This is the third 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 introduce a key quality improvement tool and discuss its use in maternity services. To hear about the latest developments in maternity quality improvement, sign up for monthly maternity news to your inbox.
Executed well, quality improvement tools are an effective way to plan, implement and evaluate change. Many NHS organisations rated ‘outstanding’ by the Care Quality Commission (like East London, Salford Royal and Western Sussex NHS foundation trusts) embrace continuous quality improvement as their core business strategy (Warburton 2016).
One effective tool that can be used to support continuous quality improvement is the plan-do-study-act (PDSA) cycle, used as part of a suite of quality improvement methods, informed by an overall methodology such as the Model for Improvement (Langley et al 1994).
How and why is the PDSA cycle used?
The Model for Improvement sets the context for the use of the PDSA cycle – it asks us to think about the purpose of our PDSA cycle, how we will evaluate success and what changes could be made to see the desired improvement.
Used well, the PDSA cycle encourages an iterative approach to change which is ideally suited to difficult, complex problems (Taylor et al 2013). And can help design, implement and evaluate interventions as part of a process of continuous quality improvement (Reed & Card 2016).
The World Health Organisation recommends the PDSA cycle as the way to implement change as part of their ‘quality of care framework’ to end preventable mortality and morbidity among mothers and newborns (Tuncalp et al 2015).
Why is the PDSA cycle effective in complex environments?
There is considerable complexity in maternity services. In my view, there are three key drivers of this complexity in the UK and other high income countries:
- Women’s medical and social situations are increasing in complexity. Women who are older, obese or have existing medical conditions need more care. Vulnerable women are less likely to access services early in pregnancy and this puts pressure on services. (Kings Fund 2008)
- Women and their families are supported by a wide range of healthcare professionals and support staff – including anaesthetists, GPs, maternity support workers, midwives, obstetricians, neonatologists, paediatricians, radiologists, sonographers, ward clerks and others – so communication (information transfer) and teamwork (how teams communicate and organise themselves) needs to be consistently excellent to ensure high quality care.
- Clinical teams guide women in their choices about maternity care based on internal policies and processes and guidance from external bodies. The volume of and content within these documents is immense. In the UK, external bodies providing guidance include the National Institute for Health & Care Excellence (NICE), the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists along with many other public and third sector organisations. NICE produces 29 ‘products’ covering intrapartum care alone (NICE 2016).
The PDSA cycle is effective in complex environments, like maternity services, because it allows implementation of quality improvement ideas to be adjusted to respond to local circumstances (Taylor et al 2013), such as the: social and clinical situations of the women and their babies; staffing skill mix and team dynamics; and operational circumstances.
Testing begins at a small scale, to allow rapid assessment and to allow adjustments according to feedback (Taylor et al 2013). This minimises clinical and operational risk as well as giving the opportunity to engage stakeholders as the efficacy of the intervention is established (Taylor et al 2013).
How should the PDSA cycle be used?
The PDSA cycle is not a tool to be used once or in isolation. It is best used as: part of a process of continuous quality improvement, so learning from one cycle feeds into the next; and alongside a suite of quality improvement tools so that the area for improvement is properly understood and plans are formulated well (Reed & Card 2016).
Time in the planning and study phase of the cycle is crucial: a challenge in busy environments where the focus can be on ‘doing’. As initiatives are scaled up, the level of preparation, management support and financial investment needs to be adjusted. To give quality improvement initiatives every chance of success, significant investment in leadership, expertise and resources for change is required (Reed & Card 2016).
In summary, the PDSA cycle used in conjunction with the Model for Improvement and other quality improvement methods is an effective way to improve quality in complex environments, such as maternity services. Investment is required in leadership, expertise and resources to ensure implementation is effective.