Quality Improvement models

Total Quality Management
Six Sigma
Continuous Quality Improvement

Several models for quality improvement have emerged from manufacturing industry and can be applied to improving patient care pathways or education. Examples of effective application exist within the NHS. The search is on for the most efficient way to produce focused improvements. Getting that balance between time invested and effective change. The key appears to be gathering feedback from, and then checking proposals, with a representative person in every step in the patient care pathway.

Total Quality Management

Total Quality Management (TQM) is a review of the whole pathway or process from start to the end product. It involves discussion with everyone related to that process, who all contribute suggestions for improvements.

The example is a failing American television manufacturer who was taken over by a Japanese company. The new owner took on a process of TQM and reduced the failure rate of televisions from 5% to 0.2%. They were able to close the “reworking line” which dealt with the faulty televisions and convert these savings to a profit


Kaizen is a Japanese phrase that means “change good” in English. It is a process of incremental change by every worker who submits suggestions for improvement. It is a managing change system. Every suggestion is reviewed with a plan and if it helps the suggestion is adopted. One business generated 127 suggestions per worker with a total of 200,000.  Of these 90% were adopted

Six Sigma

Six Sigma has been described as TQM on steroids. Like TQM if involves everyone in a review of the pathway or process with the aim of reducing errors. Executive leads encourage and guide this review.

A DMAIC approach is followed: Define Measure Analyse Improve Control. This is an advance on the Plan Do Study Act (PDSA) cycle. Define looks at customer goals. Control involves documentation and training to reduce errors.

An example is Victoria Health in New Jersey USA. They undertook a Six Sigma programme for heart failure care. Hospital stay was reduced from six to four days, patient education increased from 27% to 80% and consistency of chart records increased form 67% to 93%

Continuous Quality Improvement (CQI)

Also know as “lean” CQI has been applied in universities and the NHS with training courses available to those interested. The steps involve:

  • Seeing the “customer” to determine what is wanted
  • Mapping the activities to identify areas of inefficiency and waste
  • Improvement
  • Review

Suggestions for change are generated within workshops and plotted on a “Pain Gain” chart to help decide which are tackled. Vertical axis is from “High Benefit” to “Low Benefit”. Horizontal axis from “Hard to implement” to “Easy to implement” Each axis intersects in the centre as a cross.

Project teams are established to plan and implement each proposal with review by the team and a CQI board which co-ordinates, updates and maintains momentum

Information on CQI is from Dr Mary Beech GP training lead in the Wales Deanery based on work with the Cardiff University Lean unit, which reviewed the training of doctors. Thankyou

Information on quality improvement models is from Clare Whittle Knowledge Transfer Partnership Associate Severn School of primary care Sept 2010, thankyou