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Table of Contents
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 128-131

Quality improvement: A new paradigm in health care

1 Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
2 RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission08-May-2019
Date of Acceptance09-May-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Ashok Deorari
Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_20_19

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How to cite this article:
Deorari A, Chandra P. Quality improvement: A new paradigm in health care. Apollo Med 2019;16:128-31

How to cite this URL:
Deorari A, Chandra P. Quality improvement: A new paradigm in health care. Apollo Med [serial online] 2019 [cited 2022 Dec 5];16:128-31. Available from: https://apollomedicine.org/text.asp?2019/16/2/128/260683

  Introduction Top

Health care should be safe, effective, patient-centered, timely, efficient, and equitable.[1] While optimal resources and clinical skills are necessary to ensure a satisfactory quality of health care, they are not enough by themselves. Approaches to ensure that patients receive high-quality care can be divided into two broad categories: quality assurance (QA) and quality improvement (QI). QA focuses on ensuring that requisite infrastructure, supplies, standard operative procedures, and trained staff are in place to facilitate delivery of quality care. It relies on periodic audits (typically by external evaluators) to determine whether predefined standards are being met and identifies gaps that need to be addressed by healthcare facilities. Thus, accreditation done by National Accreditation Board for Hospitals and Healthcare Providers (NABH) or National Health Systems Resource Centre (NHSRC) based on National Quality Assurance Standards for hospitals is typically the responsibility of health system administrators. QI approaches, on the other hand, focus on equipping frontline healthcare workers and managers with skills to identify and solve problems at their own level by improving systems and processes of care.

The terms QA and QI are often used interchangeably, but they are two sides of the same coin, and both are essential to ensure optimal functioning of health systems. Due to lack of awareness, QI approaches have been less widely used in health care but provide health workers and health system administrators with tools that can help resolve problems that QA approaches will not be able to address.

There are multiple approaches to QI that can be driven by frontline health workers.[2] In essence, they all provide methods to solve the problem by getting to the root cause using a team approach and relying on measurement of data over time. One such QI learning tool designed for developing countries is the four-step simplified approach, point of care QI (POCQI available on www.pocqi.org). This has been extensively used and disseminated across disciplines of health sciences in India.[3],[4],[5]

QI approaches focus on bridging the gap between the current knowledge and the actual practices in the real world. They share four cardinal principles. First, they emphasize working in multidisciplinary teams, which includes clinical experts who know what should be happening as well as frontline staff delivering the care who know what is actually happening to patients. Second, understanding local systems to identify barriers preventing delivery of quality care, from which potential solutions emerge. Third, testing the potential solutions using sequential small tests of change (plan-do-study-act [PDSA] cycles) to learn if they are feasible and effective and to adapt them to the local context. Fourth, a focus on using measurement and data to understand problems and learn if solutions are actually achieving their objectives.

For example, in our institution, we had a problem with babies waiting for retinal surgery being kept in the surgery waiting room for a long time. We formed a team of staff from the ophthalmology operation room, neonatology, and the eye ward. The residents and nurses responsible for the coordination between the different units identified several problems in patient transfer from ward to the operating room. PDSA was used to iteratively test different ways of rearranging patient flow, which led to 87% reduction in waiting time and virtually eliminated the problem of postponed cases.[6]

  Quality Improvement Is of Prime Importance for Developing Countries Top

In developing countries, a large patient load has been considered as the biggest hurdle to delivering quality care, especially in public hospitals. Improving flow of patients and reducing waiting times enhance patient satisfaction.[7] It is well known that use of checklist reduces the complication rates and reduces mortality in patients undergoing surgery; but, despite this, they are not implemented and audited at many hospitals.[8]

The science of QI looks at opportunities for improvement even within the constrained resources and aims to improve patient experience by bringing in efficiency. While our efforts often focus on coverage, improving the quality of care is equally important. Universal coverage for antenatal care will be of no value, if all the components (weight record, fundal height, looking for pedal edema, urine examination, and recording blood pressure) are not provided during each visit. Better health care can be delivered by improving outcomes or reducing costs using QI science.[9] Under the program for prevention of retinopathy of prematurity in Madhya Pradesh, the rational rational use of oxygen and its delivery by prongs (instead of hood) could save nearly 650,000 rupees annually per special care newborn unit.[10] Reducing unnecessary investigations[11] or saving on cost of needed accessories/equipment without compromising on clinical care are other good examples of using QI methodology.[12]

Global reports raise concern on unnecessary care and waste of resources on equipment and supplies in low- and middle-income countries.[13],[14] There is an abundance of evidence-based guidelines and recommendations postulating the ideal healthcare standards. The World Health Organization has laid out the standards of care for maternal and newborn care, and for care of children and young adolescents. Implementation of these guidelines however remains a challenge. Such standards provide guidance on what needs to be done while QI methodologies provide tools for implementation providing the “How” for bringing about these changes.

  Emerging Role of Clinicians and Nurses in Quality Improvement Top

Healthcare professionals while performing the task of treating the patients are naturally inclined toward improving the way the care is delivered. As frontline workers, they are responsible for the delivery of care. They are aware of challenges in healthcare delivery and even possible solutions within their area of work and control. The QI approach helps them to move in a systematic and scientific manner to identify, prioritize, and solve problems by working as teams. The feasible solutions are tested by them in small PDSA cycles and adopted or adapted leading to sustained improvement. It is important to document sustainable change by collecting the data over time, the results of which motivates them and other team members to further bring about improvement.

  Quality Improvement Versus Research Top

Clinical research is resource intensive, with fixed protocol and takes long time to get the results. On the other hand, QI is implementation research. A typical example is translation of evidence-based guidelines by the frontline team as per standards. This can be done within existing resources, with iterative cycles of testing a change on small numbers. The results are evident immediately within a short time and finally sustaining the improvement is essential.

  Quality Improvement Helps Frontline Workers Become Better Top

QI methodology helps in solving problems with small achievable smart aims by testing new change ideas within short time periods (4–6 weeks). The outcomes and benefits are shared and are readily evident to team members. The issues may be small or serious such as improving experience of care, reduction of errors, or ensuring implementation of standard practice guidelines.

Measurement is critical for documenting improvement

Data collection and analysis requires clear operational definitions and rigor to to be useful. The team should be clear on what simple data can be collected within available resources and not burden the providers with too many extra variables. Data variables that are few but focused on providing direction to improve processes of change are most important for success of QI projects. QI approaches also help to build on skills such as interprofessional learning, building teams, enhancing leadership qualities, and teaching data handling and analysis to healthcare professionals.

  Quality Improvement Is Very Relevant for Resident Doctors Top

QI science is like implementation research, while making sure that the evidence-based guidelines are translated for patient care. Reducing waiting time in operation theatres,[6] improving compliance to antibiotic administration 1 hour before incision, improving 1st hour breastfeeding rates,[15] documenting and reducing complications such as postoperative infections or urinary tract infections following catheterization or reducing central line infections[16] are suggested areas for improvement, but with the prerequisite that data are collected before and after the proposed change ideas.

Resident doctors can take QI projects as dissertation projects, publish them in high-impact journals, present them as papers/posters in conferences, and win awards as well. The turnaround time of these projects is shorter, needs fewer resources and the testing of change ideas is ever-evolving. Students learn the art of data collation and analysis in the process. They also learn about the standard methodology for writing a paper for publication.[17]

  Quality Improvement in Pre-Service Education Top

Making a change in the undergraduate training curriculum to focus on interprofessional learning,[18] skill-based learning, and improving communication will eventually lead to better quality of care for patients. Instilling the understanding of QI methodologies early in professional life can ensure that an entire generation of healthcare professionals will be enabled with problem-solving skills.

Often health professionals believe that knowledge and training alone will lead to improvement in care, but this may not be true. All healthcare professionals must learn QI methodology[3] and should be on lookout for problems in their areas and have clear intent and motivation to fix them. The science of QI is the missing link that can bridge the gap between the prevalent and the desirable.

  Key Ingredients for Success in Quality Improvement Implementation Top

The authors suggest that the following are the key ingredients for successful implementation of QI initiatives:[12]

  1. Constant support and unwavering belief of the institution leadership is a must for creation of a quality cell to support QI activities for improvement and patient safety. For sustenance, QI needs health systems' approach and often inputs for structure are required (like equipment and workforce)
  2. Team leadership plays a crucial role in imbibing and sustaining QI. An effective team leader would have enough leverage to remove the obstacles to improvement in the specific target area and liaise with the institutional leadership
  3. There is a need for local champions to drive the QI projects on a day-to-day basis and continuously motivate and challenge the teams. The enthusiasm and momentum that these “project champions” bring to the team is crucial
  4. The team must include frontline workers and administrators who have knowledge of the key processes involved. Otherwise, it may result in wrong choice of problems to be addressed, faulty analyses, and flawed improvement approaches
  5. Despite knowing what is the ideal care to be provided, implementation in local context of a healthcare facility may be a challenge. This should be surmounted by local teams in consultation with administrators
  6. Appreciation and regular team meetings with celebration of small wins/targets keep the teams motivated
  7. Sharing QI stories at group meetings leads to quick dissemination of information and will help in developing collaborations. Attendees are benefitted as they may not make similar mistakes and learn quickly from others' successes and failures
  8. For making a cultural change, QI science should be included in pre-service education of nurses and medical graduates
  9. Coaching support by occasional face-to-face contact or remotely using video conferencing/apps will keep the teams focused and on track of improvement.

  Conclusion Top

Healthcare professionals need to know that QI is much more than QA (structure) and relates to the implementation of best evidence-based practices, in a safe environment with equity, efficiency, and better experience of care. Often challenges are faced by frontline workers in health facilities; yet, they need to be empowered and be made capable to solve their problems by altering the processes or testing new ideas and document improvement in outcomes by measurement of data. Learning QI methodology can save considerable resources and add value to health care in resource-constrained countries.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001. Available from: http://www.ncbi.nlm.nih.gov/books/NBK222274/. [Last accessed on 2019 May 01].  Back to cited text no. 1
Deorari A, Livesley N. Delivering quality healthcare in India: Beginning of improvement journey. Indian Pediatr 2018;55:735-7.  Back to cited text no. 2
Mehta R, Sharma KA. Use of learning platforms for quality improvement. Indian Pediatr 2018;55:803-8.  Back to cited text no. 3
Mallick A, Banerjee M, Mondal B, Mandal S, Acharya B, Basu B. A quality improvement initiative for early initiation of emergency management for sick neonates. Indian Pediatr 2018;55:768-72.  Back to cited text no. 4
Mehta P, Srivastava S, Aggrohiya D, Garg A. Quality improvement initiative to improve the screening rate of retinopathy of prematurity in outborn neonatal intensive care graduates. Indian Pediatr 2018;55:780-3.  Back to cited text no. 5
Chandra P, Tewari R, Dolma Y, Das D, Kumawat D. Reducing preoperative waiting-time in a pediatric eye operation theater by optimizing process flow: A pilot quality improvement project. Indian Pediatr 2018;55:773-5.  Back to cited text no. 6
Chandra P, Kumawat D, Tewari R, Panyala RR, Sreeshankar SS. Reducing waiting-time of preterm babies at a retinopathy of prematurity clinic: A quality improvement project. Indian Pediatr 2018;55:776-9.  Back to cited text no. 7
Ramsay G, Haynes AB, Lipsitz SR, Solsky I, Leitch J, Gawande AA, et al. Reducing surgical mortality in Scotland by use of the WHO surgical safety checklist. Br J Surg 2019. doi: 10.1002/bjs.11151.  Back to cited text no. 8
Ho T, Zupancic JA, Pursley DM, Dukhovny D. Improving value in neonatal intensive care. Clin Perinatol 2017;44:617-25.  Back to cited text no. 9
Deorari A, Kumar P, Chawla D, Sachdeva A, Parmar JP, Burman M, et al. Rationalizing and reducing oxygen usage in special neonatal care units (SNCU) of state of Madhya Pradesh, India (Quality improvement initiative). In: Poster. Baltimore MD: Pediatric Academic Society Meeting; 2019.  Back to cited text no. 10
Devarapalli S, Saini SS, Sundaram V, Kumar P. Optimizing utilization of laboratory investigations in neonatal intensive care unit. Indian Pediatr 2018;55:784-7.  Back to cited text no. 11
Sivanandan S, Sethi A, Joshi M, Thukral A, Sankar MJ, Deorari AK, et al. Gains from quality improvement initiatives – Experience from a tertiary-care institute in India. Indian Pediatr 2018;55:809-17.  Back to cited text no. 12
Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the sustainable development goals era: Time for a revolution. Lancet Glob Health 2018;6:e1196-e1252.  Back to cited text no. 13
Berwick DM, Kelley E, Kruk ME, Nishtar S, Pate MA. Three global health-care quality reports in 2018. Lancet 2018;392:194-5.  Back to cited text no. 14
Dudeja S, Sikka P, Jain K, Suri V, Kumar P. Improving first-hour breastfeeding initiation rate after cesarean deliveries: A quality improvement study. Indian Pediatr 2018;55:761-4.  Back to cited text no. 15
Balla KC, Rao SP, Arul C, Shashidhar A, Prashantha YN, Nagaraj S, et al. Decreasing central line-associated bloodstream infections through quality improvement initiative. Indian Pediatr 2018;55:753-6.  Back to cited text no. 16
Wong BM, Sullivan GM. How to write up your quality improvement initiatives for publication. J Grad Med Educ 2016;8:128-33.  Back to cited text no. 17
Gorantla S, Bansal U, Singh JV, Dwivedi AD, Malhotra A, Kumar A. Introduction of an undergraduate interprofessional simulation based skills training program in obstetrics and gynaecology in India. Adv Simul (Lond) 2019;4:6.  Back to cited text no. 18


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