The health care needs of the people undergo a constant evolution which leads to its increasing complexity. In order to cope with the demands of health care, institutions have to exemplify efficiency, effectiveness and safety in its systems. These are the three mandates of the global health standards in achieving improved institutional performance and better health outcomes (World Health Organization, 2003).
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Improving a scheme is never a task too easy for any institution, especially in the broad scope of health. Quality improvement models are therefore essential in creating developments in the medical sector. These models consist of recommended processes that have been products of continuous studies and have achieved sustained developments through its application. All of these models aiming to achieve a positive impact in the health care institution and in the community that it serves (Ovretveit, 2009).
This paper discusses four quality improvement models; namely, the PDSA/PDCA model, Six Sigma, Lean and ISO9000. It focuses on the salient characteristics of each model, their limitations and a comparative analysis of each model’s features to one another. Lastly, a citation of the application of the Lean methodology to the success of the Bolton Improving Care System in United Kingdom is presented.
The PDSA/PDCA model
The Plan-Do-Study-Act (PDSA) or the Plan-Do-Check-Act (PDCA) model is an approach to continuous improvement, where changes are tested in small cycles. The PDSA/PDCA was initially coined by Stewart in the 1920s and was then modified by Deming. It is an approach that combines both management thinking and statistical analysis. The PDSA model consists of the Plan phase, where there is an identification of what can be improved and what change is needed, the Do phase or the implementation of the design change, the Study or the measurement and analysis of the process or outcome and the Act or the modification of the solution if the results are not as hoped for (Best, 2006).
Quality improvement studies have concluded that the PDSA has been known to achieve practice change/outcomes across different health care disciplines, organisational contexts and settings.
It leads to more substantial and sustained practice change when frontline staff is fully engaged with the process.
On the other hand, PDSA interventions are more likely to lead to practice change when the intended changes are measurable in the short term, rather than long term, and when practitioners can see the changes are evidence.
Moreover, the PDSA is usually applied on small scale sectors, thus, being prone on neglecting affective factors to the solution intended at a macro level (NHS, 2008).
The Six Sigma
The Six Sigma is a process or product improvement approach that focuses on reducing what customers would define as ‘defects’. The Six Sigma was devised by the Motorola Company in 1985 and was popularized by Jack Welch on his application of the strategy at General Electric. The Six Sigma upholds the DMAIC or the Define, Measure, Analyze, Improve and Control methodology which integrates the PDSA/PDCA model. It also has a unique feature of certification or the use of ‘Belts’ as its training approach (Ovretveit, 2009).
The major advantages of the six sigma are that its underpinnings create a very strong improvement structure in parallel with the management hierarchy in an organisation.
It also helps in building and maintaining management support and fostering use of methods among practitioners who are not experts in statistics (Brady & Allen 2006).
However, the applicability of the Six Sigma may not be that beneficial in some scenarios. For example, there may be a challenge of having quality data available especially in processes where no data is available to begin with.
In addition, Six Sigma can easily digress into a bureaucratic exercise if the focus is on such things as the number of trained black belts and green belts, number of projects completed, etc. instead of bottom-line savings.
Lastly, the start-up cost for institutionalising six sigma into an institutional culture can be a signi¬cant and expensive investment (Antony, 2004).
Lean is a quality management system developed by the Japanese car manufacturer, Toyota, focusing on value, flow and waste reduction. Its philosophy tends to be consumer focused quality improvement. The tools most commonly associated with lean are the Value Stream Mapping, the 5S and the Rapid Improvement Events (Ovretveit, 2009).
Lean productions, if implemented correctly, possess many advantages which can give the companies’ productivity major boost. For instance, inventory storage management is decreased with its costs.
In addition, the pull strategy gives the manufacturer the ability to manufacture the products to the customer likes and save cost of holding inventory till sale and waste (Lansbur, Russell, 2006).
Meanwhile, lean production also has its criticism such as unlimited working hours which seem to be virtually impossible to cut in the system of lean production, in spite of all its productivity strides.
In addition, the working environment of lean production involves doing repetitive task which can lead to health and safety problems. Moreover, many critics and employees feel that lean forces people to change rather than allow them to improve on their own (Berggren, 2005).
ISO 9000 is a series of standards, developed and published by the International Organization for Standardization, that define, establish, and maintain an effective quality assurance system for manufacturing and service industries. It focuses on accreditation based on 8 management principles, which are customer focus, good leadership, people involvement, process approach to quality management, management system approach, continual improvement, factual approach to decision making and supplier relationships.
The ISO 9000 standards improve operating procedure and reduce cost. It is a very powerful marketing tool for them. This is because an ISO certified institution signifies that it implements accurate measurement and calibration of products and equipment which suggests safety.
In addition, it also applies proper documentation which leads to improvement of the confidence level of the data and fast response time.
However, being ISO 9000 certified also entails stead guidelines. The actual change of operations can be very expensive. Usually designated people have to take classes and be trained as the company’s liaison for ISO 9000.
In addition, one may encounter a lot of resistance in the implementation of changes in a system. There are times when companies feel that the existing set of operational procedures is already working well and they do not feel a change is necessary.
Frequently, companies will have a customer who demands that they be ISO 9000 certified to continue doing business. Now the company has the choice of losing a customer or implementing ISO 9000 (Nurre, Gunaman, De-Almeida, 2000).
Comparison of the Quality Improvement Models
Continuous improvement approach
Quality Management standards
Identify and map the value stream
Process approach to quality management
Management system approach
Factual approach to decision making
Allows trial and error of solutions in a small scale
Uniformed Process output, faster processes, less inventory, performance measure for managers is fluctuations
Reduced flow time, less inventory, new accounting system, performance measure for managers is flow
Reduces audits, enhances marketing, improves employee motivation, awareness, and morale, promotes international trade, increases profit
Tends to oversimplify the improvement process, a reactive rather than a proactive approach, fails to consider the people element
Systems improve independently with little value for system interaction
Statistical analysis not valued
Takes effort, time and a lot of paper works for registration, focuses on inspection of the correct procedures over broader aspects of quality, promotes specification, control, and procedures rather than understanding and improvement
Bolton Improving Care System: Application of Lean Methodology
The Quality Improvement Models have produced several success stories in different areas of health care, whether in the hospital or in the community. One victorious Quality Improvement Project (QIP) was the Bolton Improving Care System (BICS) which was implemented in the Royal Bolton Hospital in United Kingdom, through the application of the Lean Methodology. The adaptation of the Lean Methodology for QIP was actually instituted by its Chief Executive David Filling ham in 2005. During these times, the hospital was facing patient safety issues due to the increasing incident report, the staffs were displaying low work morale and a large percentage of the hospital’s financial goals were not met annually (Bolton NHS, 2012).
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The BICS had four general objectives which were to improve the health of the community, to deliver the best possible cure for the patients, to have joy and pride in work and to commit in providing value for money. The hospital formulated the BICS based on the following Lean principles: specifying value from the patient’s stand point, seeing all work as a process, involving front-line staff in the redesign of work, achieving smooth continuous flow and seeking continuous improvement.
Through the application of the Lean methodology, the Bolton Hospital was able to implement system improvements that led to progressive results. Some of the BICS devised solutions were the formed alliance with the other organizations, creation of value streams by classifying procedures as simple and complex and creating clinical pathways through them and the elimination of wastes via the true north goals (Bolton NHS, 2012).
BICS has been working for more than 5 years for the Bolton Hospital and has created positive impacts. Some of these developments are the reduced post-op mortality by 37% through the help of the trauma pathway, a 300,000 pounds improved income from the laundry savings, flow time of blood specimen sample in the laboratory from 300 to 35 minutes and the list of evidence based results goes on (Schenk, 2006). The Lean methodology has been a QIS milestone that saved the Royal Bolton Hospital.
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