In our first guest commentary, Dr William Taylor of the Royal College of General Practitioners takes us through the successes and struggles accompanying the implementation of quality improvement (QI) in human healthcare.
The majority of people that work in a caring profession wish to improve the quality of care they provide. This is equally true for GPs and vets but how to do this can be a subject for debate.
The Juran trilogy helps separate three different components of quality, quality planning, quality control and quality improvement (QI). Quality planning can be defined as a process for designing and organising services that meet new goals and ensure that patient needs are met. Quality control includes national inspection through to local practice/practitioner evaluation and peer group review.
QI has been described by the RCGP (Royal College of General Practitioners) as ‘a commitment to continuously improving the quality of healthcare, focusing on the preferences and needs of the people who use services’. It encompasses a set of values (which include a commitment to self-reflection, shared learning, the use of theory, partnership working, leadership and an understanding of context); and a set of methods (which include measurement, understanding variation, cyclical change, benchmarking and a set of tools and techniques). The veterinary profession needs to understand the differences between these three components.
Each element of the trilogy needs to be in place but recently parts of the NHS have been focusing on quality control. In England, the Care Quality Commission has been monitoring, inspecting and rating services. Too much focus on inspection can lead to a culture of fear and this stifles innovation and improvement.
Don Berwick, President Emeritus and Senior Fellow of the Institute for Healthcare Improvement, has described three eras. Era one focused on self-regulating professions, era two on measurement, rewards and punishment and era three on less inspection and more improvement science. His report, A promise to learn – a commitment to act, advised NHS England to move towards this third era which would make quality improvement much more prominent. Vets probably need to follow era three.
Quality improvement has been introduced gradually to the NHS and it varies over the four nations. In England there have been various national bodies which have come and gone, such as the NHS Institute for Innovation and Improvement. At present NHS Improvement in England has as one of its aims to build QI capacity and capability. These central bodies are useful in providing resources online for QI but often fail to engage with frontline staff. The bewildering number of bodies and changes can confuse NHS staff. Scotland has tried to put all the bodies that are trying to drive improvement into one body, Healthcare Improvement Scotland, to make the landscape less confusing. Regional bodies and networks such as AQuA (Advancing Quality Alliance) and UCLPartners have sprung up and been able to engage staff better. Some of these provide training in QI, some local support, and some both. Some hospitals have established departments to train and support QI. The Royal College of Veterinary Surgeons (RCVS) can act as the one central body but how can the profession provide local support for QI?
The Health Foundation discusses some of the challenges faced by the NHS in implementing QI projects and how to overcome them in one of their review of evidence publications. They are listed as:
- Convincing people there is a problem
- Convincing people the solution is the correct one
- Getting data and collecting systems right
- Excess ambitions
- The organisational context, culture and capabilities
- Tribalism and lack of staff engagement
- Balancing carrots and sticks
- Securing sustainability
- Considering the side effects of change
The veterinary community will need to know how to overcome these barriers before embarking on a QI project.
The General Medical Council in its generic professional capabilities framework includes QI, so this is now an integral part of postgraduate training. Undergraduates need to understand the principles and methods of QI. The framework for appraisal and revalidation for all doctors includes QI. The Academy of Medical Royal Colleges recommends that ‘a progressive curriculum in quality improvement activity should underpin all training stages of a doctor’. The RCVS needs to consider where QI sits in undergraduate and postgraduate training.
The RCGP was at the forefront of promoting two tools of quality improvement: clinical audit and significant event analysis (SEA). There is evidence (i. ii. iii.) that the quality of both activities is variable.
Even if carried out well, clinical audit has its limitations in that it only measures change in two points in time which does not allow for common-cause variation, due to natural or ordinary causes. Vets should continue to promote and support good quality audit but be aware of its limitations and promote other QI tools.
The RCGP has a guide, Quality Improvement for General Practice, which contains guidance on various methods and tools relevant and specific to general practice. The guide is based on the QI wheel:
Training has been conducted for various groups in the general practice team. Attracting delegates to these courses continues to be a challenge. The RCGP has also developed QI Ready which includes an online learning network, a self-accreditation system and e-learning modules.
There is great opportunity for the RCVS to learn from the experiences of others in introducing QI to their profession. It needs to work towards, in the words of QI experts Batalden and Davidoff, QI being ‘an intrinsic part of everyone’s job, every day’. A strategy should be developed to achieve this.