Methods & Tools

Improving Quality

The Four-Step Approach to Quality Improvement. Quality improvement (QI) methodology has evolved over the years. Early QI efforts assumed that improvements could be readily attained by adding new or more things, such as new machines, procedures, training, or supplies. It was believed that simply adding more resources or inputs would improve quality. People working to improve quality learned that increasing resources does not always ensure their efficient use and, consequently, may not lead to improvements in quality. In fact, a key lesson is that in many cases quality can be improved by making changes to healthcare systems without necessarily increasing resources. Interestingly, improving the processes of healthcare not only creates better outcomes, but also reduces the cost of delivering services by eliminating waste, unnecessary work, and rework.Inspecting main activities or processes is another approach that managers have used to identify and solve problems. This method tried to increase control over staff and often blamed people for mistakes. This philosophy of improving quality showed limited success because it did not necessarily identify barriers to improvement or generate the support of workers, who felt resistant to being evaluated. In contrast, current QI approaches examine how activities can be changed so employees can do their work better. For example, poor employee performance may stem from a lack of supplies, inefficient processes, or the lack of training or coaching rather than worker performance. The philosophy behind the QA Project’s approach to QI recognizes that both the resources (inputs) and activities carried out (processes) must be addressed together to ensure or improve the quality of care.In response to the wide variety of settings and circumstances it has encountered in over 30 developing countries, the QA Project defines quality improvement as consisting of four key steps.

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QI is not limited to carrying out these four steps, but rather emphasizes continuously looking for ways to further improve quality. When improvements in quality are achieved, teams can continue to strive for further improvements with the same problem and/or address other opportunities for improvement that have been identified.

Step one: Identify. The goal of the first step, identify, is to determine what to improve. This may involve a problem that needs a solution, an opportunity for improvement that requires definition, or a process or system that needs to be improved. Examples of problems or processes that are commonly identified include low coverage, inadequate counseling, lack of drugs, lost lab reports, and excessive waiting time.This first step involves recognizing an opportunity for improvement and then setting a goal to improve it. Quality improvement starts by asking these questions:

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Step two: Analyze. Once areas for quality improvement have been identified, the second step is to analyze what we need to know or understand about this opportunity for improvement before considering changes. The objectives of the analysis stage can be any combination of the following:

To reach these objectives, this step requires the use of existing data or data collection. The extent to which data are needed depends on the quality improvement approach chosen. Techniques to analyze problems include clarifying processes through flowcharts or cause-effect analyses, reviewing existing data, and, when needed, collecting additional data.

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Step three: Develop. The third step, develop, uses the information accumulated from the previous steps to explore what changes would yield improvement. A hypothesis is formulated about which changes, interventions, or solutions would reduce the problem and thus improve the quality of care. A solution strategy is then developed based on this hypothesis. It is important to remember that at this point the hypothesis remains a theory, as it has not yet been tested. A hypothesis is a tentative assumption made in order to test its consequences. It is based on people’s knowledge and beliefs about the likely causes and solutions of the problem.

Step four: Test and implement. This step, test and implement, builds on the first three. A hypothesis is tested to see if the proposed intervention or solution yields the expected improvement. Because interventions that prove to be effective may not yield immediate results, allowing time for change to occur is important in the testing process. The results of this test determine the next step.

Determining the Next Step after Solution Testing

 

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The Spectrum of Quality Improvement Approaches

Rapid Team Problem Solving. Rapid team problem solving is an approach in which a series of small incremental changes in a system is tested—and possibly implemented—to improve quality. This approach entails many small to medium size tests of individual changes in similar systems. Like individual problem solving, this approach could be used in any setting, although it generally requires that teams have some experience in problem solving and/or seek a mentor to help implement this approach quickly. This approach to quality improvement is less rigorous in the time and resources required than the next two approaches because it largely relies on existing data and group intuition, thereby minimizing lengthy data collection procedures. Rapid team problem solving may involve cause analysis, but implemented in a less rigorous fashion than in systematic problem solving. Teams are ad hoc (temporary) and disband once the desired level of improvement has been achieved.

Systematic Team Problem Solving. Systematic team problem solving is often used for complex or recurring problems that require a detailed analysis; it frequently results in significant changes to a system or process. The mainstay of this approach is a detailed study of the causes of problems and then developing solutions accordingly. This detailed analysis usually involves data collection and therefore often requires considerable time and resources. While systematic team problem solving can be used in any setting, due to its indepth nature, it is most appropriate when the ad hoc team can work together over a period of time. Typically, such teams disband once sufficient improvement objectives are reached.

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Process Improvement. The most complex of the four approaches, process improvement, involves a permanent team that continuously collects, monitors, and analyzes data to improve a key process over time. Process improvement generally occurs in organizations where permanent resources are allocated to quality improvement. The permanent team may use any of the other three QI approaches, for example, forming ad hoc teams to solve specific problems. Process improvement is often used to assure the quality of important services in a health facility or organization. Since this approach is often used to respond to core processes of a system, various stakeholders contribute to the analysis stage.The table below compares the four QI approaches.

In sum, experience with quality improvement has rendered it a simpler, more robust methodology, and the application of QI methodology to a wide range of settings has become clearer. The settings include both clinical and nonclinical environments, with the approaches ranging from individual problem solving to process improvement by permanent teams. In all of these approaches, the methodology and principles remain unchanged, though their specific methods may vary.

Continue to Improving Quality (Performance Improvement & Benchmarking)

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