Step 1 - Introduction to QI

QI can be defined as a systematic approach to making changes that lead to better patient outcomes, stronger system performance and enhanced professional development.

G Mery, 2017

We will acknowledge quite a few times throughout the guide that modern healthcare systems are complex. In fact when you try and picture just how complex they are it can be mind-boggling! We have dozens of different job roles and the different grades/seniorities within these, hundreds of different care pathways, and services in different settings such as hospital wards, GP practices, theatres, outpatient clinics, peoples’ own homes etc. These all interact with each other to deliver the best care possible to individual patients.

What this means is when trying to make improvements there are innumerable factors that influence the results of our efforts, many more than we could directly influence or even possibly track. The QI methodology we will cover is effective because it is designed to be used in systems as complex as this. To understand how, let’s take a look at where it came from.

Origins of QI Methods

The origins of modern QI methods come from the work of W. Edwards Deming (1900-1993, picture opposite). He was an engineer and statistician who after World War II championed the work of an earlier statistician, Walter Shewhart (1891-1967). This work included industrial quality control, and the use of the ‘Shewhart Cycle’ to maximise learning from changes to processes. Deming used these methods with great success in Japan in the 1950s and 60s, as well as developing them further (Shewhart cycles became PDSA cycles, for example) and is credited with helping drive the ‘Japanese economic miracle’, which saw the country go from losing the war to becoming the 2nd largest economy in the world in a few short years.

The Model for Improvement and Bringing it to Healthcare

A group of 6 individuals, who were students of Deming, formed Associates for Process Improvement (API) and worked with other organisations to improve their processes using Deming’s methods. API built upon these by developing the Model for Improvement (MFI), a simple yet effective tool to bring about positive change. The MFI is the basis for the TIPSQI Guide.

Although the methods Deming pioneered were originally developed for use in industry, they can in theory be used to successfully improve any area. In particular they are useful when dealing with complex systems, where the way to improve isn’t always obvious or has many influencing factors. Modern healthcare definitely consists of complex systems and the first person to establish the use of Deming’s methods in this field was a paediatrician called Don Berwick, who in 1991 went on to found the Institute for Healthcare Improvement (IHI) in Boston, USA. Berwick worked closely with API, using the Model for Improvement as the basis for the IHI’s work. In the 27 years since, the culmination of all the contributions from those in the field who came before – from Shewhart to Deming to API and the IHI themselves – is now the basis for QI globally, including in the NHS.

A Few Words on Other Improvement Approaches

There are other approaches in existence that are used to improve healthcare quality, other than that of the Model for Improvement and complementary tools developed by the IHI. The most common alternative you may encounter (depending on where you work) is ‘Lean’. As well as having a different historical background the underlying philosophy also slightly differs. The question is often asked which approach is ‘best’ out of these two, and for all intents and purposes the answer is neither. The reality is that when applied in practice there is very little difference – both depend on setting an aim, collecting regular data over time and continuous use of rapid-cycle testing of changes to practice through Plan-Do-Study-Act cycles (all concepts that will become familiar with you as you work through the guide).

At TIPSQI we stick to the IHI’s methods as they’re what we are most familiar with and the approach used most often in the NHS. For this latter reason, we suggest sticking to the IHI approach. We’ve mentioned Lean briefly now because you may come across it but the message is to not get hung up on minor differences – they are more or less the same.


Step 2