Quality improvement

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In this assignment I will be reflecting on my quality improvement project

that was done within the team. This quality improvement project has
given me lots of knowledge and helped me understand leadership role in
health care sector. Hence I was able to analysis why we need change in
the health sector for quality improvement and overcome some of the
resistance we face while change takes place in the health organisation.
Colton (2000) states the origins of quality improvement are often trace
back to the work of W. Edwards Deming and Joseph Juran, who in the early
1950s were invited to Japan to help industry their recovery from the
devastation of World War 2. By late 1980s there was substantial evidence
that organisations implementing quality improvement methods were
experiencing significant gains in workmanship, customer satisfaction and
profitability.
While working in the team I have developed leadership qualities and steps
of quality improvement while doing the project. Nurses and doctors often
see the road to quality care as different journeys even though the route
may be the same and the ultimate destination should be the same. This
means constructive collaboration between doctors and nurses with
ultimate authority to care coming from the patients themselves. Nurses
view any health care plans for continuous quality improvement needing to
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include the patients needs, beliefs and capabilities. The goal of good
quality cost-effective health care is the balance between staff members
and the skill mix, and so therefore the importance of freer

communication between nursing and medicine is a likely benefit for

patients and their health outcomes. Alexander et al (2003) mentioned
nurses who engage in effective team work will help to restore the publics
confidence in the quality and safety of our health care system. In health
care there is

continuous

quality

improvement.

Continuous

quality

improvement can be described as a systematic approach to the

measurement, evaluation and improvement of the quality of all products
and services, through the use of disciplined inquiry and teamwork (Hunter
et al 1995).
In this project I have learnt that quality improvement efforts work best
when problems are addressed systematically using a consistent and
analytic approach that is the methodology shouldnt change just because
the problem changes. Keeping the steps to problem solving simple allows
me to learn the process and how to use the tools effectively. While
working with the team I learnt communication played important part in
quality improvement and all members of the team ideas were valued. Our
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team used mostly the virtual integrated practice. Mininick et al (2008)
described using one or more of four virtual integrated practice methods
such as:
Planned communication in which the members decide what date to
share, which information needs to be communicated in the real time
and how best to communicate.

Standardized clinical process that identify specific responsibilities for

each member of the team and structured workflow process through
the office or community.
Patient self management.
Group activity to enhance efficiency and consistency.
Bolton & Goodenough (2003) states quality improvement in nursing
was first introduced by Florence Nightingale during the American war.
Today nursing quality continues to look at processes, however has
evolved to an emphasis on patent care outcomes. I have learnt that
the hospital needs to support the nurses to enable them to exercise
their

professional

knowledge,

judgement

and

skills

to

initiate
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interventions to rescue patients from dire and costly consequences.
Bolton

&

Goodenough

(2003)

mentioned

magnet

hospital

organisational structure enables professional nurses to use their

knowledge to do what they know should be done for clients in a
manner consistent and professional standard. This is key to provide
high quality and cost effective patient care because registered nurses
are health care providers who coordinate care, who perform round the
clock patient surveillance and they are the physicians primary source
of information about changes in their patients.
My reflection towards quality improvement has six steps and our team
also used the six steps. Theses steps are:

Problem identification with in health care

Root cause identification and analysis
Optimal solution based on root causes
Finalise how the corrective action will be implemented
Implement the plan

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Track the effectiveness of the implementation and verify that the
desired results are met.
Nursing performance improvement process described as a vital
contribution nursing makes to performance improvement in a
magnet designated nursing service. Nursing is crucial at every level
of performance improvement in health care

organisations when

quality activity address patent process and outcomes because the

registered nurses is at the centre of the interdisciplinary team role
of coordinator of care (Bolton & Goodenough 2003) . I believe it is
essential to include direct patient care providers in the quality work
because those at the bedside have a comprehensive appreciation of
patients needs. The demand for competency and quality continues
to be a driving force as the health care environment becomes more
complex and in some cases frenetic in its propensity for rapid
change. Through

continuous performance improvement and research efforts that we will

achieve organisational valves and honour our social contract to provide
quality care.

Quality improvement

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There were some issues used while doing the project such as what steps
to follow, inviting some management officials for the meeting but they will
not turn up. Alexander and Herald (2009) mentioned some related issues
in quality improvement effectiveness studies is that it is often difficult to
determine whether the intervention was fully implemented. Indeed the
vast majority of studies assume that the change has been successfully
implemented and the research focuses on testing for empirical association
between the unmeasured innovation and the outcome of interest. I have
also learnt plan-do-study-act cycles of total quality management and
continuous improvement.

The Deming cycle or PDSA cycle is a

continuous quality improvement consisting of a logical sequence of four

repetitive steps for continuous improvement and learning. Plan, do, study
and act as it was invented by statistician W. Edwards Deming. (Walton
and Deming 1986). A more integrated system through a new leadership
culture is much more likely to succeed in achieving better quality and
health gains.
Leaders need time to stand back, to work ON as well as IN the business.
Time to reflect, to plan, to evaluate, to develop the vision. If we spend
10% of our time working on the business (which we may feel shy about
because we are not producing), we can actually achieve a greater
productivity because we keep our direction. A commitment to deliver high
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quality care should be at heart of everyday clinical practice as I have

learnt during my nursing career. Clinical governance is to be the main
vehicle for continuous improving the quality of patient care and
developing the capacity of the NHS in England to maintain high standards
(including dealing with poor professional performance). It requires an
organisation

wide

transformation,

clinical

leadership

and

positive

organisational cultures are particularly important. (Scally&Donaldson

1998). Scally & Donaldson (1998) defined clinical governance is a system
through

which NHS organisation are accountable for continuously

improving the quality of their services and safe guarding high standard to
be useful. Thornely et al (2003) stated Quality improvement is where we
need to head combining quality assurance activities with an explicit
concern for quality and continuous improvement. Quality improvement is
underpinned by incremental change where all individuals, teams and
organisations (from small providers to the Ministry of Health) critically
evaluate their practice, incorporate new learning into their work and,
importantly, share their learning with others (as per figure 1 below). This
is not a simple linear process with a beginning and an end, but an ongoing
cycle of reflection and action. A quality-improvement approach calls for us
to examine not just what we are doing (outputs), but also how we are
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doing it and what we are getting the outcomes. This implies monitoring
the total process of care, and measurement of outcomes rather than
outputs.

Figure 1. Quality dimensions for the New Zealand health and disability
system. Thornely et al (2003).

However a major shift towards improving quality will occur only if district
health boards

in the middle range of health care professionals

performance are transformed. This is if the mean of the quality curve is

shifted. This will require more widespread adoption of the principles and
methods of continuous quality improvement initially developed in the
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industrial sector then later applied in the health care. These involve
district health board wide approach to quality improvement with emphasis
on preventing adverse outcomes through simplifying and improving the
process of care. Leadership and commitment from the top management,
teamwork, consumer focus and good data are also important. Hunter et al
(1995) mentioned for quality improvement to be successful, it is critical
that data is

generated be understood and used daily. By excising data gathering and

data describing techniques, such as statistical process control, employees
can determine what variability in the process can be reduced and how to
eliminate it. Working in teams is the most instrumental principle in the
foundation in quality improvement. Using an empowered employee to
provide solutions to problems, leadership has improved it chances of
producing a quality process without problems.
Hunter et al (1995) described five steps for leaders to prompt their health
professionals to do some of the following:
Find the problem
Fix the problem

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Have no barriers to customer

Perform their ideas
Make own business decisions through appropriate actions.
By emphazing active teamwork in the part of all team participants, this
model exemplifies tow heads are better than one. (Hunter et al (1995). I
believe continuous quality improvement is crucial to maintenance of
quality care and assist in the progressive improvement of the care
delivered. Akpunonu et al (1994) suggest that academic faculty

should play leadership roles in the continuous quality improvement

process and include teaching models. Improved and increased academic
faculty participation could be realized, when educational values, research
activities and cost analysis are incorporated in to the continuous quality
improvement process. However Su &Sax (2009) suggest many standards
indicators cannot measure users perceived quality because they focus on
the professionals perspective and quality measured from health providers
viewpoint, is often different from the users perception. Generally users of
health services focus more on the interpersonal component of the process
of care. Health care providers and management emphasis more on the
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structural and technical components and high level planners and policy
makers are more interested in outcomes and patterns of needs.
Ware et al described quality using 8 dimensions:

Interpersonal and technical quality of care.

Finance

Accessibility

Availability
Physical environment
Efficiency

Continuity of care.
Weiner et al (1996) states health workers are apparently reluctant to
participate in continuous quality improvement due to distrust of hospital
motives , lack of time , and fear that emphasis on reducing variation in
clinical process will compromise their ability to tailor care to meet
individual patients needs. I have experienced that workforce need training
programs in quality assessment and assurance, the pressures leading to
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the current situation are coming from diverse external sources. Ziegenfuss
(1991) suggest diversity of pressure representing the external push for
quality improvement includes issues in technological, economic, political,
legal, educational, demographic, cultural, and sociological and resource
areas.
My reflection is that there is a link between an organisational leadership
commitment

and

culture

and

its

ability

to

implement

quality

improvement initiative.

Conclusion
In terms of leadership and quality improvement I consider a hospital
emphasis on innovation and teamwork because quality improvement
principles and techniques represent a substantial departure from
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traditional hospital quality assurance methods, hospital with cultures
that emphasize innovation and risk taking maybe better prepared to
adopt quality improvement. Parker et al (1999) suggest that managers
interested in developing a strong quality improvement orientation for
their organisation need to be concerned with some existing managerial
characteric. I believe a key component to any solution; however, is the
routine availability of information on performance at all levels
making such information available will require a major overhaul of our
current health systems.

References

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Akpunnonu, B., Mutgi, A., Federman, D., Wasielewski, N., White, P., &
Donabedian, H. (1994). Enhancing faculty participation and interest in
Quality improvement in academic centres. American Journal of Medical
Quality. 9 (18), 18-23.
Alexander, C., Campbell, D., Lieberman, J., Mabey, T., MARKEN, S., Myers.,
Pengra, A., Reyburn-Orne, T., Sunden,T., & Zwingman-Bagley,C. (2003).
Quality improvement processes in growing a service line. Journal of
Nursing Administration Quaterly. 27(4), 297-306.
Alexander, J,. & Hearld, L. (2009). What can we learn from quality
improvement research: a critical review of research methods. Journal of
Medical Care Research and review. 66 (3), 235-271.
Bolton, L. & Goodenough, A. (2003). A magnet nursing service approach to
nursing role in quality improvement. Journal of nursing administration
Quarterly. 27(4), 344-354.
Colton, D. (2000). Quality improvement in health care: conceptual and
historical foundation. Evaluation the Health Professions. 23(1), 7-42.
Deming, E. (1986).The Deming Cycle. Retrieved October 10 2009,
http://www.valuebasedmanagement.net/methods_demingcycle

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Hunter, D,. Kernan, M., & Grubbs, R., (1995). Team works: a model for
continuous quality improvement in the health care industry. American
Journal of Medical Quality. 10(4).

Mcglynn, E., Asch, S., Adams, J., Keesey, J., Hicks, J., Decrstrofaro, A., &
Kerr, E, A., (2003). The quality of health care delivered to adults in the
United States. The New England Journal of Medicine. 348 (26), 2635-2645.
Minmick, A., Catrambone, C., Rothschild, S., &Halstead, L. (2008). A nurse
coach quality improvement intervention. Western Journal of Nursing
research. 30(6), 690-703.
Parker, V., Wubbenhost, W., Young, G., Desai, K., & Charns, M. (1999).
Implementing quality improvement in hospital: Role of leadership and
culture. American Journal of Medical Quality. 14, 64-69.
Scally, B, G. & Donaldson, L. (1998). Clinical governance and the drive for
quality improvement in new NHS in England. British Medical Journal. 317.
61-65.
Su, T. & Sax, S. (2009). Key quality Aspect: a fundamental step for quality
improvement in a resource poor setting. Asia Pacific Journal of Public
Health. 1. 1-9.
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Thornley ,L., Logan, R.,& Bloomfield, A. (2003). Quality Improvement :
Time for radical thought and measurable action. The

New Zealand

Medical Journal . 116 (1181). Retrieved on the October 27 2009 ,

http://www.nzmj.com/journal/116-1181/579/.
Ware ,J,E., Snyder,M , K., Wright,R.,&davies,A,R. (1983) . Defining and
measuring patient satisfaction with medical care. Evaluation Program
Plann. 6(2), 247-263.

Weiner, B, J., Alexander, J, A,. & Shortell, S, M,. (1996). Leadership for
quality improvement in health care: empirical evidence on hospital
boards, managers and physicians. Journal of Medical Care Research and
Review. 53 (4), 397-409.
Ziegenfuss, J, T. (1991). Organisational barriers to quality improvement in
medical and health care organisations. American Journal of Medical
Quality. 6 (4), 115-121.

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