Continuous Quality Improvement: A new concept for healthcare

Dr Manoj Jain

Five years ago, I was completely shaken off by the scores of infections that were occurring in my intensive care unit. They just seemed out of control even in a resource-rich country like the United States. Our ICU was rattled with six urinary tract infections per 1000 catheter-days, seven blood stream infections per 1000 line-days and seven ventilator associated pneumonia per 1000 ventilator-days - all above the national norms.

Yet, today I know better. Through a methodical process by which the aviation industry and the automotive industry have achieved successes, we have reduced our infection rates by half in our ICU. We have also reduced our adverse events by many folds. Now in a collaborative effort, such changes are being piloted in the heart of India in Indore, Madhya Pradesh at four hospitals.

So what is this process that is saving money, improving care, and saving lives? It is called continuous quality improvement (CQI).

What is CQI?

CQI (synonymous with total quality improvement) is a philosophy that we can continuously improve in a step by step manner - much like a mountain climber. The key is knowing how to climb (this is the process), to try different paths to the peak (learning by trial) and to hold the elevation we have gained (adopting the successful processes into our day to day routine).

Every MBA student knows about the CQI process, but in healthcare, we either do not know it or have failed to realise its potential. Today, doctors and executives in America and Europe are paying thousands of dollars to learn this process and have clinician accept this methodology for improvement.

Several institutes, such as the Institute for Healthcare Improvement (IHI) and Intermountain Healthcare are creating this revival of quality improvement in the healthcare arena. The end result is cost savings for the organisation, better care and lives saved for the patient and overall reduction of medical error.

CQI has four key elements as presented by Hubert Rampersad in the book Total Quality Management - An executive guide to continuous improvement. First is a problem solving discipline, second is interpersonal skills, third is teamwork and the last is a quality improvement process.

In this article I will focus on the quality improvement process and the model which is best presented by Langley and colleagues in their book 'The Improvement Guide - A Practical Approach to Enhancing Organisational Performance'.

Healthcare: A system property

The delivery of healthcare today is complex - it is a 'system' property not just an isolated event such as a doctor giving medicine to the patient. The tuberculosis programme in India has learned this well. The Directly Observed Treatment Short-course (DOTS) programme's success depends on how well the system works (a national protocol is developed-a physician makes a diagnosis of TB, the protocol is followed and re-evaluated, the medicines are delivered, follow up is done, data is evaluated). Lack of success is not due to individuals rather it is the responsibility of the system that was created and is being redesigned.

Three fundamental questions for achieving improvement

Improvement is based on knowledge. Knowledge must then be applied. The answers to three fundamental questions form the basis of improvement based on applied knowledge.

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in improvement?

All our lives, like Darwin's natural selection, we have used 'trial and error' to evolve and improve. The new process of improvement is similar but with a twist. It's not 'trial and error' but 'trial and learning'.

The above three questions lead to this new process of 'trial and learning'. Trail means we do a small test of change. Learning means that we identify the criteria that has led to the change and then we measure the change and incorporate it as our fundamental way of working.

What are we trying to accomplish? We may be trying to improve our cricket game or trying to reduce the infection rate in the ICU, but we must have an 'aims statement'. This statement must be focused, succinct and written down so that others can become partners in the process.

How will we know that a change is an improvement? This question implies that we must measure and if we improve and the improvement is sustained over time then we must conclude that the change lead to the improvement.

Plan-Do-Study-Act Cycle

What changes can we make that will result in improvement? So here lies the core of the improvement process. It is the PDSA cycle or the Plan, Do, Study and Act. What this emphasises is:

Plan: A change or test. Here you ask questions and predict what will change the process. You plan to carry out the cycle, the details of which include who, what where when.

Do: Carry out the plan. You collect the data and begin analysing the data

Study: Summarise what was learned by completing the analysis of the data and comparing the data to predictions

Act: Determine what changes are to be made and what will be the next cycle. Also, evaluate what changes to keep and what to discard?

The cycle is then repeated again and again, each time with a small test of change, data gathering, analysis and a decision to keep or discard the change.

Summary

As humans we will always strive for improvement. However we have the options of following trial and error where we have to wait decades for improvement to work or trial and learning where we can see change in days.

Healthcare is an ideal setting to test the model of change - and no doubt we have much to improve in the area of drug delivery, hospital care, medical error reduction, and hospital infection reduction.

The model of improvement of Plan-Do-Study-Act is the first bold step any executive or clinician can take in trying to improve care at his/her facility. Surprisingly, after the initial hesitation, the clinicians are often quick to adopt this method, because this process is data driven and utilises the rigorous scientific methods in which they are well trained.

Figure 1: The improvement model has three fundamental question and the answer to the third question is embedded in the results of the Plan-Do-Study-Act cycle.

Figure2: Adverse events per ICU day. Each annotation highlights a new small test of change in the PDSA cycle. The continuous data is analysed and recorded in run charts.

Figure3: Once the PDSA cycle is started, it is repeated a number of times until the desire result is achieved based on hunches and theories of what will bring about a change.

Figure4: The rates of infection were reduced after implementation of a quality improvement process. BSI - blood stream infections rates are per thousand line days, VAP- ventilator associated pneumonia rates per thousand ventilator days, UTI - urinary tract infections per 1000 urinary tract catheter days.

The writer is infectious disease specialist at Tennesse University, US. Email: mkjain@aol.com