Aiming to provide care that is safe, effective, and acceptable to healthcare users is a fundamental cornerstone of healthcare services. A number of similar processes have been adopted in healthcare management, collectively known as continuous quality improvement. These processes aim to ensure that problems in care provision are identified, addressed, and resolved in a way that ensure continuous and ongoing improvements in the quality of care provided by healthcare services. There isn’t a healthcare provider, funder, or user who does not want to see the highest quality of healthcare provision – myself included.
Many of the continuous quality improvement approaches that have been picked up by healthcare systems had their origins in manufacturing businesses, such as Lean Management and Sigma Six. It is reasonable to ask whether these approaches are fit for purpose in healthcare. Hill et al. (2020) have recently taken on this task. Based in the United Kingdom, this research team searched for randomised controlled trials that assessed the effectiveness of a variety of quality improvement projects and summarised the outcomes achieved.
Details about the studies included
Hill et al. searched several research databases from their inception to 2019, with 28 studies meeting their inclusion criteria, namely the comparison of a quality improvement approach with either no change in practice or a non-quality improvement intervention. This strikes me as a relatively small number of studies for such a long time period. Most were conducted in high-income countries, and ten related to hospital care. The “Plan-Do-Study-Act” approach was the most commonly assessed, used in twelve of the studies. Only two studies related to maternity care provision: a study examining a project aiming to improve the prevention of mother to child transmission of HIV in Nigeria, and another aiming to improve maternal and perinatal mortality in Malawi. The risk of bias relating to the design of the studies was assessed as high in 26 of the 28 studies.
Was there evidence of improvement in quality in outcomes for healthcare users?
The majority of the studies (n = 24) looked for improvements in process outcomes, such as adherence with a protocol. “Patient” outcomes were assessed in seventeen studies, with eleven of these showing no statistically significant improvement in outcome from the application of the quality improvement process (65%). More recent studies (since 2010) which reported on patient outcomes were less likely to demonstrate improved outcomes than older studies, refuting suggestions that the application of quality improvement methodologies has improved over time.
A cautious approach to quality improvement is wise
The findings of this literature review serve as a timely reminder to not take for granted the effectiveness of well-intentioned approaches to improve healthcare. While measuring improvements in processes are easier to achieve, these don’t always translate to improvements in outcomes that matter to recipients of healthcare, and such outcomes may not be measured at all. In many high-income countries, hospital accreditation processes stipulate the use of quality improvement processes to achieve and maintain accreditation, despite the relative absence of evidence that these processes are effective.
Root cause analysis, routine enquiries into maternal and perinatal outcomes, mortality and morbidity committees, and other quality improvement processes have become standard features in maternity care provision. There is a risk that these processes might primarily benefit healthcare organisations by maintaining an appearance of doing the right thing, while not actually doing anything useful, or potentially causing harm to healthcare users. It would be wise to maintain a cautious approach to the use of such quality improvement processes in maternity care, where good research of the effectiveness of specific quality improvement approaches is sorely lacking. In the absence of this evidence, well designed audits which measure outcomes of interest to healthcare users (rather than process measures such as the number of people who attend a workshop) should be employed to inform local health services of whether their efforts have been effective or not.
Reference
Hill, J. E., Stephani, A. M., Sapple, P., & Clegg, A. J. (2020). The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review. Implementation Science, 15(1), 23. https://doi.org/10.1186/s13012-020-0975-2
Categories: New research
Tags: Quality improvement
Birth Small Talk 
Thank you for this important post. I would like to suggest that if readers are not already aware of it, there is an organization called “Choosing Wisely” dedicated to helping “promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests of procedures already received, free from harm and truly necessary.” The website, https://www.choosingwisely.org/, provides an array of resources and evidence-based recommendations from a wide range of medical societies.
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Thanks Caroline.
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