Quality improvement: beyond the buzz
Quality improvement seem to be the latest buzzwords in the NHS. And rightly so! There is an imperative to continually improve patient care even in the face of rising demand for services and constrained finances. It is an imperative closely aligned to the Hippocratic oath of ‘do no harm.’ But how do we make sure that quality improvement – as a practical way of improving care – moves beyond buzzword status to become an embodied habit for the NHS workforce?
Excellent care is delivered by the NHS every-day, but no-one would deny that there is also ample evidence of poor care and a necessity for quality improvement. The Mid Staffs scandal is perhaps the most high-profile recent example. The subsequent public inquiry chaired by Robert Francis QC (Report of the Mid Staffordshire NHS foundation Trust Public Inquiry: 2013) and the independent report authored by Don Berwick (A Promise to learn – a commitment to act: 2013) starkly highlighted both the need for, and the challenges of, making improvements in the NHS system. The need for a systemic mindset shift was identified. Patient care needed to be relocated at the core of both clinical and non-clinical decision making, and a culture of blame replaced by support and learning. Indeed, Berwick’s underpinning challenge to the NHS was that it must become a ‘learning organisation’ which facilitates the development of its workforce and seeks to continuously improve itself.
Much was improved after the Mid Staffs experience. Despite organisational pressures (including ongoing systemic reorganisation in the NHS) there are many promising initiatives working towards improving the deficits highlighted by Francis and Berwick (Sign-up to Safety and East London Foundation Trust Quality Improvement are just two of the many ongoing initiatives).
But the reality remains that in a healthcare system where uncertainty is rife and money is tight there isn’t always time to release frontline workers to reflect on their practice and to learn from it. In fact, these pressures accentuate an approach to improvement where the emphasis is on DOING an improvement project; merely ticking it off a list of things-to-do. And this is when the phrase quality improvement is devalued as mere buzzwords rather than the watchwords they should be; because improvement is about much more than DOING a quality improvement project.
In his thought paper The Habits of an Improver: Thinking about learning for improvement in healthcare (2015) Bill Lucas underlines this risk. In the NHS, he states, “improvement tends to become ‘an improvement project’. Or, at an even more precise level, a single plan-do-study-act (PDSA) cycle.” The focus is on the underpinning improvement theory or a set of improvement tools and techniques. Theses tangible elements of improvement are easier to teach and assess. They meet the impetus to demonstrate that we are DOING improvement. But in focussing on these more tangible aspects we sidestep thinking on what it means to be an improver; to embody improvement.
Lucas suggests that alongside the tools and techniques of improvement we should also think about the habits or behaviours that improvers should embody. He outlines five key habits (Learning; Influencing; Resilience; Creativity; Systems Thinking) each of which has underpinning characteristics.
Image taken from: The habits of an improver: Thinking about learning for improvement in health care. The Health Foundation. 2015
This focus on habits enables designers and learners to focus on practical outcomes. It enables us to revisit improvement science from the learner’s perspective and to ask: What are the habits that build improvement capability? What habits are useful within your context? Which of these habits will enable you to achieve your improvement aims? How can we design our learning so that it better facilitates the development of habits?
Because above all else improvement science must be practical and it must have relevance to the real-world. By all means read about and understand improvement theory, and do select some practical tools to help you achieve your improvement aims. But developing the right habits and having the right mindset are just as important.
In this way the notion of quality improvement has a longevity beyond the buzz. It becomes a journey of continuous learning; it becomes a way of being as well as doing. If we refocus our approach with the habits of an improver in mind, perhaps we can really start to achieve Berwick’s vision of the NHS as a ‘learning organisation’.