For more than a decade I have been studying the application of quality improvement methods within healthcare contexts. I have observed many a flirtation with lean, six sigma, lean-sigma and countless other variations. Lured by the promise of improving quality while simultaneously driving down the cost of care delivery, quality improvement methods such as lean are a seductive proposition for any self-respecting CEO.
But do these methods live up to their hype? The answer is both yes and no. They can, but more often they don’t. So why should we continue to pay attention to quality improvement methods and are they still relevant in the current COVID-19 crisis?
Emerging evidence in the US and the UK link a systematic approach to improvement to outstanding hospital performance. In the UK, almost all hospitals rated outstanding have adopted a ‘systematic approach to quality improvement’ (S-QI), defined as a management system whereby strategy, infastructure, training and daily work fosters a culture of continuous improvement.
Since January 2018 I’ve been leading a comprehensive evaluation of S-QI in five National Health Service (NHS) hospitals in England. The goal is for each NHS trust to develop a ‘sustainable culture of continuous improvement capability’ and for the evaluation to derive lessons more broadly for the NHS.
While the evaluation is not due to formally report until 2021, our emerging findings reveal important insights regarding the role of quality improvement routines in shaping employee engagement, collaboration and culture. The research highlights three reasons why S-QI routines matter now in the COVID-19 pandemic more than ever.
1 Focuses attention on the customer
For healthcare, defining value from the perspective of the customer can be challenging at times. Resources are not infinite, with a careful balance between quality and cost is essential to maintain high quality healthcare delivery free at the point of use, as happens in the UK.
But delivery of high-quality safe care isn’t an optional extra, it is mission critical to hospitals. Delivery of high quality, safe care connects quality improvement routines to the mission critical tasks; in essence it represents why we are here.
But who is the customer? We don’t like to call patients ‘customers’, it feels detached from the business of caring. In my years of teaching quality improvement I have always talked about the many customers a hospital must serve (the patient, the family of the patient, the wider public, the commissioner, the regulator etc), but I have always maintained the most important customer is the patient.
To this day, nobody has ever challenged me. But now I feel it is time to challenge myself. COVID-19 has shone a light on the salience of the health and wellbeing of healthcare workers. Too often we forget to care for those who care.
Respect for people is a cornerstone of S-QI and I’m certain that respect for people across all society (as demonstrated in the UK Government’s simple and consistent message: stay home, protect the NHS, save lives) will guide us through this crisis.
2 Helps employees regularly connect
Relationships matter. S-QI routines should not be viewed as providing a technical solution to a problem, but a social one. Remember, it’s not tools that solve problems, it’s people.
In large complex organisations like hospitals and the NHS more broadly, people must work together to understand problems together, identify solutions together and implement changes together. Often, improvement ideas fail not because they are unsuitable but because they haven’t engaged people in the problem or the need for a solution.
One of the most striking findings from my recent work is the importance of curating opportunities for frequent, informal and multi-disciplinary meetings to foster collaboration as instrumental to developing a continuous improvement culture. Whether that’s a daily ‘huddle’ at ward level or a monthly leadership meeting.
These meetings should not be regarded as mere formality, they should be seen as opportunities to build relationships, to get to know your colleagues as people and provide a safe space to talk about things that really matter, not to say what we think others want to hear.
Regular multi-disciplinary meetings are opportunities to reinforce shared goals, foster shared learning and collaborate for improvement. If a sustainable culture of continuous improvement capability is to firmly take root we must create and explore new opportunities for collaboration.
3 Fosters a learning culture
There has been much discussion of late about the importance of leadership in a crisis (see my colleague Dimitrios Spyriodinis’ article).
S-QI requires facilitative leadership, where the role of the leader is not as a ‘problem-solver’ but a ‘problem framer’. The ability to rapidly ‘solve’ problems (or demand that others solve problems) characterises the career of many a successful healthcare leader.
As one medical professional candidly told me: “The table banging, 'things must change, this isn’t good enough' model just doesn’t work."
When a leader frames a problem, they give permission to those who know the work to improve the work, thereby developing a learning capability that forms the fabric of a continuous improvement culture.
Finally, beware the Crisis Paradox
Some of the world’s most successful implementations of S-QI were borne out of a crisis. Virginia Mason Medical Centre in Seattle, US, began their quality improvement journey in 2001 when the organisation was struggling financially and quality wasn’t always up to the mark.
Today, Virginia Mason credits its management system (adapted from car manufacturer Toyota’s Production System) for enabling them to become one of the safest hospitals in the world.
By contrast, in hospitals where S-QI appears embedded in the routines and practices of an organisation for a period of many years, an unexpected crisis can rapidly deflect energy and attention away from improvement routines and back to a command/control approach to problem solving.
When a crisis hits, we tend to view S-QI routines as an ‘optional extra’, casting them aside until the storm settles and we can all go back to ‘normal’. But a culture of continuous improvement is fundamentally a learning culture. If we are to respond to this crisis effectively and to prepare for others that may come, we must embrace learning and we must embrace S-QI.
Johnson, M., Burgess, N. and Sethi, S. (2020) "Temporal pacing of outcomes for improving patient flow : design science research in a National Health Service hospital ", Journal of Operations Management, 66, 1-2, 35-53.
Burgess, N., Currie, G., Crump, B., Richmond, J. G. and Johnson, M. (2019) "Improving together : collaboration needs to start with regulators", BMJ, 367, l6392.
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