Continuous/Quality Improvement, PDSA, EBCD, Agile, LEAN Six Sigma: It’s all Greek to me!
The new Aged Care Quality Standards reference continuous improvement 16 times in the Guidance material and the concept is evident across all 8 Standards (Aged Care Quality and Safety Commission, 2019). But what does it mean, and how do you do it? The Guidance material includes a definition in the Glossary but, to me, continuous improvement means an organisation or service:
a. Knows what people want (e.g. consumers, family, visitors, staff, community, government).
b. Constantly monitors and reviews whether it is providing what people want using a range of data/ methods.
c. Acts and makes changes to continue to better itself – this means addressing any “gaps” but also recognising and reinforcing what’s working well.
Continuous improvement should occur at all levels: individual, service and organisation. The ISO 9001:2016 provides detailed instruction for establishing a quality management system regardless of the business. However, for care providers:
· At the individual level, it means that staff are encouraged and supported to constantly tweak and tailor the care they provide to consumers in accordance with their diverse and dynamic needs, goals and preferences. That is, moving away from one size fits all care towards partnerships with consumers and their representatives; and empowerment and enablement of staff to make decisions about how best to care for individuals.
· At a service level, it means understanding the consumer and staff experience as a collective, measuring outcomes and seeking to improve journeys, systems and processes e.g. the admission or care planning process or the mealtime experience.
· At an organisational level, it means that the governing body and management are constantly monitoring operational service delivery to ensure it meets organisational values, strategy and purpose; aligns with community and consumer needs and expectations; and is achieving outcomes. Collection and analysis of a comprehensive and quality dataset is key.
This article provides a basic intro about how to run a continuous or quality improvement project. A quick Google will provide you with a range of approaches and methods including PDSA, Lean Six Sigma, Experience Based Codesign, Agile, Design Thinking etc. While each of these approaches gives good instruction and food for thought, it can be resource intensive to train and deliver a specific methodology and most follow similar theories/ patterns. In my practical experience, quality improvement projects should include the following steps:
1. Identify your area of focus e.g. admission or discharge process or experience, increasing rate of falls or medication errors, varied completion/ quality of care plans or assessments, challenges integrating or coordinating care with other providers. These areas for improvement could be identified from consumer surveys or feedback, internal reviews/ audits / reports, external assessments, a change in evidence or policy.
2. Next, gather more data and information about the extent of the problem or opportunity for improvement. This could include:
· Review of organisational documents and data including policy and procedures, incident and feedback trends, and survey or audit results.
· A literature review to find the evidence and current best practice or understand how other organisations and sectors are responding to the issue.
· Conversations or workshops with consumers, consumer representatives to understand their experience and outcomes. This could include journey mapping, collecting patient stories or conducting baseline assessments.
· Observations of the environment, interactions or practice to understand systems, processes, workflow and how these can be improved.
3. Now you’ve got the information, you need to make sense of the data. This means analysing the data to identify:
· What’s working well and what’s not working well
· Where there are gaps or variation between evidence/ best practice, policy and service delivery
· Opportunities for improvement
4. Develop solutions and prioritise improvements: from the above steps, you should have greater clarity and evidence for the areas that are most in need of change/ improvement. Now it’s a case of validating that with your stakeholders – present your findings to key representatives, ask them to comment, and begin problem solving. There are a range of simple facilitation tools that can assist, however, the most important thing is to make sure the culture and atmosphere is right to stimulate open and honest discussion and creativity.
5. The next step is the most important – implementation. Save energy, resources and time for making and sustaining the change. This will involve project management – detailing what needs to happen, by whom and when – and identification of the Executive Sponsor; the person of sufficient seniority to drive and champion the project and ensure it meets milestones. A multifaceted communications plan is critical for change management and to help people understand what is happening, why and how they can get involved.
6. Finally, evaluate. You’ll need to check and demonstrate whether the improvement had the intended effect. Your baseline data can be what you collected in step 2. You will need determine a timeframe to follow up the same data and assess the impact of the improvement. Have incidents or complaints reduced? Do survey or other feedback results demonstrate consumer and staff satisfaction with the improvement? Has it impacted outcomes e.g. improved wellbeing, reduced pain etc? Has a process or efficiency improved e.g. rate of care plan completion or duration of admission process?
Although this looks like a big commitment, it doesn’t have to be life’s work! Once you establish the approach, culture and governance; and create appropriate tools and templates like project plans things should start flowing more readily. It is important that you have the right team of people involved to ensure the improvement is as successful as possible including representation from management, frontline staff, clinicians, consumers and families (as appropriate). The Institute for Health Care Improvement has lots of good information and resources to support you as you begin your journey to developing and sustaining a continuous improvement culture and practice.
What do you think is the most important and hardest part of fostering continuous improvement or seeing out quality improvement projects? Do you need more support to kickstart continuous improvements? We can help!
Aged Care Quality and Safety Commission (2019). Guidance and Resources for Providers to support the Aged Care Quality Standards.
Australian/New Zealand Standard ISO 9001:2016 Quality Management Systems – Requirements.
Department of Health Victoria (2010). The Plan Do Study Act (PDSA) Model for Improvement Project Workbook. Available at: https://www2.health.vic.gov.au/about/publications/ResearchAndReports/plan-do-study-act-psda-model-workbook.
Institute for Healthcare Improvement (2019). How to improve. Available at: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx.