Quality assurance and quality improvement

Introduction

Quality in the emergency department (ED) can be defined as consistently providing optimal care to patients. There is often a gap between best practice and the care provided in a health care setting due to a variety of factors, independent of the will, skill, and attitude of the people who work in that system. To improve the system, quality management must be applied to the system requiring leadership, commitment to change management processes, effective communication, staff engagement and accountability. Patient engagement is another fundamental aspect of quality management so that improvement aligns with their needs, preferences and values. The six key aims for improvement in health care are:

• 1.

  Safety—reducing the likelihood of patient harm by medical errors.

• 2.

  Effectiveness—avoiding the underuse and overuse of services and resources.

• 3.

  Patient-centeredness—provision of a service that relates to patients and their families, accommodating their needs when making decisions.

• 4.

  Timeliness—the reduction of waiting times.

• 5.

  Efficiency—reducing waste and cost.

• 6.

  Equity—the closure of racial and income gaps in health care.

Ideally, a quality culture exists where health care workers, leaders, patients and carers are continually focussed on improving processes and are empowered and resourced to do so.

Definitions

Quality Assurance (QA) is the monitoring of the system for detecting emerging problems, taking steps to address them and ensuring stability over time. QA processes used in EDs include morbidity, mortality and complaint audits, infection control, credentialing and standard setting.

Quality Improvement (QI) is a formal and systematic approach to the analysis and efforts to enhance performance. The difference between QA and QI is that QA ensures compliance with standards by means of measurement and inspection, with a focus on finding deviation from agreed standards. It is often externally driven and relies on monitoring. QI offers tools to focus on processes and systems that translate the ideal patient management into the care that happens every day. It is often driven internally by clinicians; however, to be successful requires the support of management.

Health care providers can use QI to hypothesize process change that will result in improvement. Key activities involved in the QI process include:

• multi-disciplinary collaboration within working groups

• patient involvement

• review of existing processes

• identification of performance measures

• implementing a change

• data collection and analysis

• communication of outcomes, with incorporation of key learning into process redesign, education and training.

When gaps are detected between expected and observed performance, a QI approach may be undertaken to close the gap. In QI, a variety of methods and tools are used to develop, test and implement changes. Following successful improvement, QA can then be used to monitor the redesigned process to ensure it performs at the expected level. Measuring and monitoring performance is essential to demonstrating effectiveness and provision of the best service possible. The difference between research and QI is that QI provides enough data to show improvement in common clinical situations, whereas research requires a large amount of data in ideal conditions to create new knowledge; however, convergence can occur.

Continuous QI is a management approach that focuses on processes that review, critique and implement positive change to achieve QI in a health care setting, therefore continuously improving the quality of patient care.

Benchmarking compares performance with others with the use of best practice as a marker for improvement.

Credentialing is a formal process to recognize and verify and individual’s qualifications to assess their capacity to safely perform a task.