A model for improvement

Quality of health care can be improved through various means. Experience over the past 100 years, beginning in industrial and commercial settings and eventually spreading to service sectors like health care, has shown that there is a scientific basis to improving work—a “science of improvement”—which is essentially about how to make change effective.

The science underlying improvement draws on psychology, organizational behavior, adult learning, and statistical analysis of variation, and it is grounded in a systems understanding of work. It draws on the work of W. Edwards Deming, who inspired the quality movement in Japan in the 1950s and is considered by many as the father of quality management.

One widely used approach to improve health care is the model for improvement (Langley et al. 2009). The model, shown at the right, is a change management strategy that stems from the work of Deming and the plan-do-study-act (PDSA) cycle developed by industrial engineer Walter Shewhart in the 1920s.

The model includes three basic questions to help structure improvement through trial and learning:

  1. What are we trying to accomplish?
  2. How will we know that a change is an improvement?
  1. What changes can we make that will result in improvement?

A key tenet of improvement is that making care better always requires change, but not all change necessarily leads to improvement. Without “change,” every system will continue to produce the same results it has always produced. In other words, “every system is perfectly designed to get the results it gets” (Paul Batalden). Managing change is central to improvement efforts, whether or not such efforts are prospective (e.g., defining aims and proactively testing changes to processes of care to try to reach the aim) or retrospective (e.g., auditing records to identify quality failures to identify and correct root problems that contribute to poor quality).

The PDSA cycle in the model for improvement guides tests of change by health care teams to determine if a change leads to improvement. Improvement teams typically comprise front-line health care workers, supervisors, and others involved in care, either as providers or recipients, who identify and test feasible changes to usual processes to improve care in their local setting.

While context has a strong influence on which changes may be most feasible and effective for overcoming gaps in a specific setting, categories of quality and system gaps and effective changes (solutions) are often common across settings. Diverse settings can learn from each other to overcome common quality and system gaps. Increasingly, many improvement approaches mobilize teams to work together across health system levels and geographic sites to identify, test, and share successful changes for overcoming important quality and system gaps. Promoting regular shared learning among teams helps to accelerate and scale up best practices for overcoming common barriers to delivery of high quality of care.

Text box: Evolution of Efforts to Improve Health Care Quality

Traditional health care improvement strategies in USAID-assisted countries have focused on adding more or different inputs or greater use of control systems or structures to enforce or assure quality. Such approaches were often referred to as quality assurance (QA). Such strategies have included developing standards and policies that articulate expectations for quality; organization of quality structures (such as national quality assurance programs) and dissemination of standards and best practices through education materials and guidelines; training health workers to increase their knowledge and skills; and assessment of whether minimum conditions are being met by health workers or health facilities as part of licensing or accreditation activities.

Today, consensus is widespread in the field of quality improvement that QA approaches in the absence of interventions to change care processes have not yielded impact, largely because such efforts tend to address only inputs to health systems with little or no focus on processes of care delivery (Davis et al. 1992; Oxman et al. 1995; Wensing et al. 1998; Massoud et al. 2006).

By the early 1990s, the improvement approaches in USAID-assisted countries began to build on traditional strategies to adapt and incorporate modern quality improvement approaches (Massoud et al. 2001). These approaches were applied to the delivery of priority health services, including obstetric care, immunizations, management of diarrhea, pneumonia, and malaria; and family planning (Heiby 1998). Based on results achieved, interest in improvement grew rapidly, with many organizations developing branded models and applying them in USAID-supported programs. While these models use different terminology, they often share common core elements, such as process analysis, use of standards, identification of key barriers, and closure of gaps between ideal and observed performance through active change to care processes, defining priorities for the improvement effort, empowering providers to identify problems and find solutions, and monitoring results (Tawfik et al. 2010). The repeated presentation of similar sets of ideas and methods under different names and terminologies has been termed “pseudoinnovation,” which can lead to inefficiencies and confusion (Walshe 2009).

The field of modern quality improvement is increasingly focused on how to improve care at scale (McCannon et al. 2007; Massoud et al. 2010). WHO’s efforts to mobilize action on simple safety interventions like hand hygiene and the surgical safety checklists through global campaigns are promising (Haynes et al. 2009).