Continuous Quality Improvement in Healthcare, Explained

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Continuous Quality Improvement in Healthcare

Healthcare Organization and Management · Chapter 12: Quality Improvement and Process Excellence in HealthcareSection 12.1 · lesson 69 of 10510 min · free with a free account

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In this lesson

Testing changes with PDSA cycles, clear aims, and run charts.

  • Distinguish quality assurance, quality control, and quality improvement
  • Apply plan, do, study, act cycles with a written prediction and small tests of change
  • Write an aim statement and choose process, outcome, and balancing measures
  • Interpret a run chart to tell common cause from special cause variation

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Transcript

Everything said in the video, section by section (1,394 words). Read along, or search it.

Opening Case

A Monday Launch for Teach-Back

Ellen Murphy, charge nurse on 4 North, has a good idea. Patients going home on new medications get their teaching in the rush of discharge day, and many leave confused. Her plan: do teach-back the day before, when there's time to ask the patient to explain each medicine in their own words. Her team agrees. She plans to start it across the whole unit on Monday. Farah Siddiqui, director of quality, asks two questions. What do you predict will happen? And how will you know it worked?

Definitions

Assurance, Control, and Improvement Differ

Farah starts with a distinction. The word quality covers three different activities. Quality assurance checks performance against a standard, and acts when it falls short. Its output is a judgment: audit, inspection, external review. Quality control watches a process while it runs, to catch departures early. Its output is a signal. Quality improvement changes a process so its ordinary performance is better. Its output is a new way of working. A unit meeting its standard can still have plenty to improve, because a standard is a floor. And more auditing applied to an improvement problem just finds the same problem again.

PDSA Cycle

Plan, Do, Study, Act With a Prediction

The basic unit of improvement work is the cycle: plan, do, study, act. It grew from Walter Shewhart's work at Bell Labs, and W. Edwards Deming made it famous. Plan states the change, who does what, and the predicted result. Do runs the test and records what happened, including what went wrong. Study compares the result with the prediction. Act decides whether to adopt, adapt, or abandon the change, and sets up the next cycle. The prediction is what separates this from trial and error. A result that misses it is even more valuable, because it shows your theory of the process was wrong. Skip the prediction, and you can always explain the result afterward, so you learn nothing you didn't already believe.

Model for Improvement

Three Questions in the Right Order

Before any cycle, three questions frame the work. They come from the Model for Improvement, developed by Associates in Process Improvement and taught by the Institute for Healthcare Improvement. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? The order matters, and teams usually reverse it. They arrive with a change someone wants, then work backward to justify it. Answering the first two first stops a unit from solving a problem it hasn't defined and can't measure. Ellen realizes she has only answered the third.

Aim Statement

A Measure, a Number, a Boundary, a Date

So Ellen writes an aim statement: what the effort will accomplish, with a measure, a numeric target, a boundary, and a date. 'Improve discharge teaching' is a topic. Her aim: raise the share of 4 North patients on new medications who complete teach-back before discharge day, from about forty percent to ninety percent, by June thirtieth. The number surfaces disagreement early. A team split between seventy and ninety-five percent, has an argument about ambition that would otherwise erupt in month four. And the date forces small tests instead of endless design.

Three Measures

Process, Outcome, and Balancing Measures

Every improvement needs three kinds of measure. A process measure shows whether the change is actually being done: the share of patients whose teach-back started the day before. An outcome measure shows whether what you care about improved: patients who can explain their medicines on the follow-up call two days after going home. And a balancing measure shows whether something else got worse: nurse time per patient, and discharge delays. Process measures move first, so watch them weekly. Balancing measures are the ones most often left out, and they separate a serious effort from an enthusiastic one.

Quick Check

What a Pain Reassessment Aim Lacks

Quick check. Danny Reyes, a new nurse on 4 North, drafts his own aim: improve pain reassessment on 4 North by March thirty-first. What is it missing? Pause, and decide. Something to count, and how much. It has a boundary, 4 North, and a date. But nothing says what will be counted, or how much better counts as success. A better aim: raise reassessments done within an hour of a pain medicine dose from sixty to ninety percent, on 4 North, by March thirty-first.

Small Tests

Two Patients on One Day Shift

Then Ellen does the opposite of a Monday launch. Danny tests the change with two patients, on one day shift. A one-nurse, one-day test costs almost nothing, so it runs this week. It surfaces the practical obstacles no design anticipates. And it fails safely, on one shift instead of a unit. Danny predicted ten minutes per patient. It took twenty, because the pharmacy's discharge medication list usually isn't ready the day before. That's exactly the information the team needed, found cheaply. They adapt: pharmacy agrees to send the list by two p.m. Then one nurse for a week, then a shift, then the unit, each step decided on the evidence.

Run Charts

Common Cause Versus Special Cause Variation

To read the results, the team uses a run chart: the measure plotted in time order, with the median drawn across it. It separates two kinds of variation, an idea that also goes back to Shewhart. Common cause variation is the ordinary wobble of a stable process. Special cause variation means something actually happened. Confuse them, and you pay either way. Chase every bad week, and you waste attention and may destabilize the process. Dismiss a genuine shift, and you miss the signal worth acting on. Comparing this month with last month can never tell them apart. One widely used rule: six or more points in a row on one side of the median signal a shift.

Quick Check

Seven Points Above the Median

Quick check. The team made its change in week ten. Weeks eleven through seventeen all land above the median. Week fourteen was lower than week thirteen, and someone is worried. What does the chart show? Pause, and decide. The new level is holding. Seven points in a row above the median is too unlikely to be ordinary wobble. The dip in week fourteen is the tempting distraction. Comparing two neighboring points can't separate signal from noise, and the dip stays above the median anyway.

Common Failures

Most Changes Are Not Improvements

Every improvement requires a change, but most changes aren't improvements. That's why measurement is the work, not paperwork. Three failures recur. The change was launched but never adopted, so the process measure never moved. The change was adopted, but the outcome didn't follow, so the theory linking them was wrong. That's valuable, if the team will say so. Or the outcome improved while a balancing measure got worse, so the problem was moved, not solved.

Spread and Sustainment

Testing Locally and Holding the Gain

Success on one unit raises two new problems. Spread is other units adopting a proven change. Sustainment is the change lasting after the project ends. Spread fails when a unit is handed a conclusion instead of a test. What works: invite 4 South to test it locally and adapt it, trading some standardization for real adoption. Sustainment fails because the attention holding the change was temporary. Structures hold it instead: standard work, a named owner after the team disbands, and lighter but continued measurement.

Four Absences

Protected Time Underpins Improvement Work

Most improvement work fails from one of four absences. No aim, so it can't be finished. No measure, so nobody knows if anything changed. No test, so everyone meets the obstacles at once. No owner, so the work belongs to a meeting. Underneath all four is something only a manager can provide: protected time. Priya Nair, the chief nursing officer, gives Ellen and two nurses one hour a week, with their shifts covered. Work squeezed in between patients is done by whoever's least busy, and it stops in the first short-staffed week.

Case Resolved

Five Small Tests and a Real Shift

Back to Ellen. There was no Monday launch. In the first month, her team ran five small tests, and each one changed the design. The pharmacy timing problem surfaced with two patients, not forty. And her balancing measure caught a new one: teach-back was spilling into evening medication rounds, so they moved it to mid-afternoon. By week seventeen, the run chart shows a real shift. She isn't at ninety percent yet, and she knows exactly what the next test is. So Farah's two questions get answers. Ellen predicted, and she knows, because she measured.

Key Takeaways

Improvement Habits Worth Keeping

To recap. Assurance judges against a standard; improvement redesigns the process. Run plan, do, study, act cycles, and always write the prediction down. An aim has a measure, a number, a boundary, and a date. Track process, outcome, and balancing measures. Test small, then read a run chart, not this month against last.

About Healthcare Organization and Management at UPI Study

Healthcare Organization and Management (Health 302) is a self-paced online course of 105 video lessons in 18 chapters, from health systems and the law to ethics, leadership, teams, strategy, informatics, finance, quality, human resources, marketing and evidence-based practice. It carries a NCCRS credit recommendation for 3 semester credits.

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Why students take Healthcare Organization and Management with UPI Study

How hospitals and clinics are runHealthcare Organization and Management covers how care organizations are led and run: health law and ethics, leadership and teams, strategic planning, health informatics, budgets, quality improvement, staffing and marketing. It is a core course in healthcare administration and health management degrees.
Credit at a fraction of the priceThe same 3 credits can cost $750 or more at a US college. Here it is one payment, self-paced, with lifetime access.
Finish your degree soonerTransfer credits reduce the courses you still owe, so you can graduate earlier or lighten a heavy semester.
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130,000+students helped with college creditsACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities.

Where the credit goes

Universities that work with NCCRS

Healthcare Organization and Management carries a NCCRS credit recommendation. These universities work with NCCRS; some are UPI Study's signed partners. ACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities.

Thomas Edison State UniversityThomas Edison State UniversitySigned partnerUniversity of the PeopleUniversity of the PeopleSigned partnerCharter Oak State CollegeCharter Oak State CollegeSigned partnerStrayer UniversityStrayer UniversitySigned partnerColumbia Southern UniversityColumbia Southern UniversitySigned partnerIndiana TechIndiana TechSigned partnerPenn StatePenn StateWorks with NCCRSSouthern New Hampshire UniversitySouthern New Hampshire UniversityWorks with NCCRSSUNYSUNYWorks with NCCRS +many more cooperating universitiesFind my college →

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FAQ

Questions students ask us

About Continuous Quality Improvement in Healthcare

What is the difference between quality assurance, quality control, and quality improvement?
Quality assurance checks performance against a standard and acts when it falls short, producing a judgment through audit, inspection, or external review. Quality control watches a process while it runs to catch departures early, producing a signal. Quality improvement changes a process so its ordinary performance gets better, producing a new way of working. A unit meeting its standard can still improve, because a standard is a floor.
What is a PDSA cycle in healthcare quality improvement?
A PDSA cycle, short for plan, do, study, act, is the basic unit of improvement work. Plan states the change and the predicted result, Do runs the test and records what happened, Study compares the result with the prediction, and Act decides whether to adopt, adapt, or abandon the change. It grew from Walter Shewhart's work and was made famous by W. Edwards Deming.
What makes a good aim statement for a quality improvement project?
A good aim statement names a measure, a numeric target, a boundary, and a date. A phrase like improve discharge teaching is only a topic. A usable aim would raise the share of patients on one unit who complete medication teach-back before discharge day from 40 percent to 90 percent by June 30. The number surfaces disagreement early, and the date pushes the team toward small tests.
How do you read a run chart to tell whether a change worked?
A run chart plots a measure in time order with the median drawn across it, which helps separate common cause variation, the ordinary wobble of a stable process, from special cause variation, a sign that something actually changed. One widely used rule treats six or more consecutive points on one side of the median as a shift. Comparing this month with last month cannot tell the two apart.

About the Healthcare Organization and Management course

How many college credits is Healthcare Organization and Management?
Healthcare Organization and Management (Health 302) carries a NCCRS credit recommendation for 3 semester credits. ACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities.
How much does Healthcare Organization and Management cost and what is included?
$250, paid once, with lifetime access: all 105 video lessons, a practice quiz after each, the graded work and final exam, and an official transcript when you finish. Students who want several courses choose UPI Study PRO instead.
Which universities accept UPI Study credits?
UPI Study has signed partner agreements with universities such as Thomas Edison State University, University of the People and Charter Oak State College, and works with universities such as Penn State, SNHU and SUNY. ACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities. Use "Find my college" on this page to check yours.
How long does Healthcare Organization and Management take?
It is self-paced with no deadlines. The 105 lessons total about 17 hours of video; most students add reading and practice time and finish in a few weeks to a few months, on their own schedule.
How are the exams done?
Quizzes and assignments are online in the course. The final exam is taken online with proctoring; a person on the UPI Study team checks assignments, usually within two days.
How do my credits reach my college?
When the course shows 100% complete, request the official transcript from your dashboard. It is sent to the college you name, and you can send it to more than one. Check your college first with "Find my college" on this page, or ask Athena.

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