Quality improvement (QI) is a process where changes in healthcare delivery are centred around improving patient outcomes and experiences. In 2007, Batalden and Davidoff (2007) define quality improvement as: “the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning).”1 Evidence shows that quality improvement projects (QIPs) are effective for implementing change and are recommended by the Royal Colleges and the GMC2.
Traditional approaches to medical school training have involved the acquisition of knowledge and skills in order to be able to manage patients and their conditions independently. Along this training pathway, doctors have previously been expected to undertake or participate in a number of audit projects with the aim of improving healthcare service. However, formal training in these areas has been variable. Additionally local audit programmes or initiatives may be fragmented and because trainees spend a relatively short time in post (typically 3-6 months), the opportunity to complete the audit cycle and observe a change in practice is usually difficult. In a survey by Garg et al (2012)3 where 504 trainees responded, only 42% had completed at least one audit cycle and most striking, two-thirds of all audits went unnoticed because of inadequate dissemination and implementation. In another study looking at paediatric audits, only 27% were considered to be complete and only 22% were reaudited4. Typically this can result in trainee demotivation, the conception that local audits do not result in service improvement3 and the feeling that clinical audit is more of a “tick-box” exercise than a process which has a positive impact. Yet junior doctors may be best placed to identify and act on areas of healthcare particularly as they may highlight areas that more senior doctors take for granted.5 More recently, efforts have been made to widen the approach from clinical audit to quality improvement, a term where audit sits within. In the WHO document “Quality of Care: a process for making strategic choices in health systems” published in 2006, six dimensions for quality of care are described.
Dimensions of Quality of Care
effective, delivering health care that is adherent to an evidence base and results in improved health outcomes for individuals and communities, based on need.
efficient, delivering health care in a manner which maximises resource use and avoids waste.
accessible, delivering health care that is timely, geographically reasonable, and provided in a setting where skills and resources are appropriate to medical need.
acceptable/patient-centred, delivering health care which takes into account the preferences and aspirations of individual service users and the cultures of their communities.
equitable, delivering health care which does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status.
safe, delivering health care which minimizes risks and harm to service users.
Whilst audit might incorporate one or more of these dimensions, its impact may be limited as it usually involves areas of healthcare based on strong evidence from research studies. Whilst this is ideal, there may be other areas where medical evidence is lacking or inconclusive and therefore a greater likelihood that these areas will be neglected even though they might represent important areas of healthcare. The institute of Improvement7 developed a model based on Langley et al8- the PDSA cycle (plan-do-study-act) which has been influential in driving quality improvement. This encourages the introduction of new ideas that might improve healthcare despite the lack of strong medical evidence and allows assessment of these ideas to determine if they have had a positive impact before possible incorporation into clinical practice.
PDSA cycle – Langley et al 20098
Below is a link to the Institute of Innovation and Improvement tool to use PDSA cycle:
A document Involving Junior Doctors in Quality Improvement produced by the Health Foundation in 20119 highlighted factors that could hinder junior doctors’ uptake of QI work. These include slow transitions to new roles, poor organisational culture, lack of support and supervision, long working clinical hours and lack of on-going learning opportunities. The most commonly researched initiatives to improve trainee engagement include specific teaching and training about QI, practical projects developed by junior doctors themselves and participation in QI initiatives developed by others to improve the care provided by junior doctors. The latter is directed at trainees building an awareness of the principles and benefits of quality improvement. For these to occur trainees require a supportive educational environment and time to learn, support from senior clinicians and leaders who make it clear that QI is important and an organisational culture that values improvement and supports change. Additionally there is a need for a working environment that affords space and time for improvement as well as appropriate resources to allow change to happen. Educational approaches could include formal courses, simulation, problem based learning and practical projects. The recent publication of the Healthcare Leadership model by the NHS leadership academy10 (revised from the Medical Leadership Competency Framework) is likely to drive training in this area. Dissemination of QIPs in the form of publication, poster or oral presentations at national and local levels could also be motivating factors and opportunities should be made available for dissemination, not just of the benefit of the trainee but to the wider healthcare community to learn about positive or negative QI initiatives from the experience of others.
Trainee doctors represent a valuable proportion of the workforce as they may highlight areas for healthcare improvement that more senior members of the workforce take for granted. Overcoming such barriers include better formal training and a change in organisational culture. Within this there is a need for better support and supervision with the allocation of appropriate time and resources together with vehicles for QI dissemination that will allow trainees to develop as QI champions.
Batalden P, Davidoff F. What is “Quality Improvement” and how can it transform healthcare? Qual Saf Health Care 2007; 16:2-3.
Øvretveit J. Does improving quality save money? A review of evidence of which improvements to quality reduce costs to health service providers. London: the Health Foundation.
Garg D, Singhal A, Neelam K. Clinical audits by trainee doctors: obstacles and solutions. Clinical Governance: An International Journal 2012; 17:45-53.
John CM, Mathew DE, Gnanalingham MG. An audit of paediatric audits. Arch Dis Child 2004; 89:1128-9.
Gaiser RR. The teaching of professionalism during residency: why it is failing and suggestion to improve its success. Anesth Analg 2009; 108:948-54.
Quality of Care: a process for making strategic choices in health systems. World Health Organisation 2006
Langley G.L. Nolan K.M. Nolan T.W. Norman C.L. Provost L.P (2009) The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition). Jossey Bass, San Francisco, CA.
The Health Foundation. Evidence Scan: Involving junior doctors in quality improvement 2011.
http://www.health.org.uk/publications/involving-junior-doctors-in-quality-improvement/ (accessed 22/03/2014)