Many quality improvement methods in healthcare are directed at improving processes.

All work is a process. Healthcare processes are the steps that are taken or involve, either explicitly or implicitly, whether sequentially or in parallel, by people or machines, carrying out activities that are designed to improve or maintain health.

For example, the process of a referral to hospital can involve the decision to refer (a cognitive process), following discussion with a patient of his or her needs or wants, a communication (e.g. letter) transferred to the hospital, and an electronic appointment, letter or telephone call to the patient to let him or her know a date or time of an appointment.

Improvements can be achieved by understanding processes, by mapping the steps involved and analysing these, to eliminate wasteful steps and reinforce steps that deliver better care.

The aim is to reduce unintended variation, increase reliability of the process and deliver high-quality care consistently.

Logic models

The logic model is a useful starting point for understanding and improving processes.

A logic model defines what exactly we are trying to improve (the aims or priorities for improvement), describes who we are trying to improve it for (the population for which improvement is intended) and explains why we are trying to improve a particularly area of healthcare (the problem identified as in need of improvement).

The model next describes the inputs, which include people, work methods, equipment, materials, environment and measurements. It also describes how we will go about improving care in terms of who we will involve (the participants), what they will do to bring about improvement (the activities) and what we wish to achieve in terms of processes (the outputs) that are intended, or have been shown, to lead to longer-term benefits.

Benefits are described in terms of health or wider gains as well as possible harms (the outcomes), whether intended or unintended (incidental) and whether in the short, medium or longer term.

Linked to the logic model it is helpful to develop a programme theory or theory of change which explains in more detail how and why the inputs and activities lead to intended outputs and outcomes.

Activities for understanding and improving processes

  • Problem, population and priorities
    • Interviews (discovery, narrative), focus groups
    • Patient or practitioner surveys
    • Direct observation
  • Inputs
    • Process maps
    • Cause and effect (‘fishbone’) diagram
    • Driver diagrams
    • Critical-to-quality trees
  • Outputs
    • Process or outcome indicators/measures

Various activities can help us understand the elements involved, and this understanding can then be used to improve them.

The problem, population of interest and priorities for improvement can be elucidated using interviews or surveys of patients and staff or direct observation of processes.

The series of steps in a process of care or a patient journey can be shown pictorially using a process map. This can be constructed very simply by writing down the steps of a process on ’post-it’ notes and connecting these on a large piece of paper using arrows. This is best done with the team or group involved in the process and concerned with improving it. Constructing the process map leads naturally to analyse and improve it by removing redundant, unhelpful, or duplicating steps which waste time and resources

The process map as well as showing redundant or wasteful steps can also help us to identify which steps in a process are critical to quality. This enables unhelpful, or harmful steps to be removed. These measurable characteristics of a process, where standards need to be achieved to meet the quality requirements of the user, can be summarised using a critical-to-quality tree.

Cause and effect (fishbone, Ishikara) diagram

Inputs can be expanded, either as a whole or in specific areas to form a ‘cause and effect’ (sometimes call a fishbone or Ishikawa) diagram. The diagram helps elucidate the causes of a problem and is an aid to finding solutions.

The central line represents the patient pathway leading to the outcome of interest and this is affected by various inputs, including patients themselves. The inputs include people, both patients and healthcare staff; work methods and organisational processes; equipment such as machines and materials; and the environment, which incorporates features such as policies, guidelines, protocols and organisational culture.

Each in turn is influenced by various factors (represented by the subsidiary arrows).

Driver diagram: improving reliability

Processes can also be summarised using a driver diagram.

Driver diagrams enable a high-level improvement goal to be translated into a logical set of underpinning goals (‘primary drivers’) and specific actions (‘secondary drivers’) that can also be converted to measures.

The driver diagram shown represents the stages involved in improving the reliability of a process.

The first stage involves preventing failure, which can be achieved through standardisation of processes using guidelines and protocols, checklists for practitioners, feedback to individual staff or groups, and education and training for staff.

The next stage involves provider prompts and ‘forcing functions’, which prevent failure by ensuring that a (critical-to-quality) process is completed before another can be undertaken.

The final stage involves further redesign of the system to ensure that the process is as ‘lean’ as possible, minimising wasteful steps, reducing rework, reducing the chances of failure and maximising the efficient delivery of the process