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Delivering quality improvement: the need to believe it is necessary R E Klaber,1,2 D Roland1,2 1

Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK 2 Emergency Medicine Academic Group, Cardiovascular Sciences, Leicester University, Leicester, Leics, UK Correspondence to Dr Bob Klaber, Department of Paediatrics, Imperial College Healthcare NHS Trust, 6-10 The Bays Building, Off South Wharf Road, St Mary’s Hospital, London W2 1NY, UK; [email protected] Received 17 June 2013 Revised 23 October 2013 Accepted 24 October 2013 Published Online First 14 November 2013

ABSTRACT Quality improvement (QI) is described as being about changing the way in which patient care is delivered. It is more than just a theoretical framework against which innovations can be introduced; it is about a rigorous patient-centric approach to the design and delivery of care. In this paper we will explore some of the practicalities of delivering quality improvement in paediatrics and child health, and explain why it is an approach that we all must take.

BACKGROUND Quality improvement: fundamental practice or a fashionable fad? The focus on Quality within healthcare is not a new concept,1–3 but the work of Darzi4 and others determining that future healthcare systems need to be underpinned by high quality care for patients has very much taken hold. In the last decade health policy, medical education and training, and the majority of healthcare-related stories in the media, have been very focused on the delivery of high quality care. This approach is built on a quality improvement (QI) literature which is substantial and includes examples of methodological approaches, evidence based implementation strategies, and a variety of system based and individual approaches.5 Recent catastrophic organisational failures in which there was a loss of safe and compassionate care6 demonstrate that the quality agenda is not a vague rhetoric. Whilst one might assume that that all clinicians should be able to recognise and act on systems that are failing to deliver the best possible patient care, there has been very little historical interest in this area. Both the original Hippocratic oath7 and subsequent revisions via the Declaration of Geneva8 do not even mention improving skills and providing the highest quality care to patients. It may well be that these are implicit in the very nature of being a doctor or health care professional but recent tragedies and failings of care6 9 10 highlight that constant reminders are needed.

Quality improvement: enhancing clinical governance

To cite: Klaber RE, Roland D. Arch Dis Child 2014;99:175–179.

Paediatricians often think of themselves as clinicians who are always willing to go that extra mile for their patients and that no child will receive less than the best care on offer. Unfortunately, looking at the wider healthcare system, evidence does not bear this out, in terms of overall mortality rates,11 12 variance in care13 and patient experience.14 15 Until recently most doctors in paediatric training in the UK have been required to undertake clinical audit in each post. This fundamental part of clinical

Klaber RE, et al. Arch Dis Child 2014;99:175–179. doi:10.1136/archdischild-2012-303563

governance (defined as the systematic approach to maintaining and improving the quality of patient care within a health system) is a vital part of maintaining and improving care. However the output of this work has often been of questionable value, both for patient care and for the learning and development of the doctors who have participated in it. So why might quality improvement (QI) be any different? QI promotes the realisation and implementation of findings from clinical governance, and gives doctors and other health professionals the tools and approach through which to deliver improvements in care. The introduction of QI into curricula16 and alteration of training programmes has begun to improve, although there is a risk that a shortage of well trained supervisors can lead to the depth of this learning being somewhat superficial.

Quality improvement: new approaches to research Quality improvement (QI) also uses different approaches compared with how research has traditionally been conducted. A formal research project will use specific statistical outcomes, and may struggle to fit into the less rigid, iterative processes used in QI.16 This tends to result in a division and delay between research on new techniques or methodologies and the implementation and improvement phases of delivering high quality care. Ultimately, if the need to provide the best possible healthcare outcomes and experiences for children is obvious, we need to better understand why the actual implementation of change is, in practice, so difficult in so many organisations17? One possible reason as to why it has been so difficult to implement systemwide improvements may be that paediatricians don’t consider their work within the context of the current paradigms of QI. It may well be that the term ‘quality improvement’ is misunderstood or mistrusted. The concept of evidence-based medicine (EBM) took years to be accepted by the medical profession and it seems likely QI may suffer from similar resistance.16 The groundbreaking commitment to new discoveries and cutting-edge research is something that we should be proud of, but our track record on sustainable implementation is very poor. Perhaps there is an argument that we should stop doing randomised controlled trials (RCTs) until we learn to implement the evidence we have at the moment? As illustrated by Smith and Pell’s brilliant systematic review to determine whether parachutes are effective in preventing major trauma related to gravitational challenge,18 we should, at the very least, become much more pragmatic, flexible and 175

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Review thoughtful about how we use many different sources of evidence to improve care.

Quality improvement terminology: definitions and domains There are many different definitions and descriptions of quality improvement. Of these perhaps the best known definition comes from the Institute of Medicine,19 which identified six domains of quality as: ▸ Effectiveness ▸ Patient Centred ▸ Timeliness ▸ Safety ▸ Efficiency ▸ Equity For a number of paediatricians, who have successfully run improvement projects, these domains give a clear framework on which improvement work can sit. However, there is a risk that for others the language used sounds too technical and too far removed from the realities of the wards, emergency departments, intensive care units and clinics where so many of us work. For those who feel less comfortable with this framework, perhaps it is most useful to think about QI as an approach, or method, that focuses on changing how care is delivered. Underpinning this approach is an emphasis on quality that encapsulates the delivery of care in a rounded, patient-focused manner. Achieving this requires an unceasing effort from all of us to make the changes that will lead to better outcomes for patients, better performance of the system and a better culture of lifelong learning.20

decade. This programme incorporated into a national child health strategy has implemented a quality improvement structure throughout the country.26 Collaboration between centers aids a number of system wide quality improvement initiatives. At Cincinnati Children’s Hospital there has been an ongoing strategy to concentrate on the worst outcomes, correct these and then focus on the next worse. In the last decade they have achieved significant reductions in a number of serious safety events from ventilator acquired pneumonias to never events. Part of this success has been through their public demonstration of their data. They are part of a collaborative of 81 children’s hospitals in the USA of America comparing outcomes in all aspects of their work.27

Tools, techniques and approaches to improving patient care A variety of tools, techniques and approaches exist to deliver and understand quality improvement. These should not be considered in isolation, nor thought of as being linear, as in reality they are connected to each other in a strongly interrelated fashion (see figure 1). It is important that quality improvement processes are iterative and ongoing as one improvement cycle will not fix all the issues simultaneously. Further information on the practical application of these tools is available throughout the Education & Practice Equipped series.

MAKING QUALITY IMPROVEMENT HAPPEN This section describes six crucially important factors in making quality improvement actually happen.

Recognise our responsibility to improve the system QUALITY IMPROVEMENT IN PRACTICE Moving beyond audit Audit is a key quality improvement tool, and one that will be further explored later on in the Equipped series. However, where they are not viewed through a QI lens, there is a risk that audit cycles can remain one of repeated audits rather than achieving any material change.21 Box 1 illustrates four key questions that can be used to assess the impact of a locally run audit. The implementation of formal QI techniques can have radical impact22 and it therefore just seems unacceptable now to undertake audit with no clear plan to effect change.23 24 The tools, techniques and approaches available within the quality improvement movement should be able to help you to plan and deliver the change that you and your patients want to achieve.

Learning from quality improvement initiatives that have delivered Quality improvement programmes can have success at national, regional and local levels. Nationally the World Health Organisation has many quality improvement initiatives focused on the developing world.25 In the Solomon Islands for example a training strategy for nurses to cascade down to child health workers through the nation has been in operation in the last

Box 1 Assessing the impact of your last local audit Considering the last audit performed in your department: What change resulted from the audit? Have these changes been sustained? Has the audit been repeated since the changes? If, not is there a review date set for repeat audit? 176

‘We all have two jobs: to do our work and to improve it’20 from Paul Batalden (paediatrician and Senior Fellow at the Institute for Healthcare Improvement) reminds us of our responsibilities to continuously strive to improve the system in which we work. This has been embraced in philosophy by the most recent iteration of the UK GMC Good Medical Practice28: ‘all doctors have a responsibility to contribute to and comply with systems to protect patients’. In addition to trainees needing to show that they have met the leadership and quality improvement related competencies all paediatricians in the UK will need to demonstrate evidence and reflective practice in this area in order to be recommended for revalidation.

Measure useful things Effective data collection and measurement have significant roles in helping to determine whether a change is really an improvement. This usually requires a number of different measures which, balanced together, will give a picture as to whether or not the system is improved. There are three types of measure: 1. Outcome measures—taking the perspective of the patient; what is the result? 2. Process measures—are the steps in the system working as had been planned? 3. Balancing measures—is the system as a whole being improved? Although most paediatricians worldwide will have become used to collecting and examining process measures within their services, finding meaningful patient-centered outcome measures is a significant challenge. While surgical, intensive care and some sub-specialty services (eg HbA1c in diabetes) have developed relatively strong outcome measures, for most paediatricians, particularly those working in general paediatric or community paediatric settings, the “How do you know you are any good?” question is a very difficult one to answer.29 There is

Klaber RE, et al. Arch Dis Child 2014;99:175–179. doi:10.1136/archdischild-2012-303563

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Figure 1 Key components of quality improvement in paediatrics and child health. no doubt that patient experience data is of real importance, but the lack of meaningful patient-centric outcome measures is an important weakness within paediatrics that needs significant focus in the years ahead.

Leadership and engagement for improvement There is increasingly good evidence that organisations with a culture of engagement between clinicians and managers have better organisational performance and outcomes for patients than those who do not.30 28 In their annual leadership summit in 2012, the UK-based leadership think-tank The King’s Fund stated ‘A new style of leadership is needed in the NHS in which leaders engage staff, patients and partner organisations to improve patient care and health outcomes’.31 The Paired Learning initiative,32 33 which was established at Imperial College Healthcare NHS Trust in 2010, and has now spread to many other organisations across the UK, is a leadership development programme that seeks to do just that. Clinicians and managers are paired together and, through conversation, shadowing, supporting workshops and the opportunity to work together on an improvement project, they develop new perspectives and learn new approaches to delivering system-wide change.

Another important factor in enabling a culture of continuous improvement within an organisation is the vision and support given by the senior leadership team.34 35 36 While part of this role is one of setting the strategic vision for quality improvement, perhaps more important is developing a working environment within the organisation where there is ‘permission’ to try things out (even if they might be unsuccessful), encouragement for ‘bottom-up’ initiatives to emerge and be supported by senior staff, and above all an open culture of feedback and learning.

Co-production at the heart of quality improvement As illustrated by the Institute of Medicine’s patient-centred domain of quality,19 it is crucial that our QI work in paediatrics is underpinned by the meaningful involvement and engagement of children, young people, parents and carers. Co-production, a concept that emerged from social policy in the 1970s, encourages collaboration between service users and providers. Co-production is based on both the sharing of information and on shared decision making between service users and providers, and, going further than just engagement, builds on the assumption that both groups have a key role to play in the processes as they each contribute different perspectives and knowledge.37 38 39 40 There is clearly a strong role for this approach within QI, although it must be acknowledged that achieving strong models of co-production requires significant expertise. This seems likely to be an important area for paediatricians to develop experience and understanding, so that future involvement of service users in QI is undertaken in a valid and meaningful way.

Being more than a movement of early adopters

Figure 2 Roger’s adopter categorisation on the basis of innovativeness.42

QI is often described as a movement, whose origins are now well over 40 years old, yet there is still significant contention about what this movement has actually achieved.41 Reflecting on Roger’s seminal work on the adoption of new ideas or innovations,42 Figure 2 shows the normal frequency distributions divided into five categories: innovators, early adopters, early

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Review majority, late majority and laggards, with the labels showing the estimated percentage of the population that would sit within each section. The QI movement undoubtedly is full of innovators and has been extremely successful at motivating and energising a good number of early adopters, yet to what extent it has reached the early majority, and certainly the late majority is debateable. The challenge for healthcare leaders and QI enthusiasts is to encourage and support colleagues to see the opportunities to improve care for their patients that QI provides. Change, and therefore quality improvement, is not easy to deliver and this must be acknowledged. Too often the virtues of a QI approach are unhelpfully eulogised in a way that at times lacks perspective of the stresses and pressures on different healthcare professionals within their very varied workplaces.

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Trainees and junior staff as a key catalyst One group who have been a key catalyst for quality improvement and change have been paediatric trainees or other ‘junior’ child health professionals. Their insight from the delivery end of many different clinical services gives them a unique perspective on the quality of the services they help to provide, yet too often their opinions are never asked. An example of a different approach, that can easily be replicated, comes with induction of new staff. As opposed to the traditional message junior doctors often receive in induction of ‘make sure you do it our way’, running a session titled ‘What can we learn from you?’43 creates a culture of openness and peer-learning from the very beginning, as well as generating the ideas and momentum for initiatives that will improve the quality of care in the host department. A number of national organisations have been set up by trainees themselves (eg and the Running Horse Group to give trainees a platform on which to share and publish ideas and improvement projects. Ensuring trainees and other junior staff feel that they have the permission and support of senior colleagues to make improvements to patient care is often relatively light-touch, but does require proactive leadership and an understanding that there will be times when ideas and projects are unsuccessful.


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CONCLUSION Quality improvement is both a process and an ideology. Paediatricians have always been leaders in working with patients and striving to improve care. However, fully embracing a quality improvement culture has not occurred across all child health services and there is much still to be done to improve outcomes for children and young people. Education and Practice has begun to publish a series of articles on quality improvement, called the Equipped series.44 It is hoped that the uptake of the ideas generated by organisations, departments, senior and junior staff will support improvements to the quality of care for children in an evolving, sustainable way.

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Contributors REK and DE conceived, designed, drafted and checked through the final version of this manuscript, and amended the revised version in light of the reviewers’ comments. Competing interests Dr Damian Roland is chair of the Running Horse Group Dr Bob Klaber is the RCPCH Officer for Educational Provision. Provenance and peer review Commissioned; externally peer reviewed.


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Delivering quality improvement: the need to believe it is necessary R E Klaber and D Roland Arch Dis Child 2014 99: 175-179 originally published online November 14, 2013

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Delivering quality improvement: the need to believe it is necessary.

Quality improvement (QI) is described as being about changing the way in which patient care is delivered. It is more than just a theoretical framework...
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