Finding the balance in an improvement framework: Quality assurance or quality improvement?

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The last twenty years have seen substantial investment and growth in health and care quality and performance. Many different improvement approaches, initiatives and methods including for example clinical audit, benchmarking, lean, collaboratives, appreciative enquiry and human factors, have been used to improve care quality.  Concurrently, national bodies and governments have put in place systems to scrutinise and assure care through performance measurement, inspection and regulation as a means of improving care quality, performance and safety.  Critics argue that these differing approaches to quality sometimes clash, have different levels of effectiveness, and that healthcare systems can over-emphasise the need to assure quality at the expense of quality improvement.

Acknowledging this tension, prior to the COVID-19 pandemic, healthcare policy makers indicated that a new improvement framework will be developed to bring together the different improvement approaches from across the health and care system in England into a quality management system. One theory the framework might draw upon is Juran’s Quality Trilogy (1986), building on existing work in the NHS in Scotland.

The Quality Trilogy consists of three elements: quality planning, quality control and quality improvement needed to develop an organisational approach to managing quality – a quality management system. The trilogy was initially developed for a manufacturing context and based on the financial model of financial planning, financial control and financial improvement. Quality planning incorporates activities such as new product development, annual planning, procurement, and the design of work processes and the development of work instructions. Quality control incorporates the main operational practices needed to deliver product and services within the planned requirements and expectations, in situ, at the point where the work is done, such as quickly resolving the unanticipated problems that emerge during operational delivery.  Quality improvement, on the other hand seeks to breakthrough from previous quality requirements to new performance levels, making what was previously unachievable become possible.  Interestingly, Juran emphasises that quality control is different to quality assurance, where a third party checks, verifies and confirms that quality of a service or product is as intended after the eventQuality assurance is not explicitly part of the quality trilogy despite often being conflated with ‘quality control’.

An improvement framework is important for policymakers and practitioners in health and care, to help to identify and draw out specific areas of perceived over or under-emphasis, such as quality improvement, allowing resources and priorities to shift in response to those most in need of attention.  Our research (Furnival et al, 2017) has identified 70 other quality management systems and improvement frameworks, including ones you might recognise like the model from European Foundation for Quality Management (EFQM) and the Deming Prize. We found that there is considerable variation within the content of improvement frameworks and few are theoretically informed or validated, meaning the use of the Juran Trilogy may be helpful.  We also found that there is no ‘one’ best way of conceptualising quality improvement, there are different reasons for using a framework and we found a lack of consensus for the constructs and content within an improvement framework.  We suggest that this may be due to different paradigms in use by organisations and teams having different views as to what ‘good improvement’ looks like.  We also noted that the combination of dimensions and constructs of an improvement framework may need to be different and relate differently, not only at a team, organisational, regional and national level, but also within different operating contexts and environments (Furnival et al., 2019). For example, the need for quality assurance by national and regional bodies as well as ensuring quality planning, quality control and quality improvement.

The purpose of an improvement framework is important when selecting, designing and testing one.  Therefore, it could be important in the first instance for policymakers to set out clear the aims and intent for any planned improvement framework, and set out to use theory such as Juran’s Trilogy.  For example, would an improvement framework be used for self-evaluating purposes only by providing organisations and teams?  And/or would it be used be external bodies to assess and evaluate improvement status of organisations? Will it be used by improvement functions, clinical or operational teams or all or some?  How flexible will the framework and any variants be for different organisations across health and care? How responsive would an improvement framework be? What discretion will leaders and system actors have to interpret and enact the policy?  How might improvement framework be used by a third party such as a commissioner, scrutiny or performance management function or regulatory agency, who may have responsibilities to assure care and hold to account, as well as to improve care?

This final question is important as it gets to the nub of the challenge, of how to rebalance a quality management system that is currently perceived as overemphasising control and assurance over quality improvement, which feels even more relevant as we continue through this COVID-19 pandemic. A good place to start might be to acknowledge the needs and demands of quality assurance, performance management and accountability, as well as demands for improved quality management for different parts of the health and care sector and consider how they may need to balance differently across the sector with tailored solutions. It may also be helpful to consider how aims from different parts of the sector in healthcare providers and national bodies can be mutually compatible and support each other, rather than be presented as competing improvement approaches, to ensure higher quality and improved care for patients, the public and populations.

Reference without a URL:

Juran, J. M. (1986). ‘Quality Trilogy’, Quality Progress, 19(8), pp. 19-24.


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