Q Exchange
Back to Basics. Let’s get our terminology right when talking about QI
- Idea
- 2018
Meet the team: B2B
Also:
- David Joseph McLaren, Researcher/Project Manager, NHS Tayside, Scotland
Have a look at Juran’s definitions of the word quality:
1. “Quality” means those features of products/services which meet customer needs and thereby provide customer satisfaction. In this sense, the meaning of quality is orientated to income. The purpose of such higher quality is to provide greater customer satisfaction and, one hopes, to increase income. However, providing more and/or better quality features usually requires an investment and hence usually involves increases in costs. Higher quality in this sense usually “costs more”.
2. “Quality” means freedom from deficiencies – freedom from errors that require doing work over again (rework) or that results in field failures, customer dissatisfaction, customer claims, and so on. In this sense, the meaning of quality is oriented to costs, and higher quality usually “costs less”.
The following helps to explain why some meetings on managing for quality end in confusion.
Product features that meet customer needs – Higher quality enables organisations to:
- Increase customer satisfaction
- Make products or services saleable
- Meet competition
- Increase market share
- Provide sales income
- Secure premium prices.
The major effect is on sales. Usually, higher quality cost more.
Freedom from deficiencies – Higher quality enables organisations to:
- Reduce error rates
- Reduce rework, waste
- Reduce field failures, warranty charges
- Reduce customer dissatisfaction
- Reduce inspection, test
- Shorten time to put new products/services on the market
- Increase yields, capacity
- Improve delivery performance.
Major effect is on costs. Usually, higher quality costs less.
They are different but it is important that you know which is being used by your organisation.
Have you heard of Big Q and little q? Are Policy, process and procedure all the same thing? What is the difference between Quality planning, Quality control (QC), Quality assurance (QA) and Quality improvement?
Now have a look at Big Q and little q:
Definition of Big Q and little q: Big Q is defined as managing the quality in all business processes, products and services, and small q is defined as mainly product quality with a much narrower scope.
This difference between Big Q and little q is important! Is it understood in the NHS?
This project will produce some materials that can be used by Q members and the wider NHS to inform and educate people in these very important different interpretations of what quality and quality improvement is all about.
The project will undertake some research from within the Q membership to find out whether current quality improvement (QI) activity in the NHS is defined by Big Q or little q. If, as expected, it is found to be little q then this situation needs to change if the Q Community are going to have the desired effect on quality within the NHS.
British industry drives forward ‘Continuous Improvement’, the NHS drives forward ‘Quality Improvement’. Is there a difference?
What is the difference between ‘Quality Improvement’ and ‘Patient Safety’?
I’ve put together a list of the documents that I have found to be most consistent and useful when researching improvement in the NHS. Here it is:
- Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. An independent report for the Department of Health by Lord Carter of Coles. February 2016 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productivity_A.pdf
- The challenge and potential of whole system flow: Improving the flow of people, information and resources across whole health and social care economies by David Fillingham, Bryan Jones and Penny Pereira. The Health Foundation and AQuA (Advancing Quality Alliance). December 2016 www.health.org.uk/sites/health/files/ChallengeAndPotentialOfWholeSystemFlow.pdf
- National Safety Standards for Invasive Procedures (NatSSIPs). NHS England patient Safety Domain. 07 September 2015 https://www.england.nhs.uk/wp-content/uploads/2015/…/natssips-safety-standards.pdf
- Getting it Right First Time: Improving the Quality of Orthopaedic Care within the National Health Service in England by Professor Timothy WR Briggs. Royal National Orthopaedic Hospital. September 2012 http://www.gettingitrightfirsttime.com/report/
- Releasing Time to Care: The Productive Ward series. NHS Institute for Innovation and Improvement. May 2008
- Organising care at the NHS front line – Who is responsible?. The King’s Fund. May 2017. https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Organising_care_NHS_front_line_Kings_Fund_May_2017.pdf
- Quality improvement made simple – What everyone should know about health care quality improvement . The Health Foundation, Quick guide, August 2013. https://s20056.pcdn.co/wp-content/uploads/2018/05/QualityImprovementMadeSimple.pdf
In the words of Don Berwick ‘Go to the gemba’. We can only do that by engaging with the workforce – not patient representatives!
Going to the gemba:
- Use patient feedback to identify top sources of dissatisfaction (or opportunities).
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Assign a team to each process that needs to be redesigned. Give the team special sponsorship and resources.
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Develop and implement improvements in an expedited time frame.
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Use measurements to continually improve the process.
Although this Q Exchange idea has not been shortlisted I do intend to carry on with the project. I will post updates, ask for comments and publish the final pamphlet via the ‘Process Visualization’ SIG. If you would like to contribute to this important work then please join the SIG. Regards Tom
How you can contribute
- Support for this project.
- Your comments on the project and on your understanding of the topic.
- Is your organisation in the Big Q category? Please comment.
- AIMS form submitted!! Please continue to support.
Further information
Does quality improvement improve quaity (PDF, 185KB)
Comments
Mark Sadler 19 Jun 2019
Nice idea Tom,
I have to agree, Q needs to push the basics. Education is key! Perhaps you could ask Q to email a PDF to all members? Perhaps Q should accept submissions which are educational and mail them out or feature them on the front page of the website each month?
When institutions have too much money they aren't used to thinking about how to maximise the value of the money and things they already have.... The low hanging fruit is overlooked in favour of something shiny and expensive.
Thomas John Rose 20 Jun 2019
Thanks for your comment Mark. I'm almost ready to publish the work that I've been doing for this project. I'll send you a draft for comment before I publish if you would like.
Regards
Tom
Emma Adams 9 Aug 2018
Hi Tom. Good to speak to you on the phone. As discussed, we have been looking at quality in its widest sense through some of the Q Visits available to Q members. Often it is better to "see" how things can be improved, rather than read about it. We would be happy to explore any suggestions you might have for a Q visit that demonstrates some of the concepts you have introduced above, and perhaps to combine that with some of the theory/knowledge that underpins this. Kind regards, Emma
Chris Collison 22 Jul 2018
Hi Tom,
My project has made is through to the next round. If we get over the final hurdle, then I'll be in touch to see how we can be faithful to your project intent in any products/frameworks which arise from ours...
Cheers,
Chris
Thomas John Rose 29 Jul 2018
Thanks Chris. Regards Tom
Thomas John Rose 21 Jul 2018
Although this Q Exchange idea has not been shortlisted I do intend to carry on with the project. I will post updates, ask for comments and publish the final pamphlet via the 'Process Visualization' SIG. If you would like to contribute to this important work then please join the SIG. Regards Tom
Caroline Bruckner-holt 17 Jun 2018
This is a good proposed project and very much needed....good luck with the funding! Gaining a better understanding of this within the NHS will be invaluable and enlightening...a benefit to all Q members I am sure.
Thomas John Rose 19 Jun 2018
Thank you for your very supportive comments Caroline. Regards Tom
Thomas John Rose 12 Jun 2018
Nancy, Thank you very much for your comments. You have cleared up some of the confusion in my mind regarding the NHS's approach to improvement. What I still don't understand is why are they using all the right improvement tools for the wrong sort of improvement, and vice-versa! I feel even more that the work outlined in this project idea is urgently required - particularly for the Q community members. Regards Tom
Thomas John Rose 4 Jun 2018
Dear Tom
Thank you very much for reading the small entry in Quality World, and writing.
I read your online document with interest, and thought it would be easier to email than write a comment.
It is an obvious statement that healthcare is different from business and industry and ‘product’-oriented definitions of quality are difficult to apply to healthcare delivery. There are two ways in which quality is ‘focused’ in healthcare, how well the ‘customer’ is treated, referred to as ‘patient experience’, and how well the patient’s clinical condition is managed, referred to generally as ‘clinical effectiveness’. Both these concepts are embedded in quality in healthcare, as it relates to Juran’s first definition of quality. Another concept referred to as ‘patient safety’ addresses the second definition of quality. In other words, because the concept is so complex in healthcare, the industry has different concepts for each aspect of ‘quality'.
Most people who think about ‘quality’ in healthcare settings tend to define quality as multidimensional. A frequent cited list of the important dimensions included that healthcare is: acceptable as an experience (to patients), accessible (can get it), appropriate (right decisions made), effective (the right way clinically), efficacious (right clinical result), efficient (least waste), safe (no harm), and timely (no delay that could cause harm), adapted from Institute of Medicine. Crossing the Quality Chasm. Washington DC: National Academy Press; 2001. Available at: www.nationalacademies. org/hmd/~/media/Files/ReportFiles/2001/Crossing-the-Quality-Chasm/Quality Chasm 2001 report brief.pdf
There is no NHS-wide definition of ‘quality improvement’ and there is considerable misunderstanding about what quality improvement should mean in healthcare settings. Many staff think that ‘improvement’ and ‘change’ are the same; they say ‘improvement’ but they mean ‘change’. We have researched definitions of quality improvement applied to healthcare settings and we use the definition derived by widespread consensus among healthcare professionals in the USA: Systematic, data-guided activities designed to bring about immediate, positive changes in the delivery of health care in particular settings (Lynn J, Baily MA, Bottrell M, Jennings B, Levine RJ, Davidoff F, Casarett D, Corrigan J, Fox E, Wynia MK, Agich GJ, O’Kane M, Speroff T, Schyve P, Batalden P, Tunis S, Berlinger N, Cronenwett L, Fitzmaurice JM, Dubler NN, James B. The ethics of using quality improvement methods in health care. Ann Intern Med 2007;146:666–73.) To force the issue, we have said that improvement is an outcome that has to be shown by a statistically significantly or clinically important effect of change in an aspect of quality being addressed.
NHS organisations are using a variety of approaches to quality improvement. Some are using lean almost exclusively; some are using Nolan and Nolan’s generic model for improvement, and a few are developing teamwork to achieve substantial improvements in the quality (defined by one or more of the concepts above) of care provided to patients.
Best wishes
Nancy Dixon
Nancy.Dixon@hqq.co.uk
Healthcare Quality Quest Ltd
Chris Collison 1 Jun 2018
Hi Tom,
I think this is an important bit of foundational work, and it fits really well with my Q-exchange idea just as you suggested.
If we both get through, let's make sure that we keep in step. It would be great to involve you in the work to put some flesh on the bones of a model of practice - let's make sure that we have the correct tissue type!
Thomas John Rose 1 Jun 2018
Chris, I'm up for collaborative effort. Looking forward to it. Regards Tom
Hawys Tomos 31 May 2018
Hi Tom. This is an interesting topic! I’m personally not a fan of jargon as it tends to alienate people, and when we’re talking about the NHS – a health service for everyone – I think transparency becomes even more important than in other organisations and sectors. I have to admit, as a designer specialising in healthcare, but not actually being ‘within’ the system, I am often dumbstruck by the jargon and acronyms. (I’m keen to point out that I actually value this naivety, because most people accessing services will be in a similarly naïve position).
My impression of ‘QI’ when spoken about in the context of health and care, is that it’s very different to the ‘quality’ spoken about in other industries. For example, I’m familiar with the quality assurance (QA) of products and services, or the quality control (QC) of outputs in design and engineering, and the strict standards and processes that they involve, but I have never equated them with quality improvement (QI) in healthcare.
I think it’s interesting that you’ve focussed specifically on the word ‘quality’ rather than the ‘improvement’. My impression is that the two words have lost their original individual meanings and merged to mean something very specific in this context – not just the sum of the two words, but a new ‘catch-all’ term for so many different things. The fact that they’re usually shortened to just the initials, ‘QI’, really emphasises this to me, as an ‘outsider’ looking in. I sometimes wonder whether the word ‘improvement’ alone would be more appropriate than ‘quality improvement’.
The Health Foundation’s guide is a useful resource. However, I often still don’t understand the use of the term in the field, as people seem to use it for so many different things. I think it could be argued that it’s become a ‘buzzword’ and as such is in danger of losing whatever meaning it has. I think one of the challenges is that the term, utilised in the healthcare context, needs to encompass so many vastly varying systems, approaches, topics, objects, pathways, roles… you name it. QA and QC, on the other hand, have very well defined ‘edges’. I guess, what I would ask is, what is the desired output / end-result of the use of this term, and is this accurately reflected in people’s perceptions of it when it’s used, and their resulting actions?
Thomas John Rose 1 Jun 2018
Hawys, Thank you very much for your very intuitive comments to my B2B ideas page. I think that you have made a very good explanation of the confusion I, and I'm sure others also, have regarding QI in the NHS and particularly within the Q membership. I'm sure that this confusion inhibits communication between Q members.
I have made the point, at the end of my project page, that industry do not use the term 'quality improvement' (QI) generally but prefer the term 'continuous improvement'.
I think that the NHS would be hard pressed to show any QA or QC in their processes generally and this is the area where I think Q should be more focused, but, prior to that, there needs to be better understanding of the subject hence the need for the B2B idea.
I will try to change the focus of my idea from quality to improvement although 'Quality' Management, QA and QC, is the name of the game - but only if by Quality we are talking about Big Q and not little q! Regards Tom
Thomas John Rose 28 May 2018
Stephanie, Thank you for your support. Whether this work is done via this project or through some other medium, I do think that it is important that it is done sooner rather than later. Regards Tom
Thomas John Rose 22 May 2018
Thanks for your support Helen. I know that difficult subject for the NHS! You can get a better insight into the issues if you compare this document
https://www.rcplondon.ac.uk/projects/outputs/future-hospital-programme-delivering-future-hospital
with the one included under 'further information' above. I'd be interested in your thoughts. Regards Tom
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