Application of quality improvement methodology
Optimal results from QI initiatives do not just happen by chance or as a matter of course. QI is a science and an art, and appropriate methods have to be employed in order to secure the desired effects.
This was recognized decades ago in the manufacturing industry but only recently in the healthcare sector.
Poorly planned initiatives often turn out to be mere tick-box exercises but well-designed interventions have been shown to produce demonstrable benefit in obstetrics (8, 9) and gynaecology (10).A range of QI methodologies has been devised, researched, and refined in the industry. This includes continuous QI, Six Sigma, total quality management (TQM), Plan-Do-Study-Act (PDSA) cycles, statistical process control (SPC), Lean, and Lean Six Sigma. Systematic reviews showed that these methodologies potentially have significant effects on improving surgical care (11, 12).
A full discussion of QI methodologies is beyond the scope of this chapter. One methodology, the Model for Improvement (13), which is readily applicable in healthcare QI is briefly described. This methodology is based on three questions: (1) What are we trying to achieve? (2) How will we know that a change is an improvement? (3) What changes can we make that will result in an improvement? These questions require that a specific and measureable aim should be stated, that the right measures or measurements should be taken, and that collection of information should be purposeful and incremental. Changes are made using iterative Plan (planning what needs done), Do (running the test), Study (observing the results), Act (acting on what has been learned) cycles—better known as PDSA cycles. A test of change is performed in a small area with a small sample, and if there is demonstrable improvement, the test is extended to a broader area. An example of the use of PDSA cycles in gynaecology can be seen in a project which aimed to reduce the overuse of beta-human chorionic gonadotropin measurements in the emergency gynaecology clinic (14). The measure being assessed in a PDSA cycle may be a process measure (9, 14) or an outcome measure (8). It is helpful to also have a ‘balancing measure' to check that the planned change has not had unintended consequences. For example, in implementing an enhanced recovery programme so that women with an uncomplicated caesarean delivery are discharged home the day after delivery, a balancing measure could be the number of readmissions or a measure of user satisfaction.