Quality improvement and the clinician

Learning objectives

By the end of this chapter the reader should:

Be aware of the main quality issues relating to paediatric care
Understand the concepts of quality improvement
Be able to describe basic improvement tools
Be able to provide examples of quality improvement in child health

The concept of quality in healthcare and the understanding of its relevance and role have evolved over the past twenty years. Our aim as paediatricians is to improve the quality of care and outcomes for children. Our challenge is to work with children and families to understand the issues they face, to jointly define the potential solutions and then develop improvement programmes to implement them. We now understand that advances in medical science achieved in the last century are insufficient to guarantee good clinical outcomes. The UK reviews following the paediatric cardiac surgery clinical crisis at Bristol and high profile child protection cases confirm that we need more than our knowledge about clinical medicine and guidelines to achieve good clinical outcomes. These seminal events led first to the development of clinical governance and clinical audit, and subsequently raised the profile of the patient safety agenda and the concept of quality improvement.

Question 40.1

Quality improvement and patient safety concepts

Following is a list of patient safety and quality improvement terminology:

A.
Effectiveness
B.
Healthcare-associated harm
C.
Natural variation
D.
Medication error
E.
Patient safety
F.
Reliable healthcare
G.
Risk management
H.
Unwarranted variation

Which of the above terms is the most appropriate description for each of the following scenarios? Select ONE answer for each question:

1.
Children presenting in status epilepticus receive treatment according to the NICE guideline when they present to the emergency department at their local hospital.
2.
A child on the PICU dies as a result of a central line associated bacteraemia and review reveals that the central line care bundle has not been followed.
3.
Discharge plans for asthmatic children in the paediatric department are different depending on which consultant is on call.

Answer 40.1

1.
F. Reliable healthcare.
2.
B. Healthcare-associated harm.
3.
H. Unwarranted variation

Quality improvement in healthcare is ‘the combined and unceasing efforts of everyone, i.e. healthcare professionals, patients and their families, researchers, commissioners, planners and educators, to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)’. This implies that we all are responsible for the quality of care we deliver and that quality improvement should be part of our job as clinicians and other healthcare providers.

The purpose of quality improvement in paediatrics and child health is to ensure that children receive the care needed and wanted the first time, every time . This requires safe, effective, care that is reliably and consistently delivered and the consideration of its value. The latter is defined from the viewpoint of the child and their family, i.e. what do they value in terms of the care that is delivered, both in terms of value for money but more importantly the value in achieving the child's desired outcome? There is a definite gap between what we know to be best practice from research and the care that is delivered to children. Quality improvement provides the framework to close this gap.

Major quality issues facing the health services in general

The Institute of Medicine identified six dimensions to quality care:

Patient or person centeredness: ensures that patient values guide all clinical decisions.
Equity: aims to provide care that does not vary in quality because of personal circumstances including geographic location, ethnicity and socio-economic status.
Patient safety: intends to avoid harm from the care that is intended to help.
Effectiveness: the provision of evidence-based care based on the need of the patient.
Timely care: aims at ensuring access when and where care is needed.
Efficiency: refers to the need to decrease waste, duplication and improve the performance of healthcare.

The above principles can be translated into practical standards, which form a useful framework for an approach to quality improvement:

Governance for safety and quality in health service organizations, which incorporates clinical governance and the structures required for quality and safety.
Partnering with patients to develop services and how services are delivered.
Preventing and controlling healthcare-associated infections.
Ensuring medication safety from prescribing to dispensing to administration and reconciliation.
Patient identification and procedure matching at all times.
Reliable clinical handover at all interactions.
Blood and blood products safety.
Preventing and managing pressure injuries.
Recognizing and responding to clinical deterioration in acute settings.
Preventing falls and harm from falls.
Ensuring that the access to and the flow of patients through the system is timely and efficient.

Question 40.2

Variation in healthcare

A review of services at your local hospital reveals that there is a significant variation in the management of children admitted with asthma. This is most likely to suggest:

A.
A lack of evidence on which treatment decisions for individual children can be based.
B.
A well-constructed local guideline is in place, which identifies areas where the evidence base is inconclusive.
C.
An incomplete understanding of the pathophysiology and natural history of the condition in childhood.
D.
Outcomes are generally better for children when didactic algorithms are not in place.
E.
Outcomes for asthma care in this centre are likely to be worse than expected.

Answer 40.2

E. Outcomes for asthma care in this centre are likely to be worse than expected.

See below for discussion.

Quality problems facing children

Most of the above are adult focused but also apply to children. However, in paediatric and child health practice, children are subject to multiple and complex additional issues either in hospital or in the community. Any paediatric improvement programme either at national or local level needs to take account of and address these specific challenges.

Variations in service provision

As in adult care, variation in service provision is a key problem. An analysis of the way health services for children are organized has revealed that there are wide disparities in service provision across Europe (Wolfe et al 2013). A more consistent approach to the way we design and integrate services and how we address the totality of children's needs would result in the development of equivalent outcomes. On a system or policy level (known as the macro level), it has been recommended that in order to improve outcomes, one needs to look at the whole healthcare system and consider reconfiguration of the different elements of care in health as well as in social care and education. It is estimated that approximately 1500 preventable deaths occur in paediatric departments in the UK each year, while many more children live with preventable disabilities, chronic pain and unequal access to the services they need. Across the UK, variation in how care is delivered in different areas has a major impact on local outcomes.

There are three key components to variation in service provision: variation in how services are designed, variation in the choice of care interventions, and variation in the delivery of effective care.

1 Variation in how services are designed

The design of services and what can be provided is a major factor in the standard of care that children receive, and on their resultant outcomes. Variation is to be expected in all that we do and in all processes we undertake. This may be in the way we set up the systems and processes of care, or in the way we treat individual children. An example of systems variation is the difference in the way emergencies are managed within the working day, overnight and over weekends or bank holidays. The processes are clearly different; there is variation in the clinical expertise available and in the outcomes that are achieved. Another example is in emergency care provided when a major accident increases the number and rate of arrival of patients above the normal predicted range. This in turn can lead to problems in access and equity of delivery. Some areas may have long waiting times and others are seen promptly, depending on how the service is designed. Where a child lives determines the quality of the care they will receive. The Royal College of Paediatrics and Child Health (RCPCH) has highlighted this problem as one of the challenges that the NHS must address. Reports on disease-specific outcomes, e.g. on epilepsy, have demonstrated the impact variation can have on clinical outcomes.

2 Variation in choice of care interventions

In the past, the evidence base in paediatrics was not as robust as it is today. Many aspects of what we do now is well evidenced and the development of guidelines has provided a basis for what works and what does not. Parents will often defer to the opinion of the clinician, believing that it is based on the best evidence available. In cases where robust evidence does not yet exist, there needs to be local consensus on how to manage certain conditions in order to minimize variation.

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