Improving quality
Welcome to this edition of Future Hospital Journal with a focus on quality. So what is quality? In healthcare, the answer to this question has rapidly changed over the last 50 years. Before Sir Austin Bradford Hill published the first randomised control trial in the early 1950s, quality was dependent on the craftsmanship of the individual clinician, applying expertise, with a limited range of treatment options. Much has changed in those intervening years; medical researchers have published approaching 20,000 original papers each year driving evidence-based medicine forward, while large numbers of new diagnostic technologies and a wide range of treatment options have become available. The change in complexity of our healthcare system has been dramatic.
So what of quality today? We recognise quality in the manufactured products around us in our everyday lives, for example the car that is reliable, efficient, safe and competitively priced. We know the experience of quality in customer service; the retailer whose staff are responsive and polite, while guaranteeing us the best price. However, healthcare is different – neither a product, nor a one-way service; instead, healthcare is a co-production with our patients. The diabetic patient's HbA1c does not reflect the quality of their healthcare alone – it is a reflection of this but combined with the patient's own actions. Following the last issue of FHJ, which had a special focus on person-centred care, this edition continues the theme – as only our patients can truly define quality by their healthcare experience.
At a time when the NHS is facing unprecedented financial and user demands combined with the effects of over 5 years of public sector austerity, there is increasing tension between commissioners and providers. How should we pay attention to this urgency? ‘Improve quality, you automatically improve productivity’ advised W Edwards Deming, the grandfather of quality improvement. Despite recent additional funding for the NHS, the need to improve quality and productivity is escalating. Not only is improving quality everybody's business, as our most cherished public service faces ever increasing challenges, it is now a moral duty to help protect our NHS.
Over the last 15 years, the NHS has experienced several national approaches to distribute the materials and develop the skills for quality improvement; the Modernisation Agency, the NHS Institute for Innovation and Improvement and NHS Improving Quality all opened and subsequently closed. Professor Chris Ham, Chief Executive of the King's Fund, identifies that the healthcare organisations across the world that have successfully transformed have done it ‘from within’.1 As individuals we need to equip ourselves with the capability and knowledge to lead quality improvement from within our own organisations. Quality improvement is neither quick, nor easy – to suggest otherwise is offensive to hard working staff, often fire fighting on the NHS frontlines. Yet successful quality improvement is possible. Chris Ham identifies a handful of healthcare organisations that have successfully developed the capability for transformative change over many years, finding that improving quality is not only about bettering patient care, it is also intrinsically motivating for staff, as they become proud owners of the autonomous delivery of better outcomes.
If successful quality improvement comes from within organisations, then how is the newly formed NHS Improvement aiming to prepare the conditions to accelerate and spread success? A key concept of quality improvement is ‘positive deviancy’ – learning from those that are the best. The NHS has been unsuccessful in achieving this at scale and our media don't help. How rarely do we read of superb general NHS care compared with the myriad of articles on lapses of safety, increasing waiting times and organisation failure? If 20 years ago we had been asked to predict which would be most successful, Microsoft's encyclopaedia Encarta (developed by a large team of paid professional writers and managers) or Wikipedia (started for fun, with no-one getting paid), it would have seemed the latter was unlikely to survive. So perhaps, the framework for engaging the NHS at scale lies outside the traditional core structures? Roy Lilley, the health policy analyst whose blog2 is widely read by NHS managers and wider staff, has started the Academy of Fabulous NHS Stuff, an opportunity for NHS staff to proudly share their achievements of great care – their positive deviancy.3 Encarta's experience with Wikipedia suggests that it may be wise for the newly formed NHS Improvement to collaborate rather than compete with this growing movement.
Decorating a house while living in it is a challenge. Redesigning healthcare to improve quality is more like rebuilding the house while living in it. We hope the NHS can rise to the challenge as there doesn't appear to be a ‘Plan B’ on the horizon.
- © Royal College of Physicians 2016. All rights reserved.
References
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- Ham C
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- nhsManagers.network
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- The Academy of Fabulous NHS stuff
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