How to move beyond quality improvement projectsAmar Shah chief quality officer, East London NHS Foundation Trust; national improvement lead for theMental Health Safety Improvement Programme, NHS Improvement and RCPsych; quality improvementlead and chair of QI faculty, Royal College of Psychiatrists

What you need to know

• Quality improvement, by itself, does not represent aholistic approach to managing quality

• Quality improvement needs to be used alongsidequality planning, quality assurance, and qualitycontrol to create a single, consistent managementsystem

• Knowing when and how to use each of these fourapproaches, and creating an appropriate balanceacross all four, is the gold standard

In recent years we have seen a proliferation in theinterest and use of quality improvement in healthand healthcare. This represents a promising shift inour mental models about how to solve some of ourmost complexquality issues.Alongside the increasinguse of the word “improvement” in our everydaylanguage within healthcare, there are differences inunderstanding of what exactly we mean by the term“quality improvement.” This article explores thedifferencebetweenquality improvementandaqualitymanagement system, by defining qualityimprovement and describing how to best use qualityimprovement alongside control, assurance, andplanning as part of a more holistic managementsystem focused on quality.

Is quality improvement the same asimproving quality?Quality improvement should be seen as part of anoverall system of quality management. Qualityimprovement is a systematic and applied approachto solving a complex issue, through testing andlearning, measuring as you go, and deeply involvingthose closest to the issue in the improvementprocess.1 Anyone who has undertaken qualityimprovement work will testify that it is not easy—youare generally tackling a problem to which we do notknow the solution, and where part of the answer isabout behaviours, and hearts and minds. Qualityimprovement can be used to reduce unwarrantedvariation, reliably implement interventions that havebeen shown to improve outcomes, or discover newsolutions through a process of innovation. As we arelooking to learn whether a particular service or issuehas improved, the process also involves reviewingdata to see whether something has changed overtime.2 A range of different methods can be used, fromthe Institute for Healthcare Improvement’s Model forImprovement to the Toyota Production System andSix Sigma. The evidence suggests that there is nosignificant difference in efficacy among thesedifferent methods, the key seems to be fidelity to agiven method for a long period of time to embedchanges into the organisational culture.3

Just as all care is delivered in teams, qualityimprovement is best done as a team, of staff andpatients working together on what matters most. Weought to reserve our limited capacity to undertakequality improvement for where it will have thegreatest return—to solve complex adaptive problems.Factors related to the success of quality improvementefforts include aspects related to the qualityimprovement project team (diversity, involvement ofkey stakeholders, experience of qualityimprovement), themicrosystem (leadership, culture,capability and motivation to change) and the widerenvironment (organisational culture, leadership,external motivators).4

Whatelse isneededforqualitymanagement?If we’re using quality improvement to solve complexadaptive problems, then we need other approachesfor different types of problem. Quality improvementworks well as part of a quality management systemthat incorporates several approaches to ensure thatwe are meeting, and exceeding, the needs of thosewe serve.5

Planning or redesignPlanning or redesign involves understanding theneeds of the population, customer, or service user,and looking at the evidence and best practice acrossthe industry in order to ascertain what structures andprocesses we need to put in place to optimiseoutcomes.6 This is something we might do once ayear as part of our annual planningor commissioningprocess. The quality planning process helps us setgoals, through understanding the needs and desiresof the end user. We can then design what we need toput in place within our operational structures andprocesses to achieve this, using the available livedexperience and knowledge, as well as the evidencebase and innovation literature.7

AssuranceOne of the main mechanisms used traditionally inhealthcare to improve quality has been qualityassurance.Assurance involves occasionally checkingthat we are meeting a particular standard orthreshold. This is usually about achieving standardsand obtaining a simple binary response—OK or notOK.Audit, accreditation, and inspection are commonmechanisms of assurance in healthcare.8 Whileassurance is helpful in ensuring we are meeting setstandards and identifying gaps that need addressing,it isn’t a mechanism to help us to achieve new levelsof performance. Innovation and creativity are neededto discover new practice, and many issues requirebehavioural change. Theoccasional checkingprocess

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East London NHS Foundation Trust,London, E1 8DE, UK

amarshah@nhs.net, Twitter:@DrAmarShah

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is not conducive to exploration, deeper insight, and ownership ofchange.

Quality controlQuality control is probably the least developed part of qualitymanagement in healthcare. This incorporates good operationalmanagement,monitoring performance in real timewithin the team,taking action when needed to bring the system back into control,and escalating rapidly when we can’t solve a problem.9 Qualitycontrol ought to be owned and managed by the team or servicerather than be supported from outside the team (as assurance often

is). Features of a robust quality control system include visualmanagement that allows a transparent display of the key metricsfor the service; regular huddles around the data to discuss and takeaction; and rapid escalation when problems can’t be solved withinthe team.

How can these four approaches be combined within theservice?Together, improvement, assurance, planning and control form thequality management system (fig 1).

Fig 1 | The four aspects of a quality management system: planning, control, assurance, and improvement

This draws on the work of Joseph Juran, who developed the qualitytrilogyofplanning, control and improvement.4Whilemanufacturinghas largely managed to eradicate assurance due to the high levelof reliability and advanced quality control systems, in healthcarethere is still a significant portion of activity devoted to assurance –both within organisations, and from outside organisations. A keychallenge in healthcare is to balance energy and activity acrossthese four domains: planning ought to be an annual activity;

improvement should be used in short bursts to achieve new levelsof performance; assurance ought to be used occasionally to checkwhether standards are maintained; and control should be the waydaily work is managed in a team.

Different tools and approaches to use in the four aspects ofquality managementFigure 2 shows some of the improvement tools that might be usedwithin each type of quality function.

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Fig 2 | Examples of tools that might be used within each of the four aspects of a quality management system

One of the main responsibilities leaders have within teams andorganisations is to ensure the four different aspects of qualitymanagement are balanced and that the appropriate approach fora particular type of opportunity is deployed. In order to support ourteams and people in managing quality, it will be important to

understand how different members of the team can contribute toeach of the four aspects of quality management. Everyone in theteam, including patients, should play an active part in a robustquality management system (table 1).

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Table 1 | Roles of different team members within each aspect of the quality management system?

Quality improvementQuality assuranceQuality controlQuality planning

• Support regular time for teamreflection and help the team andservice users identify the priority areafor improvement• Bring together a diverse projectteam and help it find the time toimprove the service and to removebarriers• Support the team to share theirlearning

• Share assurance datawith the teamand helpmake sense of the differenttypes of data• Proactively take action to addressgaps against agreed standards

• Be transparent about how the teamis performing, and take correctiveaction when needed• Empower the team to share andsolve small problems on a daily basis• Stay attuned to hard and softintelligence to ensure gains areachieved and sustained

• Contribute to service planning andcommissioning• Put in place the structures andprocesses for service delivery

Team leader

• Share views with the team aboutbiggest opportunity for improvement• Contribute to change ideas to thearea that the team is currentlyworking on• Use the tools of QI to develop astrategy, test ideas and implementthese into daily practice

• Participate in assurance activitiessuch as audit, inspection, learninglessons

•Monitor how the team is performing• Listen to the feedback from serviceusers, customers, and carers• Proactively raise and solveproblems on a daily basis• Ensure that daily practice meetsagreed standards, or justify whenpractice departs from these

—Team member

• Contribute views about the team’sbiggest area of opportunity• Use clinical expertise and researchknowledge to bring ideas to the team• Support the team to involve adiverse range of people inimprovement work• Help the team find time to improvethe service and remove barriers tothis

• Help identify and set the standardsagainst which the team is measured• Participate in assurance activities

•Monitor how the team is performing• Listen to the feedback from serviceusers, customers, and carers• Proactively raise and solveproblems on a daily basis• Ensure that daily practice meetsagreed standards, or justify whenpractice departs from these

• Identify the best service model tomeet the needs of the population,using clinical expertise andknowledge of the evidence

Consultant or senior clinician

• Help the team determine the bigissues that need improving• Be able to help inform how theservice improves• Be able to contribute to theimprovement work as much asdesired• Be able to feed back whetherchanges have made a difference

• Help set standards against whichservices are measured•Be involved in auditing or inspectingservices

• Be able to feed back experiencesof the service through a variety ofways

• Be able to contribute to identifyingthe needs within the population andwhat types of service might bestmeet them

Service user

• Play a sponsor role forimprovement work• Help identify priority areas forimprovement• Help teams see how their work fitsto strategic priorities• Help teams find space and time toimprove• Link regularly with projects to helpunblock barriers and celebrate theirwork

• Ensure systems are in place tocheck that high quality care is beingprovided• Ensure that assurance activities addvalue and are meaningful

• Monitor how the system isperforming•Use data to inform decision-making• Empower and support teams tosolve complex problems• Regularly listen to the experienceof staff and service users

• Contribute to developing theorganisation’s vision, mission andstrategic plan• Communicate these to the teams• Help teams align their work to theorganisation’s mission and strategicplan•Work with external stakeholdersand partners in developing goals andpriorities across the system

Senior leader

Best practice use of quality management in a serviceThe activities in the management system should not be consideredas isolated entities, but as being interconnected and sequential.Once a year, we go through a deep quality planning or redesignprocess, involving a range of stakeholders and data to understandthe needs of the system and to develop structures and processes toachieve thedesiredoutcomes.Oncewehave completed theplanningor redesign phase, we move into quality control. This enables us tomonitor ongoing performance and respond in real time to anychanges outside the parameters that we would expect to see. Avisualmanagement board and regular huddleswith clear escalationprotocols form a robust quality control system. This allows us tobuild into our service occasional assurance activities in order tocheck that standards aremaintained. These checks couldbe throughtools such as audit or accreditation. Where a gap between actualperformance and desired performance is identified, a small diverse

team would be brought together to use quality improvement for abrief burst of rapid-cycle testing of new ideas designed to achievea new level of performance. Once this is achieved and sustained,we move back into quality control to hold onto these gains. Thesystem has, of course, undergone a number of changes through thequality improvement process, so these must be fed back into thenext quality planning process. And so the cycle repeats.

The highest performing teams reduce assurance activity, create anintentional annual planning or redesign process, build a real-timequality control system (as this rarely exists in healthcare at themoment), and use quality improvement for the right type ofproblems in short bursts of rapid-cycle testing and learning.

In summary, in order to improve health and healthcare for thosewe serve, the quality management system represents a holisticapproach to achieve this. All four types of activity will be needed,and the real challenge is to know which of the four management

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approaches is appropriate for the opportunity, and to balance ourenergy appropriately across all four.

Education into practice

• Can you describe what you currently do in your service within each ofthe quality management functions: planning, control, assurance, andimprovement?

• How are you currently balancing your energy and time across thesefour domains, and what do you think the current balance should be?

• Can you describe your role in the team’s quality management system?

How patients were involved in the creation of this article

Service users are deeply involved in the quality management system atEast London NHS Foundation Trust, including quality improvementprojects, planning and redesign, and quality assurance programmes.Shared learning over many years has contributed to our understandingof how to manage quality, what a quality management system shouldincorporate, and how to best involve and partner with service users withineach of the quality management functions.

Sources and selection criteria

This article is based on my experience of supporting our approach toquality at East London NHS Foundation Trust, which is seen as one of theworld leaders in healthcare quality improvement. Our approach to quality,and my role as chief quality officer, encompasses planning, control,assurance, and improvement as discrete but linked functions. This articleis based on our practical experience and learning of building qualitymanagement systems, at team, department, and organisational levels.

Competing interests: I have read and understood BMJ policy on declaration of interests and have norelevant interests to declare.

Provenance and peer review: Commissioned; externally peer reviewed.

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