Speaker 1: Hi everyone, welcome to my talk today, Quality Improvement and Quality Assurance in Healthcare. And I'll be giving an overview of key terms relating to these two concepts. This session is helpful for any healthcare professional or healthcare student. Do give me a thumbs up if you enjoy this session and do check out my other free videos on my YouTube channel. And I'm currently creating a playlist on quality improvement and change management that might be helpful for nurse educators. So I hope you find the session helpful. So the session today aims to help any healthcare professionals applying for jobs too. There's often questions relating to these terms in interviews and on the job description. So you need to have an understanding and an overview of key terms. Healthcare students might be being introduced to quality in healthcare on their degree course and they can become confused with all the business speak, the leadership, the management and organisational language being used. And you might be a healthcare professional who wants to develop their career and you're aspiring to become involved with quality improvement in the future. So hopefully you'll find this talk helpful. So we've got a range of terms relating to quality in healthcare and all these different frameworks, models, tools, linked to these two key umbrella concepts, quality improvement and quality assurance. Both quality improvement and quality insurance are interrelated. They both aim to improve quality patient care. Quality improvement and quality assurance terms may be used interchangeably in healthcare and across publications, which is why it can sometimes become confusing. You just need to remember that both are aiming to make it better for patients. So if we're going to look at quality improvement and quality assurance, you first need to think about what is quality. And when we look at quality in health, it's defined under three criteria by the Department of Health 2008 report, and that's entitled high quality care for all the NHS next stage review. And I have all the references at the final slide in this talk. And these are helpful to remember safety, experience of care and effectiveness of care. And you can see that I've highlighted in bold the SEE because when I go to interviews, I often use mnemonics thinking about my preparation so I don't forget things. So if we look at these three criteria, safety relates to quality care that's safe. It's about doing no harm to patients, decreasing risk, safeguarding. Experiences of care relates to providing compassionate person centred care that meets the needs of patients, their biopsychosocial needs, so they have a positive experience within the services that they're using. And the effectiveness of care, reducing waiting times, delays, preventing mortality, avoiding waste, looking at promoting positive clinical outcomes. When we look at the quality improvement and quality assurance, you can see that they're going to link to all three of these. You cannot have quality care if it's unsafe or if the patient has a bad experience and it's ineffective care. And if you're going to assure care, you're looking to assure safety. You're looking to assure that the patient has a positive experience and that the care is effective. So they're all interrelated. Two other helpful papers by Olderwick et al and Ross and Naylor I've also put in the reference list. So Olderwick et al is Making the Case for Quality Improvement, Lessons of NHS Boards and Leaders. And Ross and Naylor is Quality Improvement in Mental Health. And both are published by the Kingsland. They're great papers to get an overview of quality in health care. So let's look at the two concepts now. Firstly, quality improvement, there is no definitive definition. It's an umbrella concept. It came from manufacturing industries. Quality improvement will use a systematic approach to improve patient care. It will involve methodical frameworks, models or tools that aim to improve health care practice systems or processes. So it could be about implementing a quality improvement project, using a change management model to implement a change. It could be looking at a service evaluation and gaining feedback from service users or patients. But the ultimate aim of quality improvement is to improve patient care through enhancing patient safety outcomes and experiences of care. And I had a discussion with some students and I've had them before with early career nurses who have said that quality improvement is only about linking projects to patients directly and not staff. And that's incorrect. If you improve the quality of staff experiences through education programs, staff support, a retention project or career pathways and aiming to retain staff, for example, you're going to have better staff services, better educated staff, which will improve patient care. And it links really under the second criteria of quality on the definition on the criteria that I presented previously, that your experience of care as a patient is going to be better if you're going to be cared for by a nurse that feels supported or a health care professional that feels supported, educated and able to deliver effective care. So quality improvement aims to standardize processes and structures so that variations are reduced, patient outcomes are improved. So an example quality improvement project might aim to introduce a screening tool to improve early identification of patients with sepsis. So the variations are reduced as staff are using a standardized screening tool. Patient outcomes will improve as patients are identified early with sepsis and you're going to have a knock on effect of decreased mortality rates for sepsis. So when we're looking at quality improvement methods, it should involve frontline teams. There's a strong emphasis on co-production and service user involvement when implementing and evaluating a change in practice. And co-production, if you're unfamiliar with the term, is about individuals influencing the support and the services, or it could link to a group of people getting together to influence the design and the delivery of services. There's a range of quality improvement and change management models, and there's no clear evidence that one model is better than another. However, we do know that quality improvement needs to be systematic and consistent to work. And it's also cyclical, so there has to be an evaluative element and it's ongoing and continuous. So when we look at quality improvement and change management models and frameworks and tools, there are many, there's several, and there's some quite popular ones, such as the Plan, Do, Study, Act cycle that's recommended by the Institute of Healthcare Improvement. And the Plan, Do, Study, Act cycle, the PDSA cycle, originated from Deming's 1950 wheel that was originally Pan, Do, Check Act. And it's a cyclical model based on the principles of continuous process of improvement. Then we've got the Lean Five Principles, again, very popular, that includes specifying value, understanding demand, flow, level, and pursuing perfection. The roots of lean thinking came from the Toyota Japanese company and their production system that was applied to healthcare. And the focus in lean thinking is driving out waste. In contrast to driving out waste, the Six Sigma focuses on reducing process variation and enhancing process control. The Six Sigma include define, measure, analyze, improve, and control. And then lastly, we've got Lewin's popular change management model, a very simple three-part model that includes unfreezing, which is determining change, preparing for change, and enabling movement. So you're looking at trying to unfreeze that status quo. You make the change, you take action, you implement. And then there's the third stage is refreezing. So you're solidifying that change. And I will be doing some future videos giving some practical examples linked to the Plan, Do, Study, Act cycle and Lewin's model on a video on change management in the future. So looking at the second concept now, quality assurance. The assurance of quality in healthcare refers to making sure quality care standards are maintained and that quality care happens. Clinical risks and harm to patients are reduced. So to achieve that, there must be ongoing monitoring of the quality of the care against degree standards for quality to be measured and assured. So quality assurance is the process for checking that quality standards have been met. And you do that through various strategies, methods, and tools. So risk assessments, audits, and service evaluations, for example. Often interviewees are asked about clinical governance in healthcare, and it links very closely to quality assurance. Governance is a system or framework for managing organisations. And in healthcare, clinical governance is this overarching system or framework where healthcare organisations are accountable for sustaining and improving quality of their services and for safeguarding standards of care. And healthcare organisations must evidence that standards are met and maintained to provide quality care. We look at the term risk management. This involves predicting and evaluating clinical risk. And we do that through identifying strategies to avoid and minimise risk through analysing data from clinical incidents and complaints, for example. So often in interviews, you're going to be asked about safeguarding standards, reducing risk. And some of the strategies you would use would be implementing evidence-based standards from NICE guidelines that underpin our policies, protocols, and patient care pathways. We will conduct risk assessments, and the actions and interventions following those risk assessments aim to safeguard standards and reduce risk. We have incident reporting and action plans following analysis of incidents. We've got learning from complaints, and we have national reporting and learning systems. There's clear escalation pathways to report poor care and areas of concern. The Care Quality Commission has national key performance indicators that measure quality. And it's important if you're applying for sort of more senior role in an area to look at what are the key performance indicators within this area. So if it was in surgery, it might, or in outpatients, it might link to number of outpatient appointments or number of operations, for example. And then we've got clinical audits and service evaluations. So all healthcare professionals need to know about what an audit is. You may be involved, asked to do one. You may be asking other staff to, you might be analysing data from audits as part of your role. An audit aims to measure the quality of care or a service against agreed national standards or a benchmark. So we have handy hygiene audits, I'm sure most of you will know about, but they're underpinned by a national protocol measuring how good healthcare workers are at cleaning their hands for each of the five moments of hand hygiene. So you've got this national standard. People usually, when they're doing the audit, are going into areas observing. They've got a tool. And once it's completed, they'll analyse the data and it will be expressed as a percentage of times that hands are cleaned by staff using good handy hygiene. Post audit, managers will receive the feedback and they aim to either sustain good practice because it was a positive outcome from the audit, or they learn from the data and it will inform future actions to improve the quality of hand hygiene. And it might include staff education programme or prompting posters by the sinks, for example. But audits are always cyclical. They're always ongoing. You will go back to areas to see if quality has improved or whether it's gone down or standards have improved. And audits are used to compare the quality of care across services locally and nationally. Does the care meet the standard required? If not, how can we improve? And as I said, we learn from audits and we re-audit and monitor improvement and change. It's similar to an audit. We're looking at the standard of the service. We're trying to get feedback. So with an audit, we've got our measured standard and we're going in and observing, say, on a handy hygiene audit. But with a service evaluation, we're still making a judgment on how well things are working and what needs to improve. But it's usually gaining feedback from service users. So for example, the friends and family test where patients submit anonymous feedback on their experience of a health care service and the results from those service evaluations will provide feedback that informs future planning in a local service. So again, service evaluations should be repeated to look for changes in improvement. But essentially, audits and service evaluations are giving you data to tell you about what's happening in the service, what is the standard of care and is it needing to improve or do we need to sustain the quality of care we're currently providing? So if any of you are interested in clinical governance, you've got interviews or you've got an assignment coming up, you might have seen the seven pillars of clinical governance that came from Donna Bedean. I've got the references in the reference list who developed the concept of these pillars in the 1980s. And also Nichols et al is a key reference. So and you'll see that the seven pillars link to what we've talked about previously in the slides. You've got audit, you've got patient and public involvement and patient and public involvement, as I mentioned, links to quality improvement. You have co-production, service user feedback, service evaluations, where we get feedback from patients. You've got risk management, etc. So you might want to have a look at some of those papers. And also we have quality improvement, additional resources. So NHS websites are very good with quality improvement and quality assurance frameworks, models and tools. We have some fantastic quality improvement hubs and local quality improvement leads and networks. And the leads will have a wealth of information and are often got example quality improvement projects on their web pages. We have the Institute for Healthcare Improvement, the Healthcare Quality Improvement Partnership, and they're an independent organisation led by the Academy of Medical Royal Colleges and the Royal College of Nursing. Just make sure I get that right. The Health Foundation is an independent charity that offers programmes and grants and has lots of educational resources to help carrying out research and policy. Professional bodies and national forums such as the Royal College of Nursing and the British Medical Association and the W. Edwards Deming Institute website if you're interested in using a PDSA cycle. If you're interested, I have a video on my quality improvement and change management playlist. What's the difference between research, quality improvement, service evaluation and audit? That might be helpful for students deciding what sort of dissertation they want to focus on. And also some videos on different roles in research, how to become a nurse researcher, because quality improvement and change management projects give you an introduction and it might be that you want to go on and pursue a career in research or quality improvement. I've got a video on quality improvement and service improvement projects for nurses and one on nursing dissertation if you're a student, a healthcare student. And I'll also be creating and uploading a few more videos linked to this area. So I've got some key references here linked to my slides and also if you've got assignments linked to this area, there's some good references. So if you have any questions at all, do put them in the YouTube comments. If you've preferred to DM me privately, DM me on Twitter or my website and do check out my YouTube channel. If you're interested in either of my books, there is a link to the books in my description on YouTube as well. So I hope you found the talk helpful.