© Victoria Morgan 2016

Continuously improve clinical quality

This is the second blog in a series of four that looks at success factors for improving clinical quality in maternity services - so mothers and their babies enjoy great care and staff enjoy their work.  Here, I consider the need to continuously improve clinical quality.  To hear about the latest developments in maternity quality improvement, sign up for monthly maternity news to your inbox.

In today’s highly regulated healthcare environment, it is easy to focus on regulatory inspection and assurance work at the expense of quality improvement work.  Deming – a leading figure in quality improvement - pointed out that ‘inspection is too late – the quality, good or bad, is already in the product’ (Deming Institute 2012).  Deming encouraged quality to be built into processes.


What is quality?

Darzi (2008 pp.  47) set out three aspects of high quality care - safety, experience and effectiveness: 



Application to maternity services


Do no harm, by ensuring a safe and clean environment

Eliminate intrapartum stillbirths – according to Kirkup (2015 pp.  174) ‘these should not happen’


Patients are treated with compassion, dignity and respect.

Improvements in NHS maternity survey results.


Understand success rates from different treatments for different conditions, such as mortality or complication rates.

Improvements in wellbeing.

Aim to increase the normal birth rate towards 60% (Maternity Care Working Party 2012 pp.  2).



The Institute of Medicine’s (2001) six dimensions of quality also include: 



Application to maternity services


Avoid waste, including waste of equipment, supplies, ideas and energy.

Reduce the cost of legal claims.  One fifth of the NHS maternity budget in England is used to pay for legal claims (NAO 2013).


Reduce waits and delays for those who receive and give care.

Reduce waits for perinatal community mental health services to minimise risks to mother and baby (NHS England 2016).


Care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status.

Reduce extended perinatal mortality for babies whose mothers are of Black or Black British and Asian or Asian British ethnicity - the group at highest risk (Mankletow et al 2016).


What is quality improvement?

Various definitions have been proposed.

Batalden and Davidoff (2007) mention involving patients and families, but take too narrow a view of clinical quality in my opinion - focusing on patient outcomes, system performance and professional development, rather than the six dimensions proposed by the Institute of Medicine.

The Kings Fund (2016 pp.  3) focus on the design and redesign of work processes and systems.  This seems to constrain the application of quality improvement to the organisation, whereas behavioural changes may also be required – in both the workforce and wider population.

I like to think of quality improvement as the ongoing application of knowledge by everyone involved in healthcare in order to achieve excellent clinical quality.

Why? Because it is a continuous process (ongoing); it involves making predictions and testing them (application) based on research and/or clinical guidelines (knowledge); and it is best when everyone is engaged (read more about multidisciplinary team working that involves parents).


Why continuously improve quality?

In England, it’s a legal requirement that the NHS continuously improves the quality of services provided, under the Health & Social Care Act 2012.

The Kings Fund (2016 pp.  3) argues that the ‘NHS cannot hope to meet the health care needs of the population without a coherent, comprehensive, unifying and sustained commitment to quality improvement as its principal strategy’.

For clinical staff, it is a professional duty.  In the UK, taking part in quality improvement work is required as part of:  Core Medical Training (GMC 2016) and Continuous Professional Development for clinicians – Domain 2 of Good Medical Practice (GMC 2013); and the Nursing & Midwifery Code (NMC 2016 paragraph 25.1).


How to continuously improve quality?

Engaging staff and parents in continuous quality improvement can help services move from passive ‘fire fighting’ to active management and leadership.  Does this mean days in the classroom learning complex quality improvement techniques?  By no means!  One of the tenets of quality improvement is to actively test improvement ideas in the field.

The first step could be as simple as posing some questions in team meetings:  “what do we do well?” and “what annoys you or what do we need to improve?”  Expect a few awkward silences to begin with; the questions might need to be asked at more than one team meeting before answers are forthcoming.  The response to suggestions is crucial:  if new ideas are welcomed and staff supported to try them out, this can foster a culture of continuous improvement with staff enthusiastic about the difference that they make to services.


The next stage is to train staff in the use of quality improvement tools, to increase the impact and effectiveness of change.  In my next blog, I’ll look at one quality improvement tool that is ideally suited to testing changes in complex systems, like maternity services.