some of these challenges more prominent that others?
- Is there any evidence that improvements are at a systems level?
2. Literature Review
2.1. What Is Systems Thinking?
2.2. A Systems Approach to Healthcare Improvement
- Application of QI to focus on areas of priority with carefully designed interventions;
- The organisation is prepared and ready for change, including capable leadership, good relations with staff, and supportive information systems;
- The external environment is conducive relative to beneficial regulatory, payment policy and competitive factors.
3. Study Context
- Is it safe? Are patients protected from abuse and avoidable harm?
- Is it effective? Does the care, treatment and support provided achieve good results and help to maintain quality of life and is the care based on the best available evidence?
- Is it caring? Are patients involved in their care, are they treated with compassion, kindness, dignity and respect?
- Is it responsive? Are services organised so that these meet the needs of the patients?
- It is well led? Does the leadership of the organisation make sure high-quality care is provided and is it patient centred? Does it encourage learning and innovation and promote and open and fair culture? [35].
4. Materials and Methods
4.1. Selection of Case Studies
4.2. Data Analysis
5. Results
The Eight Challenges of Quality Improvement
- Leadership: The CQC described the case organisations as well led [20]. Therefore, it was envisaged that this challenge would be met by all the organisations. The role of leadership was indeed seen across the organisations and influences many of the eight QUASER quality improvement challenges and the transformation process. Providing a common purpose was reported to be helpful:
“The trust used the CQC inspection as a lever for clinical improvement… “we needed to get people into a room to talk together, to develop a solution.”(Case 8)
“A priority … across the trust is making sure that she [chief nurse] is visible and accessible, and communicating well with staff. She has weekly meetings with senior ward managers, matrons and divisional nurses to keep her “in touch with the shop floor all of the time”.(Case 6)
The communications team put together a full range of activities to keep staff, patients and stakeholders informed from day one. To find out the main issues for staff, {comms team] used surveys and staff focus groups. “We talked to all staff groups to get a better understanding of the challenges,” …. “Their feedback enabled us to highlight the major issues around the trust and specific areas where we could support improvement.”(Case 3)
The Chief of Service leaders, along with the executive team, started to make it clear what ‘good’ looked like through sheer commitment and determination. This element showed staff that senior clinical and managerial leaders were committed to staff and patients. Staff started to recognise that improvement was needed, and that they could make a real difference.(Case 4)
- 2.
- Political: The importance of widely engaging with stakeholders was reported as being important along with sharing key quality improvement messages:
“The trust kept staff and patients at the heart of discussions when shaping governance and processes. They kept the idea in mind: If this was your family member or friend, would the care be good enough? The trust also surveyed staff and patients to understand how people felt things were progressing.”(Case 4)
XX is one of the parents involved in helping to shape the design of the trust’s new maternity unit. She says that local people were fully involved in the development by meeting the architect and contractors, looking at the options and making suggestions. The trust acted on the parents’ suggestion of using the bereavement room as a place to stay for families with a terminally ill child or a child receiving special care.(Case 1)
- 3.
- Cultural: Building shared values was critical to quality improvement success. Staff were encouraged to share how they felt about the organisation and their roles:
The new leadership team encouraged people to say how they felt about the trust. Staff were encouraged to talk about their roles, what they felt was positive and what stopped them delivering great care. An online tool called Wayfinder was used to get staff involved and engaged in developing the trust’s values, called the ‘XXXX (hospital name) Way’.(Case 7)
“Before, some staff didn’t know who the chief nurse was–they knew the name, but had hardly spoken to them. Now you see the management team on the floor, actually walking through your door and saying, ‘well done team–thanks for all your hard work.’ Two or three little words make a massive difference for staff.”(Case 8)
“We worked with them to get them to control their own areas. We provided training for managers and non-executives mentored people and divisions.”(Case 1)
- 4.
- Educational: Organisations reported the provision of educational activities to upskill their staff in quality improvement with direct application to their day-to-day practice:
Throughout 2014, the trust provided learning sessions and a summit to engage staff in a new quality improvement methodology aimed at reducing pressure ulcers.(Case 2)
“…the new clinical lead for the tissue viability team set up training and education for ward staff, which “empowered staff to engage more with the service”. The clinical lead worked on recognising the tissue viability needs of patients on admission and improving incident forms, documentation and reviews of the service”(Case 5)
The trust has adapted the Virginia Mason system to become the XXX (Hospital name) Improvement Method. “It is transforming the way our patients move through the hospital and the way individual services redesign pathways—to take out waste and inefficiency, reduce waiting times and make the experience better for staff and patients,”(Case 7)
- 5.
- Emotional: An emotional challenge to quality improvement was the initial realisation that the organisation is failing:
“Many members of staff were shocked and disappointed when the trust entered special measures. At the time, the trust was working confidently towards gaining foundation trust status. A [non-executive director]…recalls the “complete devastation” when it was announced that the trust would go into special measures.”(Case 2)
“[Leads] felt “surprise and disappointment” at the news, but recognised that “there was a large element of learning and improvement to be taken from the report and its findings”(Case 3)
“Staff had phenomenal stories about their improvement, but I suppose when I arrived I found quite a fear of sharing improvement”(Case 6)
- 6.
- Physical and technological: A lack of physical infrastructure and IT were reported to compound flailing quality improvement endeavours:
“… the inspection period was a “perfect storm,” with issues in the new IT system, finance concerns and bed pressures, as well as a disconnect between the senior leadership team and frontline staff.”(Case 3)
“The processes and systems had been broken for some time,”…“So the financial systems and systems for setting budgets had been broken, the governance systems for managing the board, and clinical governance. All the back-office systems had been stripped out so they were at a minimal level.”(Case 6)
The ‘Happy App’ is an interactive web-based tool to gather real-time feedback from staff. They can use the app to indicate how happy they are at work and record why. The app gives managers the opportunity to monitor and understand staff satisfaction and engagement, and enables them to act on issues.(Case 5)
- 7.
- Structural: The importance of putting systems in place was stressed: “We have a systematic approach to dealing with harm now and a clear reporting mechanism,” (Case 2). For example, tell Ellie:
Previously, the trust had waited for patients to come to them and in reaction they launched the Tell Ellie campaign and took staff out into the community to meet and engage with local people.(Case 2)
“The organisation should be clinically led, but clinicians need managers to help them. “We had to try to bring back a managerial structure without worsening the financial position. Addressing that problem wasn’t cost-neutral, but there was recognition from the board that the lack of structure wasn’t sustainable.”(Case 8)
Breaking the Cycle Together events focused on operational problem-solving, and the trust introduced Schwartz rounds, a structured forum for staff to reflect on the emotional effects of caring for patients. The trust has used new posters and infographics in visual messages to staff, Chief Executive video briefings, safety bulletins, and the We are Proud to Care film, showcasing what […] “the compassion and commitment of all trust staff”.(Case 5)
- 8.
- External demands: Responding to broader social, political, economic and contextual factors was reported at several levels. The importance of understanding the population at the planning stage was described:
“It serves three of the most populous boroughs in XXX, that have the highest percentage of people with chronic illness,” …“But we only have one major regional hospital. So it’s a question of capacity. When XXX Hospital was planned, the demographic dramatically shifted beyond the original projections. So the hospital was set up to deal with a smaller and healthier population.”(Case 6)
Focus groups provided input into addressing cultural sensitivities, and faith and ablution rooms were made available. The two local Healthwatch groups, also provided valuable information, and the Listening into Action (LiA) approach was renewed and extended across the area.(Case 4)
The trust has improved its links with external organisations. “We had talks with Healthwatch, patient representative groups, councils, MPs and the press so we could provide them with reassurance about the trust,”(Case 3)
“She [chief executive] attended the British Association of Physicians of Indian Origin (BAPIO) national conference and presented the trust’s work on equality and diversity. XX thinks this was a turning point. “I think our Indian and Pakistani doctors who were there saw it as more than a token gesture.” The trust then formed an agreement with BAPIO for the development and training and established a BME network with BAPIO.”(Case 1)
6. Discussion
7. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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QUASER QI Challenge | Definition |
---|---|
Leadership | Providing clear, strategic direction. |
Political | Addressing the internal organisational politics and negotiating the conflicts and relationships surrounding any quality improvement effort. |
Cultural | Giving ‘quality’ a shared, collective meaning, value and significance within the organisation. |
Educational | Creating and nurturing a learning process that supports continuous improvement. |
Emotional | Inspiring, energising, and mobilising people for the quality improvement effort. |
Physical and technological | Designing physical systems and technological infrastructures that support improvement and quality of care. |
Structural | Structuring, planning and coordinating quality efforts. |
External demands | Responding to broader social, political and contextual factors. |
Organisation | Population | Staff | Beds | Additional Detail |
---|---|---|---|---|
Case 1 | 365,000 | 6000 | Not available | Three hospitals |
Case 2 | 521,000 | 8000 | 1041 | Two acute sites and three community sites |
Case 3 | 578,000 | 10,100 | 1400 | Two hospitals |
Case 4 | 465,000 | 3400 | 700 | Two hospitals |
Case 5 | 500,000 | 13,000 | Not available | Eight hospitals (largest NHS Trust in England) |
Case 6 | 750,000 | 7500 | Not available | Operates from two sites |
Case 7 | 78,000 from metro area and 5.4 million from surrounding community | 15,000 | 1785 | Four inpatient sites |
Case 8 | 380,000 | 4000 | 800 | Five sites |
Organisation | Special Measures | Inadequate | Requires Improvement | Good | Outstanding |
---|---|---|---|---|---|
Case 1 | June 2014 | July 2015 (out of SpM December 2015) | February 2017 | ||
Case 2 | July 2013 | May 2014 | 2015 | ||
Case 3 | September 2015 | January 2017 and came out of SpM | |||
Case 4 | February 2014 | February 2016 | |||
Case 5 | December 2014 | March 2017 | |||
Case 6 | December 2013 | March 2015 | March 2017 | ||
Case 7 | July 2014 | September 2016 | |||
Case 8 | April 2015 | December 2016 |
Case Study | Leadership (I and T) | Political (I) | Cultural (I) | Educational (I) | Emotional (T) | Physical and Technological(I) | Structural (I) | External Demands (I) |
---|---|---|---|---|---|---|---|---|
Case 1 | X | X | X | X | X | X | X | |
Case 2 | X | X | X | X | X | X | X | X |
Case 3 | X | X | X | X | X | X | X | |
Case 4 | X | X | X | X | X | X | ||
Case 5 | X | X | X | X | X | X | X | X |
Case 6 | X | X | X | X | X | X | X | X |
Case 7 | X | X | X | X | X | X | ||
Case 8 | X | X | X | X | X | X |
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Williams, S.J.; Best, S. What Does a Systems Approach to Quality Improvement Look Like in Practice? Int. J. Environ. Res. Public Health 2022, 19, 747. https://doi.org/10.3390/ijerph19020747
Williams SJ, Best S. What Does a Systems Approach to Quality Improvement Look Like in Practice? International Journal of Environmental Research and Public Health. 2022; 19(2):747. https://doi.org/10.3390/ijerph19020747
Chicago/Turabian StyleWilliams, Sharon J., and Stephanie Best. 2022. "What Does a Systems Approach to Quality Improvement Look Like in Practice?" International Journal of Environmental Research and Public Health 19, no. 2: 747. https://doi.org/10.3390/ijerph19020747