Quality Improvement Methodologies
Avedis Donabedian, one of the grandfathers of quality improvement, contributed greatly to quality assessment and improvement within health care. One of his greatest contributions was bringing to light that in order to affect outcomes, we have to affect structures and processes.1 Structures describe the settings where care is delivered; processes are the actual medical care practices that are provided to the patient; and outcomes reflect the effect of structures and processes. During the transformation and quality improvement journey, the aim is to change structures and processes.
W. Edwards Deming further contributed to quality improvement by outlining his theory of profound knowledge, which has four major components:
- System thinking—All care is delivered through a system that can be divided into sub-processes.
- Psychology of change—Leaders of practice transformation and quality improvement should create a shared vision of the future state of the enterprise. Leaders should work to ensure that all staff members support this vision. From there, all team members can contribute their energy and creative ideas to reach a common goal.
- Theory of knowledge—The system of care and everything connected to it should be studied by those interested in changing it. Theories of changing components, or processes, should be tested by PDSA (Plan, Do, Study, Act) cycles to allow for the system to evolve. Results of those changes should be examined regularly.
- Variation—All systems are developed to create outcomes. These outcomes have a natural variation. Organizations that understand data variation will not overreact to natural movement of data on a weekly or monthly basis.
Organizations require three major components to become highly reliable:
- A culture of safety
- Robust process improvement (which includes Lean, Six Sigma, or Change Management)
The foundational work established by Donabedian and Deming can be applied when health care practices use a model to assist in change. The models described in greater detail here include the IHI Model for Improvement, Lean, and Six Sigma.