PART 1 | Basic principles

Bailey & Love Bailey &

Love Bailey & Love
Human factors, patient safety
and
CHAPTER

15 quality improvement
Learning objectives
To learn:

• The importance of understanding human behaviour, quality and value in healthcare

delivery

• The importance of human factors and teamworking in reducing and rectifying error

• Medical error and its defnitions, including adverse events

and near misses

• The importance of patient safety, strategies and
application in clinical practice
• Quality improvement as an overarching activity • The need for system thinking and leadership
INTRODUCTION
In recent years, increased emphasis has been placed on the study of healthcare systems to
better understand the relation- ship of how management and administrative systems best
support clinical practice and promote quality improvement and patient safety. To some
extent this has come about as a consequence of the increasing complexity of healthcare
delivery, which, although credited with dramatically improving public health over the last
50 years, has led to the realisation that patient satisfaction and safety is frequently
compromised. This issue is multifactorial but includes poor integration of care pathways,
poor planning and utilisation of resources and errors in management and clinical care. A
disafected healthcare workforce challenged with excessive administrative and
governance workloads compounds these issues and leads to ‘burnout’, which contributes
to poor clinical outcomes and further compounds societal and patient dissatisfaction with
patient care.

Understanding healthcare systems, promoting ‘value’ for both healthcare providers and
patients and supporting the healthcare workforce to deliver high-quality and safe care
remains the biggest challenge for the healthcare industry in the current decade. This
chapter addresses some of these import- ant issues and provides a framework for
surgeons to contribute to the design of safe and efcient surgical pathways of care.

Today’s healthcare systems face two big challenges: increas- ing demand because of
greater volumes of patients who are older, who often have comorbidities and who often
require multidisciplinary care; and an increasing volume of treatment options, often of
greater complexity and cost.

Despite the ability of medical science to manage and treat an increasing array of complex
medical conditions, not all medical conditions are managed well. Implementing
evidence-based care in complex health systems is challenging.

Added to this, the fnancial cost of health care challenges both healthcare recipients and
providers and questions how best to drive the ‘quality’ agenda in healthcare delivery.

According to the Institute of Medicine, patients do not always receive the most suitable
care at the best time or in the best place. Its infuential report, Crossing the Quality
Chasm: A New Health System for the 21st Century, emphasises the need to redesign
healthcare processes and systems in response to this quality gap.

The concept of ‘value’ in health care has been developed to provide a focus for both
healthcare recipient and provider. Professor Michael Porter, director of the Harvard
Business School’s Institute for Strategy and Competitiveness, has advo- cated value-
based health care as one of the most important topics in healthcare transformation. Porter
proposed six prin- ciples that support a value-based approach to health care:

• 1 Organise care around medical conditions – care should be based upon the
medical needs of a community.
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Patient safety 237
‘Right care, right time, right place for carers’ and ‘Choosing Wisely UK’, all of which are
based on designing healthcare systems that are truly patient-centric and ofer quality
outcomes that matter to patients.

HUMAN FACTORS
The healthcare setting has become increasingly complex. Patient and societal demands
for transparency in defning and justifying treatment decisions impact on all healthcare
workers, who need to understand their professional responsibilities when working within
complex social and work environments. Healthcare workers must understand that
patients are increas- ingly better informed and wish to be included more fully within the
decision-making processes regarding treatment options. Likewise, when performance and
clinical outcomes are less than expected, patients and their supporters are entitled to
timely and honest appraisal of ‘what went wrong’ and to be part of the discussion
regarding ongoing care.

Therefore, increasingly, surgeons will need to integrate knowledge, technical skills and
mastery of complex equipment while participating in a multidisciplinary healthcare
setting, in order to deliver safe and efective care. The communica- tion skills required to
work in these complex environments and engage efectively with audit, management and
quality improvement systems are all dependent on human behaviour.

These complex skill sets are set out in the study of human factors (HF), which examines
the behavioural interrelation- ships between humans, the tools they work with and the
environment in which they work. It is a complex area that incorporates knowledge
derived from many disciplines. A bet- ter understanding of the efects of teamwork, tasks,
equipment, workspace, culture and organisation on human behaviour will improve
performance in clinical settings. A HF approach to patient safety difers from traditional
safety training in that the focus is less with the technical knowledge and skills required to
perform specifc tasks, but rather with the cognitive and inter- personal skills needed to
efectively manage team-based, high- risk activities. With time, HF training has evolved
from models describing human interactions within complex environments to more
nuanced programmes that modify workers’ behaviour and improve patient safety.

HF was originally conceived in the 1940s in the aviation industry to better understand the
relationship between a team’s behaviour, its technical surroundings and a changing
environ- ment. The ‘cognitive skills’ of the aircraft crew refers to the mental processes
used for gaining and maintaining situational awareness, for solving problems and for
making decisions, whereas ‘interpersonal skills’ are the communications and behavioural
activities associated with teamwork.

Crew resource management (CRM) training was developed to build efective

communication skills and a cohesive environ- ment among team members and to build an
atmosphere in which all personnel feel empowered to speak up when they

suspect a problem. Team members are trained to cross-check each other’s actions, ofer
assistance when needed and address errors in a non-judgemental fashion. Debriefng and
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238 CHAPTER15 Humanfactors,patientsafetyandqualityimprovement
training and services, there remains the challenge of dealing with unsafe practices,
incompetent healthcare professionals, poor governance of healthcare service delivery,
errors in diagnosis and treatment and non-compliance with accepted standards.

When errors occur, it is important that there are systems in place to ensure that all those
afected are informed and cared for, and that there is a process of analysis and learning to
uncover the causes and prevent recurrence of such events. It is equally important to learn
more about the characteristics and facilitators of safe, high-quality care. The study of
patient safety is now a healthcare discipline in its own right, encompassing patient safety
methodologies, health service design, investiga- tion of incidents and related research.
The development of risk management strategies within the healthcare setting attempts to
address these failings. Comprehensive risk management is not just an exercise in ligation
avoidance but aims to develop a cultural awareness and support for all healthcare
workers in defning and delivering high-quality clinical care.

A milestone report by the US Institute of Medicine of the National Academy of Sciences

(now the National Academy of Medicine), To Err is Human: Building a Safer Health
System, drew widespread attention to the impact of medical error on healthcare
outcomes. The World Health Organization (WHO) estimates that, even in advanced
hospital settings, one in 10 patients receiving health care will sufer preventable harm,
although measurement of the incidence of suboptimal out- comes remains challenging.
In addition to the potential for needless sufering, the fnancial burden of unsafe care
globally is compelling, resulting as it does in prolonged hospitalisation, loss of income,
disability and litigation costing many billions of dol- lars every year. In 2017 the
Organisation for Economic Co-op- eration and Development (OECD) published The
Economics of Patient Safety, which indicates that this is a problem faced in all healthcare
systems, with iatrogenic patient harm being the 15th leading cause of the global disease
burden and accounting for 15% of all OECD countries’ hospital expenditure.

While the relationship between medical error and litiga- tion is particularly complex,
sophisticated healthcare systems understand that efective strategies to promote patient
safety and quality improvement must include a whole organisational culture change with
both central senior management involve- ment and active engagement by all those within
the organ- isation. Furthermore, clinical audit, data management and incident reporting
must be carried out in a ‘blame-free’ culture with an emphasis on education and the
avoidance of an adver- sarial culture, which hinders active participation.

PATIENT SAFETY AND RISK

MANAGEMENT
Patient safety can only be considered in a broader understand- ing of risk management.
Healthcare risk management has traditionally focused on the important role of patient
safety and the reduction of medical error. However, with the increas- ing complexity of
the healthcare environment, which includes not only the increasing complexity of
medical care but also the use of new and advanced technologies, IT and cybersecurity
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Understanding patient safety incidents 239

The person approach

Human performance principles tell us that humans are fallible and that errors can occur
through doing the wrong thing – errors of commission; failure to act – errors of omission;
or errors of execution – doing the right thing incorrectly. These principles also tell us that,
by understanding the reasons why adverse events and near misses occur and by applying
the lessons learnt from past events, future errors can be prevented. However, for most
errors the person approach on its own tends to blame the individual and restricts learning.
For this reason, individual performance may be best assessed by professional appraisal
processes and clinical audit, which ensures that performance outcomes are benchmarked
across institutional, national and international norms.

The system approach

Health systems add complex organisational structures to human fallibility, thus
substantially increasing the potential for errors. A systems approach to error recognises
that adverse events rarely have an isolated cause and that they are best addressed by
examining why the system failed rather than who made the mistake. This is clearly
outlined in the 2013 report by Professor Don Berwick called A Promise to Learn – A
Commitment to Act, which looked into improving patient safety in the NHS, where the
emphasis is on a system-wide approach to patient safety.

However, greater analysis of organisational safety needs to go beyond understanding not

only why unanticipated events occur, which has been referred to as safety 1; it also needs
to understand the robustness and resilience within systems due to human innovation and
adaptability, which frequently pre-

vents untoward events and is referred to as safety 2. Safety 1 places the emphasis on
identifying errors after the event and aims to prevent them from occurring or recurring in
the future, whereas safety 2 acknowledges that healthcare work is resilient and that
everyday performance succeeds much more often than it fails. This is because clinicians
constantly adjust what they do to match the conditions. Working fexibly, and actively
trying to increase clinicians’ capacity to deliver more care more efectively, is key to this
new approach. At its heart, proactive safety management focuses on how everyday
perfor- mance usually succeeds rather than why it occasionally fails, and it actively
strives to improve the former rather than simply preventing the latter.

The publication ‘From Safety-I to Safety-II: A White Paper’ (2015) expands on this
concept and stresses the importance of assimilation of these two ways of thinking.
Sophisticated healthcare systems need not only to examine what works well but also to
examine adverse events and understand and plan for adverse outcomes. Balancing these
concepts should be con- sidered an investment not only in safety but also in improving
productivity and patient and staf well-being.
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240 CHAPTER15 Humanfactors,patientsafetyandqualityimprovement
healthcare worker is required to take responsibility for their respective roles in order to
avoid the summation of error and resultant harm. Consequently, the more layers of
responsibil- ity, the fewer the chances of adverse events occurring.

Summary box 15.2

Understanding patient safety incidents

• ● Errors can be viewed from a person-centred or a system approach

• ● The majority of near misses or adverse events are due to system factors

• ● Understanding why these errors occur and applying the lessons learnt will prevent future
injuries to patients

• ● It is important to report all near misses or adverse events so that we can constantly learn from

mistakes

• ● Error models can help us understand the factors that cause near misses and adverse events

• ● Examining what works well may be an additional constructive approach to defning safe

patient pathways
STRATEGIES FOR PATIENT SAFETY
As safety is everybody’s business, building and embedding a safety culture
into surgical service delivery is the key to improving patient outcomes. At an
institutional level, defning ‘best practice’ within a robust governance system
and bench- marking against national and international norms is required prior
to implementation of strategies for improvement. Clearly these strategies will
vary depending on local requirements and resources.
International
Since 2009, WHO has embarked on a series of global and regional initiatives
to improve surgical outcomes. Much of this work has stemmed from WHO’s
Second Global Patient Safety Challenge, Safe Surgery Saves Lives. One
specifc strategy that has been shown to be efective is the use of the surgical
checklist, which, when properly implemented, has been shown to improve
surgical outcomes in both low- and middle-income countries and in wealthier
countries.
Checklists
Checklists in the operating theatre environment are now accepted as standard
safety protocols since the Safe Surgery Saves Lives Study Group at WHO
published its results. The use of a perioperative surgical safety checklist in
eight hospitals around the world was associated with a reduction in
perioperative mortality from 1.5% to 0.7% and major inpatient complications
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Strategies for patient safety 241
Surgical Safety Checklist
Before induction of anaesthesia

(with at least nurse and anaesthetist)

Has the patient confrmed his/her identity, site, procedure, and consent?

Yes

Is the site marked?

Yes
Not applicable

Is the anaesthesia machine and medication check complete?

Yes

Is the pulse oximeter on the patient and functioning?

Yes

Does the patient have a:

Known allergy?

No Yes

Diffcult airway or aspiration risk?

No
Yes, and equipment/assistance available

Risk of >500ml blood loss (7ml/kg in children)?

No

Yes, and two IVs/central access and fuids planned

Before skin incision

(with nurse, anaesthetist and surgeon)

Confrm all team members have introduced themselves by name and role.

Confrm the patient’s name, procedure, and where the incision will be made.

Has antibiotic prophylaxis been given within the last 60 minutes?

Yes
Not applicable

Anticipated Critical Events

To Surgeon:

What are the critical or non-routine steps? How long will the case take?
What is the anticipated blood loss?

To Anaesthetist:
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242 CHAPTER15 Humanfactors,patientsafetyandqualityimprovement
SPECIFIC ISSUES IN COMMUNICATION
Professional behaviour and
maintaining ftness to practice
Professionalism is an important component of patient safety. This embraces attitudes and
behaviours that serve the patient’s best interests above and beyond other considerations.
Organ- isations responsible for maintaining ethical standards include professionalism as
one of the standards by which healthcare workers are judged (see Chapter 14).

Fitness to work or practice – competence – refers not just to knowledge and skills but
also to the attitudes required to be able to carry out one’s duties. Monitoring their own
ftness for work is the responsibility of each individual, their employer and professional
organisations. Healthcare workers are required to have transparent systems in place to
identify, monitor and assist them to maintain their competence. Credentialing is one way
to ensure that clinicians are adequately prepared to safely treat patients with particular
problems or to undertake defned procedures.

Communicating openly with patients

and their carers and obtaining consent
A patient-centred approach by medical staf, with involvement of patients and their carers
as partners, is now recognised as being of fundamental importance. There are better
treatment outcomes and fewer errors when there is good communication, while poor
communication is a common reason for patients taking legal actions.

Involving patients in and respecting their right to make decisions about their care and
treatment is crucial. Explaining risk is a difcult but important part of good
communication. It requires skill to explain the potential for harm of a procedure so that it
is fully understood because patients vary in their per- ception and understanding and it is
often difcult to assess the trade-ofs between harm and beneft.

Obtaining consent for surgery requires that surgeons provide information to help patients
to understand the posi- tives and negatives of their various treatment options (Table
15.2). Patients should be allowed to make these informed decisions without coercion or
manipulation. Consent should be obtained by someone who is capable of performing the
surgery, and this should be taken when the patient is fully aware, especially in the non-
urgent situation, well before the surgical procedure (see Chapter 14). A failure to provide
adequate time for discussion regarding consent and also to understand that consent is a
process that frequently requires multiple interactions with a patient are frequent causes of
an unsatisfactory consent process.

When things go wrong: open

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Patient safety and the surgeon: professional responsibility 243
These features of situational awareness and emotional intelligence are important in
identifying stress within oneself and other members of the healthcare team. Stress, tired-
ness and mental fatigue in the workplace are signifcant occupational health and safety
risks in health care. There is good evidence linking tiredness with medical errors. Fatigue
can also afect well-being by causing depression, anxiety and confusion, all of which
negatively impact on clinicians’ per- formance. Increasingly ‘burnout’ has been identifed
as a major cause of poor performance in the medical workforce. Burnout is characterised
by a state of emotional, mental and physical exhaustion caused by prolonged stress.
Burnout in the medical workforce has increased in recent years and has been attributed to
lack of autonomy within the profession and increased administrative workloads; the latter
is compounded by electronic record-keeping and working in an increasingly regulated
environment. Doctors sufer from burnout to a greater extent than other professions.

Organisations and those in leadership positions bear responsibility for managing the
working environment and work practices to minimise fatigue and stress. While this is
widely refected in legal restriction of working hours, much needs to be done to determine
whether reducing resident or trainee hours of work leads to greater patient safety because
of the ‘trade-of’ in requiring additional ‘handovers’ between clinical teams and
subsequent loss of continuity of care.

Prescribing safely
Patients are vulnerable to mistakes made in any one of the many steps involved in the
ordering, dispensing and admin- istration of medications. Medication errors are one of
the most common errors across all medical specialties. Accuracy requires that all steps
are correctly executed. Common medi- cation errors include:
• ● poor assessment or inadequate knowledge of patients and their clinical
conditions;

• ● inadequate knowledge of the medications;

• ● dosage calculation errors;

• ● illegible handwriting;

• ● confusion regarding the name or the mixing up medica-

tions.
PATIENT SAFETY AND THE SURGEON:
PROFESSIONAL RESPONSIBILITY
Among medical specialties, surgery is one of the most invasive healthcare
interventions that a patient can experience. More than 100 million people
worldwide undergo surgical treatment every year. Problems associated with
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Clinical outcomes, audit and improvement 245
Unconscious competence

Conscious competence

Conscious incompetence

Unconscious incompetence

Figure 15.4 Hierarchy of competence.

Never events
QUALITY IMPROVEMENT
In health care, quality improvement is defned as the continu- ous and combined eforts of
people to make changes that will lead to better patient outcomes, enhanced healthcare
system performance and better learning and professional development. Improvements
come about through the intentional actions of staf equipped with the skills and data
needed to bring about changes in patient care, either directly or indirectly. Such changes
require substantial and sustained commitments of time and resources. The feld of
improvement science provides frameworks and methodologies that help when designing
or redesigning healthcare processes and systems, especially when the aim is to ensure
more efcient, safe, timely, efective, patient-centred and equitable care. The concept of
value is an important adjunct to healthcare improvement. Value takes into account the
total cost of health care as compared with the outcomes delivered to patients and helps to
place emphasis on health, well-being and preventative care as opposed to exclusively
focusing on treatment of illness.

There are large numbers of improvement activities that range from redesigning how
teams deliver care in the multiple small clinical groupings (microsystems) that make up
health- care organisations to more large-scale reconfgurations of spe- cialist services such
as stroke care and cancer care. Other areas of healthcare improvement focus on areas as
diverse as the redesign of training, budgeting processes and information sys- tems.
Common to all healthcare improvement is the necessity for doctors and other healthcare
staf to refect on and improve the way they work and to build a culture that both
understands and values continuous improvement.

CLINICAL OUTCOMES, AUDIT AND

IMPROVEMENT
Clinical audit, a function of clinical governance, is the means by which the health care
being provided is compared with accepted standards. It allows care providers and patients
to know how their service is doing (known as quality assurance) and to identify where
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246 CHAPTER15 Humanfactors,patientsafetyandqualityimprovement
• ● support team and individual quality improvement, includ- ing providing information
for appraisal and revalidation;

• ● learn from, spread and celebrate best practice.

QUALITY MEASURES
Measurement is a key principle of quality improvement. Although many changes take
place in health care, without measurement it is impossible to determine whether those
changes actually result in improved quality. Measurement of improvement requires
diferent methods from those used in research, being concerned more with testing of
how best to efectively introduce and replicate best practice rather than determining for
the frst time what best practice should be. Quality measures are tools that help to
quantify the char- acteristics of high-quality health care and may measure the
healthcare process, its outcomes, the patient’s experience or the organisational
structures or systems that support care delivery. Quality may be measured in terms of
structure, process and outcomes.
Structural measures outline the characteristics of the health system that afect the
system’s ability to meet the healthcare needs of individual patients or a population.
Structural measures usually refer to the availability of mate- rial, infrastructural or
human resources, e.g. the number of surgeons per 100 000 population or the number
of stafed operating theatre sessions in a hospital. Structural measures are especially
useful in evaluating and improving equity of access to health care. They may include
measurement of the availability in a healthcare setting of policies or procedures
needed to deliver high-quality care, such as standards for the frequency and nature of
clinical observation of postoperative patients.
Process measures assess what the healthcare provider did for the patient and how
well it was done. The term pro- cess is used to refer to the implementation of
procedures and practices by staf when planning, prescribing, delivering and
evaluating care. Each surgical patient’s journey is a composite of multiple processes,
such as preoperative assessment, hos- pital admission and undergoing an operation,
among oth- ers. Measurement for improvement most commonly involves tracking
processes at the same site over time in an attempt to reduce inappropriate variation.
Process improvement mea- sures should be associated with better outcomes of care
and, ideally, should be important from a patient’s perspective. An example of a
clinical process measure might be the starting times of operating lists. Consistently
starting the operating day on time reduces delays for patients awaiting surgery and has
a number of associated possible benefts, such as shorter fasting times preoperatively
and a greater ability to plan the theatre day. Sometimes process measures are used as a
management

tool, comparing sites or performance against defned thresh- olds. In this example,
starting theatres on time might be part of a wider improvement plan that aims to reduce
underutilisation of stafed theatre time.

Outcome measures describe the efects of care on the health status of patients and
populations – they are specifc, observable and measurable changes that represent the
 •

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The quality improvement pathway 247
process and transition of care back to the community services if required.

The urgent, emergency or unscheduled patient journey is diferent because it is

unpredictable for each individual, although patterns of presentation do emerge when
managing large numbers. The patient commonly presents at the emer- gency department
of a hospital either as a self-referral, as a primary care referral or by ambulance. The
journey begins with triage by a team, who assess the severity of the illness and then
stream the patient to the most appropriate area for their needs, which might include, for
example, a resuscitation unit, a rapid assessment and treatment unit, an acute surgi- cal
assessment unit, a minor injuries unit or an ambulatory care unit. The objective is that the
patient is seen as soon as possible by a senior decision maker, so that the patient can be
treated or discharged as expeditiously as possible or, if admission and surgery are
required, this too can be expedited. Thereafter, the journey follows a similar course to
that of an elective admission.

This simple outline of surgical patients’ journeys serves to illustrate the many individual
steps or processes in that journey, each with scope for errors, delays and inefciencies.
Opportu- nities for improvement are almost limitless.

THE QUALITY IMPROVEMENT PATHWAY

Quality improvement can be applied to almost any step, process or activity. The science
of improvement is an applied science that prioritises innovation, rapid-cycle testing and
spread with the aim of identifying what changes, and in what contexts, will result in
improvement. Healthcare Improvement Scotland identifes seven stages when
undertaking improve- ment:

• 1 discovering – is about defning the aims and vision; understanding what the
problem is and what data are available;

• 2 exploring – is about defning the present state and visu- alising the future state;

• 3 designing – is about defning how to move from the pres- ent state to the future
state and identifying the priorities;

• 4 refning – is about testing change, learning from the data and identifying the
benefts;

5 introducing – is about managing communications and building the will and culture to
change;

6 spreading – is about showing the improvements, telling the story and disseminating
the message;

7 closing – is about capturing and sustaining the learning.

TABLE 15.5 Examples of tools used in quality improvement.
Organisational Graphical
Driver diagrams
Root cause analysis Fishbone cause and effect diagrams
Benefts realisation planning Demand and capacity Spaghetti diagrams
planning Process mapping Box, frequency and scatter plots
Value stream mapping Pareto charts
Kanban and 5 ‘S’ Run charts
Statistical process control charts

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248 CHAPTER15 Humanfactors,patientsafetyandqualityimprovement
philosophy behind lean methodologies is the elimination of waste through continuous
improvement. Lean identifes seven forms of waste, each of which is relevant to health
care (Table 15.6). Identifying waste leads inevitably to the need to defne value from the
perspective of the patient, a factor that is central to the Choosing Wisely initiative
(https://www.choosingwisely. org).

Clinical microsystems
A clinical microsystem is an interdependent quality improvement unit made up of a
small group of people who work together, usually on a regular basis, to provide care.
Such groups are typically multidisciplinary. The patients who receive that care can also
be recognised as members of a discrete group, such as patients with cancer or people
attending an emergency department. Clinical microsystems share clinical and business
aims, have linked processes and share information. Each microsystem produces services
or care that can be measured as performance outcomes. Microsystems evolve over time
and normally form part of a larger macrosystem or organisation.

They are considered ‘living adaptive systems’ as each microsystem must carry out work,
meet staf needs and main- tain its coherence as a clinical unit. Clinical microsystems can
be assessed on their evidence base, leadership, patient and staf focus, and information
systems.

Six Sigma
Six Sigma refers to another business performance meth- odology that has been adopted
for use in health care. The fundamental objective of the Six Sigma methodology is the
implementation of a measurement-based strategy that focuses

on process improvement and especially on reducing unnec- essary variation. One of its
sub-methodologies is DMAIC (Defne, Measure, Analyse, Improve, Control), which is an
improvement system for existing processes that fall below specifcation and require
incremental improvement.

Systems thinking and leadership

In a system as complex as health care, ‘systems’ thinking allows the whole system and
the relationships of the parts to be considered rather than just isolated functions. Health
care is a shared resource with many interdependencies; for surgery these include
anaesthesia, critical care, nursing and other specialties we work with to manage

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Further reading 249
adjustment also requires integrated and coherent strategies and a sustained commitment
of time, patience and resources. Health care as a sector has been slow to recognise the

important contribution that the theory and practice of qual- ity improvement are able to
make in delivering better value care. The experience of a relatively small number of
health- care organisations that have successfully done so, such as the Virginia Mason
Medical Centre in Seattle, WA, is a challenge to others to invest in acquiring the
necessary skills and capa- bilities.

A recent report by the Academy of the Medical Royal Col- leges of UK and Ireland
(2016) has argued that quality improve- ment should be at the heart of medical training
and that there is a pressing need to develop quality improvement learning across the
continuum of medical education. Understanding how health systems can be improved
and how evidence-based practice can be implemented in complex healthcare settings are
important skills for surgeons to master.

Summary box 15.5

Understanding quality improvement and its application

in health care
• ● The defnition of quality improvement and its relationship to clinical audit

• ● The different kinds of quality measures

• ● The patient’s surgical journey and its potential for improvement

• ● Examples of quality improvement pathways, organisational methodologies and tools

• ● What systems thinking is and its importance alongside leadership

• ● The requirement for more education and training in quality improvement

FURTHER READING
Ham C, Berwick D, Dixon J. Improving quality in the English NHS – a strategy for action. The
Kings Fund, 2016. Available from http:// www.kingsfund.org.uk/publications/quality-improvement

Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II: A White Paper. The Resilient
Health Care Net, 2015. Available from https://www.england.nhs.uk/signuptosafety/wp-content/
uploads/ sites/16/2015/10/safety-1-safety-2-whte-papr.pdf

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century.
Washington, DC: National Academies Press, 2001.