Learning from practice variation to improve the quality of care

Abstract

Modern medicine is complex and delivered by interdependent teams. Conscious redesign of the way in which these teams interact can contribute to improving the quality of care by reducing practice variation. This requires techniques that are different to those used for individual patient care. In this paper, we describe some of these quality improvement (QI) techniques. The first section deals with the identification of practice variation as the starting point of a systematic QI endeavour. This involves collecting data in multiple centres on a set of quality indicators as well as on case-mix variables that are thought to affect those indicators. Reporting the collected indicator data in longitudinal run charts supports teams in monitoring the effect of their QI effort. After identifying the opportunities for improvement, the second section discusses how to reduce practice variation. This includes selecting the 'package' of clinical actions to implement, identifying subsidiary actions to achieve the improvement aim, designing the implementation strategy and ways to incentivise QI.

Fig 1.

An example of a driver diagram to identify ways of reducing the incidence of sudden death in a dialysis centre. Below the top level, showing this overall improvement goal, the middle level lists primary ‘drivers’ that potentially contribute to the high incidence of sudden death. The bottom level contains secondary drivers underlying these primary drivers. Next, the dialysis centre can focus on selecting subsidiary actions that are expected to have an impact on the secondary drivers.