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Democratising quality improvement within organisations

Every week – or so it seems – we hear of yet another problem in the realm of quality assurance and quality improvement. Whether it’s business or banking, healthcare, aged care, education and training… there appears to be no end to the examples of issues, incidents and – all too often – outright failures in current quality regimes.

A growing number of commentators and thought leaders are questioning the reliance of many sectors on the compliance-based approaches of accreditation and indicator performance monitoring, particularly in human service sectors such as health, aged care and education. For what it’s worth, I have added my voice to theirs, noting the limitations of indicators, the need to rethink our perspectives on quality, the importance of structured process review to quality improvement and the need for a more preventative approach to quality and safety in health care.

Indeed, there are so many downsides to the current focus on compliance that it’s hard to understand why we’re still relying on it so heavily. Not only does it encourage a “paint to the sight lines” (to borrow an old theatre expression) approach to quality assurance, it points organisations in completely the wrong direction in terms of the rationale for quality improvement, making it about passing accreditation and achieving performance benchmarks rather than about delivering the best possible goods or services.

Perhaps the biggest problem with the focus on compliance is that it results in frontline staff becoming disengaged from concepts of quality, which is a major contributing factor to failures in quality systems. This is particularly a problem in the healthcare sector, where it’s not uncommon for frontline clinical staff to roll their eyes at every audit and quality initiative or suddenly take off in a different direction if they see a member of the Quality Unit approaching them in the corridor. Meanwhile, Quality Unit staff complain they can’t get traction for their initiatives amongst frontline staff and don’t see lasting improvements following the completion of quality projects.

To me, these are sure signs that we’re “doing quality” the wrong way in healthcare.

I’d like to propose an alternative approach.

If I were setting up a Quality Unit in a hospital, the primary function of the unit would be to facilitate regular dialogue with frontline staff about routine practices. Helping staff to reflect on what they do, why they do it that way and how they think it could be improved. Taking a proactive approach that aims to get staff to identify the latent safety threats and sources of protocol variance in daily practice that could result in patient harm, before they actually do.

My Quality Team would be responsible for establishing, attending and (where appropriate or necessary) facilitating weekly structured conversations with staff in each unit of the hospital. The framework for those conversations would be provided by the national quality and safety standards and relevant clinical care standards. The Quality Team would listen to what the staff had to say, provide a hospital-level perspective on any issues and encourage the staff to identify solutions to problems. Because they are collecting staff input from across the hospital, the Quality Team would be able to readily determine which issues are local and can/should be solved locally and which ones represent more widespread problems that might require hospital-wide solutions.

Quality Unit staff would then be responsible for prioritising and implementing the solutions proposed by frontline staff. In some cases, this might involve investigating solutions used successfully by other health services; in other cases it might involve designing the solution from scratch. The important role of the Quality Team would be to ensure that tasks on both local and organisation-wide quality improvement action plans actually get done, to avoid a situation where good ideas fall by the wayside allowing identified problems to persist. Sometimes this shepherding of tasks through to completion would involve working with frontline staff and sometimes not, recognising that clinicians might want to be involved in implementing quality improvement solutions but have limited time to be able to do so. Of course, scheduling time for frontline staff to participate in implementing solutions would also greatly assist this process.

Finally, Quality Unit staff would be responsible for analysing the data collected through the various audits, incident reporting and other systems and regularly feeding the results back to the individual wards/units of the hospital. Ideally, these data would be presented in the context of the weekly discussions, so that staff reflect collectively on how the data relate to routine practice and can see the impact of changes in practice on measureable outcomes.

The important difference between this and what currently happens is that, in this proposal, the Quality Team are the facilitators – rather than the originators – of quality improvement projects. If we want frontline staff to engage with quality improvement, then they have to actively participate in the process from the start, diagnosing the issues and identifying the opportunities for improvement. The solutions that are devised and implemented then have to reflect the input of staff and make sense in the context of frontline practice.

I have no doubt there were good intentions behind the way Quality Units were established within hospitals and that Quality Managers and Quality Coordinators are excellent and hard-working people. However, while the current approach may appear to be the most efficient in terms of not “burdening” frontline staff with quality activities, the downside has been that frontline staff are mostly not engaged with this vital aspect of their practice and see quality as someone else’s business, not their own.

Quality teams are vitally important to contemporary healthcare organisations, but their role needs to reflect partnership with their frontline colleagues, to ensure collective ownership of quality initiatives. Tools such as MEERQAT can support the partnership between Quality Units and frontline staff, but the first step is recognising that the current model has to change.

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