Resources Module 7: Using Quality Improvement Methods and Tools to Improve Patient Safety
In 1976, Dr. Jim Styner, an orthopedic surgeon, crashed his small plane into a cornfield in Nebraska, sustaining serious injuries. His wife was killed, and 3 of their 4 children were critically injured. At the local hospital, the care that he and his children received was inadequate, even by standards in those days. "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed," Dr. Styner said.
His family's tragedy and the medical mistakes that followed gave birth to Advanced Trauma Life Support (ATLS) and changed the standard of care in the first hour after trauma.
Dr. Styner helped produce the initial ATLS course. In 1980, the American College of Surgeons Committee on Trauma adopted ATLS and began disseminating the course worldwide. It has become the standard for trauma care in US emergency departments and advanced paramedical services. The Society of Trauma Nurses and National Association of Emergency Medical Technicians have developed similar programs based on ATLS.
Quality improvement method employed in this case is Clinical Practice Improvement (CPI). Before delving into this method, it will be prudent to start from the basics of quality improvement.
Using quality improvement methods and tools to improve safety
Quality improvement (QI) methods have been used for decades in other industries. In contrast, health-care professionals may be less familiar with the goal of improving quality of care, which involves changing the way they and the systems function in order to achieve better outcomes.
Quality of care and patient safety requires understanding of the processes of patient care, as well as the ability to measure patient outcomes and test whether the interventions used to address a problem are effective. Without outcomes research and measurement, it is difficult to know whether the steps taken actually improved a given risk situation.
W.E. Deming described the following four components of knowledge that underpin improvement: appreciation of a system; understanding of variation; the theory of knowledge; and psychology.
The basic principles of quality improvement are: patient/customer focus, strong leadership, involvement of all team members, use of a process approach, use of a systems approach to management, continuous improvement, a factual approach to decision-making and relationships that are mutually beneficial to all parties Most improvement models involve a questioning phase, followed by the PDSA (Plan, Do, Study, Act) cycle (Deming).
Key questions in any improvement process are:
1. What are we trying to accomplish
2. How will we know whether a change constitutes or has resulted in an improvement?
Measurement is an essential component of improvement as it forces researchers to look at what they do and how they do it. All improvement methods rely on measurement. Most activities in health care can be measured, yet they are not. There is strong evidence that when people use the appropriate tools to measure change, significant improvements can be made.
There are three main types of measures used in improvement:
Outcome measures: Examples of outcome measures include frequency of adverse events, number of unexpected deaths, patient satisfaction surveys and other processes that capture patients’ and their families’ experiences.
Process measures: Process measures refer to measurements of the workings of a system. These measures focus on the components of systems associated with a particular negative outcome, as opposed to the incidence of these events.
Balancing measures: These measures are used to ensure that any change does not create additional problems to a patient resulting in an adverse event. For example, a balancing measure might involve making sure that efforts to reduce the length of stay in hospital for some patients do not lead to increased readmission rates for those patients who could not take care of themselves.
The most popular and effective methods leading to significant improvements in health care are:
• Clinical Practice Improvement (CPI): This method is used by health-care professionals to improve the quality and safety of health service delivery. It does this through a detailed examination of the processes and outcomes in clinical care. CPI must cover each of the following five phases: Project Phase, Diagnostic Phase, Intervention Phase, Impact and Implementation Phase, Sustaining and Improvement Phase
• Failure Modes and Effects Analysis (FMEA): FMEA is a systematic and proactive approach that seeks to find and identify possible failures in the system, potential weaknesses, in order to implement strategies to prevent the failures from occurring. FMEA is usually a component of larger quality improvement efforts being undertaken by a health-care organization or hospital and involves a three-step process: risk assessment, implementation and evaluation. FMEA is useful in measuring and evaluating a new process prior to implementation and in assessing the impact of an improvement to an existing system or process.
• Root Cause Analysis (RCA): It is a structured approach to incident analysis. The RCA model focuses on prevention, not blame or punishment. The focus of this type of analysis is on system-level vulnerabilities as opposed to individual performance. The model examines multiple factors, such as communication, training, fatigue, scheduling of tasks/activities and personnel, environment, equipment, rules, policies and barriers.
Several tools for organizing and analysing data are used in healthcare quality improvement efforts. Many hospitals and clinics, routinely collect and use data for the services being delivered and statistically analyse the data to report to the health authorities or the head of the health service. The following tools are commonly used in quality improvement efforts: flowcharts; cause and effect diagrams (also known as Ishikawa or fishbone diagrams); Pareto charts; and run charts. (WHO, 2012) (WHO, 2012a) (WHO, 2012b)
Optional reading for this Topic includes: QI tools by Quality Improvement Hub, NHS Education for Scotland and by VA National Center for Patient Safety
Esanum (2021) James K Styner: How a tragedy created the ATLS [Online][Accessed on 28 April 2021] Available at [https://www.esanum.com/today/posts/james-k-styner-how-a-tragedy-created-the-atls]
NHS Education for Scotland (NHS, 2021) Quality Improvement Zone. QI Tools [Online][Accessed on 28 April 2021][Available at https://learn.nes.nhs.scot/1262/quality-improvement-zone/qi-tools]
VA National Center for Patient Safety (VA) (2021) Healthcare Failure Mode and Effect Analysis. US Department of Veterans Affairs [Online][Accessed on 28 April 2021][Available at https://www.patientsafety.va.gov/professionals/onthejob/hfmea.asp]
World Health Organization (WHO) (2012). Quality improvement methods [Online][Accessed on 28 April 2021][Available at http://www.who.int/patientsafety/education/curriculum/course7a_handout.pdf]
World Health Organization (WHO) (2012a). Root cause analysis [Online][Accessed on 28 April 2021][Available at http://www.who.int/patientsafety/education/curriculum/course5a_handout.pdf]
World Health Organization (WHO) (2012b). Using quality improvement methods to improve care [Online][Accessed on 28 April 2021][Available at http://www.who.int/patientsafety/education/curriculum/course7_handout.pdf]