Quality and Improving Quality: Concept, Implementation and Communication

Anthony Staines focused on three aspects of quality: concept, implementation and communication. He stressed that there is a discrepancy between the quality demonstrated by research to be achievable and the quality actually attained.

Starting with the history of the concept of quality, Staines explained how the concept evolved. Before the industrial revolution products were made by hand, by an individual, meaning therefore quality was ensured. After the industrial revolution, production became mechanical and organisation reached a new level. Quality was no longer determined by an individual but part of the system. Moreover quality is not just a result of the correct materials and individual expertise, it must be managed and co-ordinated.

Staines informed the audience of some of the key players in the history of the quality movement. Walther A. Stewhart of General Electric created a concept to reduce the need for physical inspection using statistical analysis of processes. This led to the cycle of continuous improvement: ACT-PLANDO- STUDY-ACT.

Within the healthcare sector specifically, Ignace Phillipe Semmelweis and Florence Nightingale discovered the causes of reduced quality; finding the origin of puerperal fever came from contamination during dissection by surgeons and that hygiene affected the mortality rates of soldiers during the Crimean war. Ernest Armory Codman is recognised as the founder of "outcomes management", the impact of the relationship between the result and the process of medical treatment. He founded the American College of surgeons and the "Hospital Standardization Program" which later became "Joint Commission International".

After this, the healthcare sector was equipped with articles, books on quality of care, its definition and evaluation. Quality analysis models were created and Archibald L Cochrane developed Evidence-Based Medicine. International societies dedicated to ensuring quality soon followed.

However, the challenge for health services is the gap between the potential revealed by scientific research (best practices) and clinical practices. Staines used the example the insertion of a central line to illustrate the difference between recommendations and what is done in practice. Recommended are checklists, hand washing, use of antiseptic etc when in reality things are very different (no checklist are used, 45% conformity with hand hygiene...).

So how do we ensure best practices? Staines believes that the system is key: if a system is good enough, individuals will adopt them.

He cites 10 key points essential for clinical quality and patient safety:

• Understanding 
• Leadership 
• Vision 
• Organisation 
• Measure and information system 
• Culture 
• Teamwork 
• Best Practices
• Objectives, Evaluation and Feedback 
• Inclusion of the Patient 
• Cost/Value

For five of these points communication is key: leadership vision, culture, inclusion of the patient, objectives evaluation and feedback and teamwork.