Recent policy emphasises the importance of midwives having the opportunity to be involved with innovation and the creation of opportunities to make grassroot level changes that improve their working environment and the quality of care provision to women and babies (NHS England, 2016; no date; Jabbal and Lewis, 2018). The NHS (2021) staff survey has captured data relating to the opportunities staff have to make improvements within their workplace, with 55.2% responding that they are able to make improvements happen. This article provides an introduction to quality improvement and signposts midwives to some simple but effective quality improvement tools.
Within the NHS, resources such as time and workforce availability are a precious commodity. Frequent change can contribute to the burden felt by team members, creating a perception of change fatigue where staff may become resistant to or feel overwhelmed by change that they perceive they have little control over (Gifford et al, 2012). It can be hard to create opportunities for innovation and improvement when faced with staff shortages and chronic excessive workload (Bailey and West, 2021). While quality improvement might easily be dismissed as something that somebody else does, having the opportunity to create simple changes and initiatives in practice can have a significant impact on the clinical working lives of midwives and care provision. An example of this is ‘the Spark’, which was an initiative undertaken by professional midwifery advocate Anna Garratt in response to low morale and feedback from midwives within a clinical ward area in practice. It was a bi-weekly forum for midwives and support staff created to help improve staff morale, teamwork and reignite the passion that individuals had all felt at some stage for their role in women's care. Its objective was to provide an inclusive forum for team members to celebrate their work and to share personal experiences. While the forum was set up and facilitated by clinical practice facilitator and professional midwifery advocate Anna Garratt, different midwives contribute each week and subjects have included the ‘brilliance of women’ and the ‘impact of the sum of our own experiences in the birthing room’, as well as stories from those who have worked outside of the UK.
For quality improvement initiatives to be successfully accepted and adopted by staff, they should be supported by a robust evidence-based rationale, have a clear purpose, and be meaningful to those involved or affected by the change. Ensuring the development of a clear vision, which staff have the opportunity to contribute to and which aligns with their values, is integral to transformational and collaborative leadership and successful quality improvement implementation (Randhawa, 2018).
‘The Spark’ was created in response to low morale raised by midwives and followed a discussion with stakeholders who helped identify issues with communication and staff attitudes within midwifery. This was supported by findings from the Patient Advice and Liaison Service Department.
Porath and Pearson (2013) discussed the ongoing impact of uncivil behaviour (even for those witnessing such behaviour) on safety and effectiveness in practice as part of the Civility Saves Lives movement and reinforced the need to address negative culture in healthcare. At the NHS Foundation Trust where the Spark was implemented, these concepts were further examined with the multidisciplinary team through the provision of group and one-to-one restorative clinical supervision sessions run by the professional midwifery advocate team, which helped to support a positive change through personal and group reflection. Wider discussions around civility were also held by the ward matron.
The restorative clinical supervision sessions and discussions led to changes to clinical ways of working (such as timed breaks and allocation of staff), changes to a more compassionate leadership style and improved multidisciplinary teamworking, the benefits of which have been widely discussed (Ockenden, 2020). Lasting change is more likely to happen in an environment where staff can reflect on how things are currently done in order to plan how they could be improved (Alderwick et al, 2017). The sessions also provided a space for staff to contribute and feel a sense of belonging and ownership of their work place, which has been highlighted as key to staff morale and wellbeing (West et al, 2020).
The Spark was set up as a discussion forum for midwives and support staff, with the aim of providing the team with an opportunity to value their contribution in an informal and unconfrontational setting. These initiatives have been well evaluated, enabling midwives and other members of the team to connect and pay attention to their colleagues, reigniting their passion for midwifery and understanding of one other, as well as having a positive impact on subsequent compassionate care provision (Atkins and Parker, 2012).
Quality improvement refers to the use of specific tools and methods in a structured and systematic way, with the aim of improving the quality of care and outcomes for patients as well as the working conditions and culture of care for staff (Jabbal, 2017; NHS Education for Scotland, 2021a). There are many tools and methods that can be used within quality improvement and some excellent resources are available on the NHS England and NHS Improvement (no date) website. Such a plethora of tools may appear daunting or confusing when first starting out with quality improvement. Often, simplicity is key and the application of tools to plan and structure change need not be complex. However, adopting a structured systematic approach means that any initiative is far more likely to be successful (NHS Improving Quality, 2014). What is important is to choose the tool that is most suited to the improvement in mind. A selection of some key quality improvement tools is presented in Table 1. Two simple but effective tools that can be used for most quality improvement projects are outlined in this article.
Table 1. Overview of simple quality improvement tools and resources
| Quality improvement tool | Description |
|---|---|
| Stakeholder analysis | Involving stakeholders in QI means communicating and making efforts to understand the perspectives of all those whose interests should be considered with the project, for example clinicians, administrative colleagues, patients and user groups (NHS England and NHS Improvement, 2021a) |
| Brainstorming | Brainstorming is used for generating lots of new ideas to identify new solutions to an issue or problem |
| Process mapping | A process map is a planning and management tool that visually describes the flow of work (NHS Education for Scotland, 2021b; 2021c). It enables the creation of a visual illustration of how the pathway or process currently works and in doing so captures the reality of what currently happens (NHS England and NHS Improvement, 2021b). It also shows where there are areas of duplication or too many steps within the process |
| Driver diagram | Driver diagrams are constructed charts of three or more levels. The first level consists of the overall improvement goal or aim followed by the second level which consists of the primary drivers required to achieve the goal. They also set out the specific projects and activities that would need to be undertaken to meet these. Basic driver diagrams show three levels consisting of goal, primary drivers and projects/actions (NHS England and NHS Improvement, 2021c; NHS Education for Scotland, 2021d) |
| Plan Do Study Act | These cycles enables change to be tested on a small scale, building on the learning from these test cycles in a structured way before wider implementation. It provides stakeholders with the opportunity to see if the planned change will succeed and is a powerful tool for learning from ideas that do and do not work (NHS England and NHS Improvement, 2021d; NHS Education for Scotland, 2021e) |
| Communication and Responsibility Charting | Communication and Responsibility Charting are ways of setting out how you will communicate with your stakeholders throughout the improvement in a structured way. Responsibility charting ensures that all involved in the project are aware of their responsibilities and the agreed actions for project implementation. This facilitates collaboration and reduces conflict, uncertainty, and duplication of work (NHS England and NHS Improvement, 2021e; 2021f) |
Involving stakeholders
Stakeholder analysis and engagement undertaken at the start and throughout improvement is the cement within the building bricks of any quality improvement project. It provides a way of identifying, prioritising, and understanding those involved or affected by the change to better understand their different needs and perspectives (NHS England and Improvement, 2021a). Stakeholders encompass the groups and individuals who need to be involved with the improvement and who are most likely to be affected. Identifying key individuals serves to help avoid conflict and delays at the start of an improvement project, while ensuring that necessary permissions are gained from appropriate personnel.
Analysis of relevant stakeholders can help identify those who have influence and enables consideration of how best to approach, engage and obtain cooperation from those identified. Understanding the characteristics and possible concerns of those affected by the change provides opportunities to consider how best to frame responses and discussions to promote effective collaboration enhancing the success of the project (NHS England and NHS Improvement, 2021a; NHS Education for Scotland, 2021f; 2021g). For improvement to become embedded and sustained over time there must be a collaborative approach. Change does not happen in a vacuum, and it is essential that the wider context for change and those it will effect is considered at the start of any quality improvement project.
Brainstorming
This simple but highly effective quality improvement tool can be used with stakeholders to help ensure engagement at grassroots level. It aims to generate different perspectives and maximum creativity through the collection of a high number of ideas on a pre-defined subject from members of a team and stakeholders (Dixon and Pearce, 2001). The objective is to produce as many broad and innovative ideas and alternatives as possible from which to further analyse, categorise and choose from. The strengths of brainstorming are that it encourages participation from all group members, encourages stakeholder engagement if they are involved with the process and can foster momentum, enthusiasm and collaboration as participants are encouraged to think outside the box and generate further insights (Institute for Healthcare Improvement, 2021). For brainstorming to be an effective exercise, there are five key rules from NHS England and NHS Improvement (2021g). These are:
- No criticism
- Aim for quantity
- Encourage thinking outside the box and wild ideas which can provide breakthrough insights
- Build upon the ideas of others
- One conversation at a time.
Conclusion
There has never been a greater focus on improving the quality of health services; however, to be effective and meaningful, those individuals who are closest to issues affecting care quality require the time, permission, skills and resources required to solve them (The Health Foundation, 2021). An understanding of quality improvement is important for anyone involved with care provision and working within an environment that supports midwives in practice to engage in quality improvement activities is a vital ingredient for success (Alderwick et al, 2015).