Billy Boland: What does continuous improvement actually mean?


I don’t know if it’s just me, but I’ve found a lot of what’s written about “continuous improvement” practically impenetrable. On the face of it, it has a lot to offer. Who can argue with an approach that systematically drives up quality? The trouble is, I’ve always found the methodology elusive. I realise that I’ve probably had unrealistic expectations, wanting it all summed up in a few paragraphs. But when I’ve sat down to learn about “lean” or “six sigma,” within minutes I’m lost in jargon. What, in fact, are the differences between Muda, Mura, and Muri… Anyone? Anyone? I can’t help feeling that improvements to business performance should be more inclusive than that.

Light was shone on all this recently for me by my colleague Eddie Short, transformation team leader at our trust. He is on a mission to try to help people across the organisation understand what continuous improvement actually is, and help them introduce it into their working lives. Eddie managed to get to the heart of the matter in a short presentation that helped show that it’s not all that complicated. So I thought I’d share with you what I’d learnt in a brief, completely unofficial, unauthorised guide to continuous improvement.

1. What is it? Well it’s a few different things…
a. It’s about continuously improving (I know. Does what it says on the tin). The stuff to improve is the stuff that the “customer” (read patient, carer, or family) values, or results in better service. In healthcare these things might be patient outcomes, waiting times, patient or staff satisfaction, safety etc.
b. It’s about how you go about your business—your mind set (individual) or culture (collective).
c. The improvement is supported by a method—a systematised way of looking at what you are doing and making changes.

2. Who should be doing it? Everyone. In any organisation, we all have our part to play. If we can measure it, we can improve it. And if we can’t measure it, we can try and figure out an aspect that we can.

3. How do we do it? There are lots of methods to choose from. Here’s a selection:
a. Data-visualisation and analysis—Look at some data that your service churns out and think about what it is saying to you. In modern health services we are spoilt for choice. Its sobering to think about how much is produced that we could use. Do you need to take action as a result?
b. Process mapping—draw out what you do. What steps does a patient go through on their care pathway? Are all of them necessary? Can any be got rid of or simplified?
c. Problem solving—Getting to the root of the problem. Approaches here include root cause analysis (unsurprisingly).
d. Lean thinking—5 principles, 8 wastes, I could go on… But in essence it’s about delivering only what is needed, when it’s needed—no more, no less. Obliterate waste and maintain or improve quality (and safety, effectiveness etc.)
e. PDSA (Plan, Do, Study, Act)—This is one of my personal favourites as it’s so intuitive, and fits in well with my current skill set. For clinicians, compare this with clinical audit, measuring your performance against a standard, making changes, and measuring again.

That’s it—simple, huh? For the tech heads, there are plenty more tools to choose from such as Ishikawa diagrams, DMAIC (Define, Measure, Analyse, Improve, Control) and MoSCoW prioritisation. But regardless of your method of choice, know that continuous improvement is likely within your gift. Ask around, potential collaborators may well be lurking, banging their heads against a continuous improvement “how to” manual.

Thanks to Eddie for allowing me to adapt and share his pearls of wisdom. He’s also kindly read over my blog to make sure I haven’t got the wrong end of the stick.

Billy Boland is a consultant psychiatrist and associate medical director for quality and safety at Hertfordshire Partnership University NHS Foundation Trust. You can follow him on Twitter @originalbboland

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.

  • Mike Chitty

    Billy. Try focussing less on the methodology and more on the philosophy and culture. Much more rewarding….Also being bi-lingual – speaking improvement and transformation and using each at the right stage of the innovation cycle is critical. I’d go back to basics. Read some Crosby and Deming….I’ll ping you some stuff…

  • Clive Poole

    I’m not in the NHS but lead Lean in manufacturing and I like the simplicity of your guide.

    Some so called gurus seem to use jargon to preserve their authority.

    For me improvement is keeping it simple, about engaging the whole workforce in using basic tools to solve everyday problems on the shop floor to make things better. In manufacturing we tend to focus on increasing output, reducing cost and increasing quality. The desired outcomes are prioritised by the key stakeholders.