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Abstract
Objectives Quality improvement (QI) is critical in facilitating advancements in patient outcomes, system efficiency and professional growth. This paper aimed to elucidate the underlying rationale and framework guiding JurongHealth Campus (JHC), a nascent Regional Health System, in developing its QI capacity and capability at all levels of the organisation.
Methods An exhaustive analysis of high-performance management systems and effective improvement frameworks was conducted, and the principles were customised to suit the local context.
A three-phased approach was applied: (1) developing the JHC QI framework; (2) building capacity through a dosing approach and (3) building capability through QI projects and initiatives using the model for improvement (MFI). Three components of the RE-AIM implementation strategy were assessed: (1) Reach—overall percentage of staff trained; (2) Effectiveness—outcomes from organisation-wide improvement projects and (3) Adoption—number of QI projects collated and presented.
Results The percentage of staff trained in QI increased from 11.3% to 22.0% between January 2020 and March 2024, with over 350 projects documented in the central repository. The effectiveness of the MFI was demonstrated by improving inpatient discharges before 12pm performance from 21.52% to 25.84% and reducing the 30-day inpatient readmission rate from 13.92% to 12.96%.
Conclusion Four critical factors for an effective QI framework were identified: (1) establishing a common language for improvement; (2) defining distinct roles and skills for improvement at different levels of the organisation; (3) adopting a dosing approach to QI training according to the defined roles and skills and (4) building a critical mass of committed staff trained in QI practice. The pragmatic approach to developing QI capability is both scalable and applicable to emerging healthcare institutions.
- Leadership
- Quality improvement methodologies
- Organizational Culture
- Healthcare quality improvement
- Quality improvement
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Leadership
- Quality improvement methodologies
- Organizational Culture
- Healthcare quality improvement
- Quality improvement
What is already known on this topic
There is substantial evidence to show that successful implementation of Quality Improvement (QI) has been associated with improved quality of care and/or reduced costs.
However healthcare systems stuggle to sustain an effective QI framework for capacity and capabliity building.
What this study adds
This study demonstrates the importance of a consistent improvement approach and organisation acceptance demonstrated through organisation-wide projects.
It also shows the JurongHealth Campus journey of building QI capacity and capability by first establishing the QI competencies for the different levls of staff then train staff through various QI programmes.
How this study might affect research, practice or policy
The approach described in this paper can help other healthcare organisations in their quality improvement capability building journey. In addition, these guiding principles are applicable and can be translated into capacity and capability building in other field areas.
Introduction
Contextual background
As new healthcare systems emerge to serve their communities, ensuring high-quality care and patient safety is paramount. Success in this pursuit relies on establishing a robust quality improvement (QI) framework, which facilitates the continuous enhancement of services and care delivery to effectively address the evolving healthcare needs of our patients. The Quality, Innovation and Improvement (QII) Department at JurongHealth Campus (JHC) was established, building on the work of a founding improvement team during the construction of Singapore’s first integrated healthcare complex. This complex comprised a 700-bed Ng Teng Fong General Hospital for acute patient care, connected to a 400-bed Jurong Community Hospital (JCH) for step-down care.1 At the onset, the founding improvement team encountered numerous obstacles as the organisation lacked a deep-rooted capability to facilitate organisational QI initiatives and effectively engage all staff groups. Ground staff grappled with different QI methodologies, expending substantial efforts and ‘trying harder’ at improving without achieving sustained results. Meanwhile, enthusiastic, middle-level leaders struggled to frame problems adequately, to empower staff to solve problems; and especially, to recognise if the actions taken had incorporated improvement methods or were merely unguided attempts. As a result, completed QI projects were not able to achieve better, sustained performance, with changes often reverting to previous practices after project completion. Against this contextual background, this paper sought to elucidate the underlying rationale and structured framework guiding JHC in developing its QI framework.
Understanding QI
QI is best defined as the combined and unceasing efforts of everyone (healthcare professionals, patients and their families, researchers, payers, planners and educators) to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning).2 Successful implementation of QI has been associated with improved quality of care and/or reduced costs, motivating organisations to initiate QI programmes.3 4 QI is a shared responsibility, which means that programmes need to be implemented and spread throughout the organisation to involve as many staff as possible. With increasing recognition that QI can extend beyond the realms of quality control (QC) based on performance management and quality assurance, hospitals have employed a variety of different approaches with varying degrees of success in developing lasting improvement capability.5 6
Anecdotally, many healthcare institutions jump onto expensive QI training programmes or rush to deliver QI training to all staff. The first key step discovered was to define the improvement language and expected QI roles at each level of the organisation. This needs to be done before tailoring differentiated training to build QI capability. This was highlighted by the Institute for Healthcare Improvement (IHI) whitepaper ‘Sustaining Improvement’7 which outlined an architectural design of a high-performance management system leveraging Juran’s Trilogy. It described the different QC and QI functions and tasks across representative levels of a typical healthcare organisation.7 A key aspect of designing QI functions was recognising that staff assumed different roles at different levels, necessitating varying levels of QI knowledge and skills to fulfil their responsibilities. This concept was termed ‘dosing’, inspired by the principles used to determine the appropriate dose of medicine.8–11 Consequently, the dosing approach established targeted levels of QI knowledge and skill delivered through various channels, including virtual learning, independent study, face-to-face workshops and experiential learning.
Prior to these developments, there was a disparate understanding of what constituted an improvement in the organisation. For any improvement to have an effect, it must contain three main components: a clear aim, a defined set of measurables and specific changes that are tested for improvement. The model for improvement (MFI)12 contained these three components and resonated strongly with JHC staff. The MFI framework also provided the basic skeletal structure for JHC to layer on more complex tools such as LEAN, Design Thinking and Human Factors, to achieve the desired actions and outcomes without losing sight of the key components as defined by the MFI. The evidence showed that no single QI method outperformed others, rather the key to success was selecting and diligently applying a consistent improvement approach in practice across the organisation.13
The MFI framework is widely employed by many healthcare organisations to improve care processes and outcomes. For instance, the East London NHS Foundation Trust (ELFT) delineated five principles for creating an organisational strategy to bolster QI capacity and capability through the MFI framework: (1) adopting a dosing approach; (2) standardising development, delivery and evaluation processes; (3) nurturing a supportive community for learners; (4) ensuring the relevance of training and (5) highlighting the significance of leadership.14 Over 10 years of developing, implementing and assessing QI initiatives, the ELFT has forged a sustainable model that went beyond training and achieved positive outcomes. With the insights gained, JHC embarked on its improvement journey, built on the foundation of an organisational QI framework and a dosing approach to delivering this renewable infrastructure towards organisational excellence.9
Methods
QI interventions
Developing the JHC QI framework
At the organisational level, a QI framework was necessary to facilitate the implementation and dissemination of the QI programme to all staff members. The QII Department, which grew out of the founding improvement team, developed the QI framework in three phases: (a) identifying staff tiers in the organisation, (b) defining key quality tasks for each staff tier and (c) listing the expected quality competencies.
Identifying staff tiers in the organisation
The QII team referred to IHI’s architecture of a high-performing management system7 and conceptualised four general tiers to fit the JHC context, as outlined in figure 1A. These were T3 ‘Senior Leaders’ setting the strategic direction and vision for the organisation; T2 ‘Middle Leaders’ ranging from assistant directors and above, who framed problems and held staff accountable to solve problems; T1 ‘Frontline Leaders’ comprising managers or executives who primarily focused on local improvement opportunities and T0 ‘Frontline Staff’ who engaged with improvement activities. Two additional tiers were crafted for staff with more QI expertise. These included ‘QI Coaches’ comprising individuals in T1 or T2 tiers who were passionate about QI and trained in QI coaching to facilitate QI projects and ‘Quality Professionals’ who were specialists within the QII team equipped with extensive technical knowledge to facilitate organisation-wide and complex improvement projects.
JurongHealth Campus improvement journey of (A) developing our QI framework by (1) identifying JHC staff tiers; (2) Defining key quality tasks and (3) listing expected quality competencies before (B) applying the dosing approach to establish targeted levels of QI knowledge (Adapted from Lloyd R)8–11. JHC, JurongHealth Campus; QI, quality improvement.
Defining key quality tasks for each staff tier
Scoville et al elaborated on the interconnected loop relationship between QI and QC,7 that drives continuous improvements and its sustainability through standard work. The high-performing management system architecture outlines the key QC and QI functions and tasks at various staff levels, where each level supports the one below and is accountable to the one above as displayed in figure 1.
Listing the expected quality competencies
Based on the identified key quality tasks for each level, the expected competencies for the various tiers are listed in figure 1. This would range from leaders practising systems thinking to front-line leaders carrying out improvement projects, collecting and interpreting data and testing changes for improvement. A deeper understanding of QI tools and concepts was indicated for the QI coaches and QI professionals.
Building capacity through a dosing approach
Capacity is defined as the ability to learn, absorb and retain information.8–11 With distinct expected competencies set in place, building capacity entailed customising QI training for each specific staff tier through (a) determining the correct doses for the staff tier and (b) designing the QI training course curriculum.
Determining the correct doses for the staff tier
The improvement knowledge was ‘dosed’ for the respective staff tiers, as reflected in figure 1. The improvement topics were derived from the Improvement Guide,9 Healthcare Data Guide15 and Kaizen principles present within the organisation. The specific doses for each group were not determined by a strict mathematical formula. Three levels of instructor-led training courses were developed based on the dosed improvement knowledge: level 1 ‘QI beginners’, a half-day course designed for front-line staff, front-line leaders and individuals who are new to QI in healthcare; level 2 ‘QI fundamentals’, a full-day course tailored for front-line leaders with previous knowledge of QI and experience in applying the MFI to an improvement project and level 3 ‘QI leadership’, a half-day course aimed at middle leaders to help them frame problems and sponsor QI projects. Other platforms were also used to introduce the MFI framework in the hospital, such as a new employee orientation programme—the JurongHealth Onboarding Programme; and the IHI Open School, an online platform accessible to all staff.16
A comparative evaluation of the JHC training curriculum was conducted with other healthcare organisations such as ELFT for alignment in QI course delivery.17 For QI coaches training, staff who had an aptitude for QI attended the Improvement Coach Professional Development Programme. This increased the capacity of QI project coaching beyond the QII team. QI professionals attended the Improvement Advisor Professional Development Programme conducted by IHI and funded by the Singapore Ministry of Health.
Designing the QI training course curriculum
Content aside, the design of the course, the mode of delivery (physical or virtual) and the techniques of training delivery were equally important. To design an engaging QI course, the training objectives were defined following the design stage of the Knirk and Gustafson Instructional Design Model.18 The Audience, Behaviour, Condition and Degree model was employed, with Bloom’s Taxonomy framework to structure the learning outcomes as well as experiences for each QI training course.19 The contents of the QI training curriculum were formulated using Gagné’s Nine Events of Instruction20 to enhance staff engagement and learning, thereby improving the overall understanding of concepts and facilitating information retention. The curriculum was piloted from August to October 2020, involving various groups of staff to gather initial feedback on its effectiveness. Subsequently, the course content was adjusted with trainer notes created to ensure consistency before rolling out organisation-wide in 2021.
Building capability through QI projects and initiatives using the MFI
As staff acquired QI knowledge and skills during the capacity-building phase, their ability to enact improvements would be limited if not put into practice as part of daily work. Therefore, building capability, defined as the ability to use improvement approaches intentionally and systematically to change processes to generate improved performance,8–11 was equally important.
This was embarked on by facilitating and coaching staff on completion of their classroom training in the proper application of the MFI framework and QI tools in their QI projects and daily work. Staff received support through the provision of QI project templates, which were accessible on the hospital’s intranet, as well as coaching from the organisation’s QI coaches. To promote improvement work in JHC, the ‘Best QI project’ competition was held as part of the annual Quality Month event. Staff were encouraged to share their improvement stories and learn from others, as leaders recognised the good work done by the staff.
Building organisation acceptance for the MFI framework
When the MFI framework was first proposed, the understanding was limited to the quality professionals and a small group of leaders. Many staff, including individuals in leadership roles, were sceptical about the organisation-wide improvement approach due to their past negative experience working with QI tools without organisational support. As such, leadership and staff needed to experience the application of MFI on pressing organisational issues before launching the QI Training programme. Support was sought and received from senior management for the quality professionals to organise and facilitate organisation-wide projects that included all staff levels, from senior management to front-line staff. At the time, the two major problems affecting the hospital were high bed occupancy rates and rising readmissions. The MFI framework was used to design two organisation-wide improvement projects, namely (1) discharge before noon (DCBN) and (2) 30-day inpatient readmission.
The DCBN project was initiated in 2017 involving two wards to improve the percentage of patients discharged before noon to at least 30%, to alleviate the high bed occupancy of the hospital. A multidisciplinary team consisting of doctors, nurses, operations, bed management and pharmacists was formed. The intention was to scale up the interventions to the organisational level when proven successful within two identified wards.
The 30-day inpatient readmission project was initiated in 2018 with six major workstreams: (1) improving initial assessment/referral/discharge planning process; (2) improving referral to hospital to home; (3) improving discharge process; (4) improving postdischarge process; (5) improving polyclinic/general practitioner (GP) collaboration and (6) improving transfer process to JCH. The team consisted of clinicians from the emergency department, medicine, general surgery and orthopaedics and was supported by clinical operations representatives. Colleagues from nursing wards and case management, medical social workers, pharmacists, community operations, JCH, representatives from polyclinics/GPs and nursing home representatives were also involved, with assistance from the medical informatics team.
In both organisation-wide improvement projects, clear lines of staff accountability were delineated from front-line project teams to senior management to play their specific QI roles. Other than achieving outcomes, a secondary goal was for staff to experience the design of an organisation-wide QI framework based on the MFI. As part of the project, staff were shown how to plot data over time, while senior management learnt to interpret the charts and distinguish sustained improvement from common cause variation in the system. This enabled better decision-making at all levels of the organisation.
Outcome measures
Three key measurements were established using the RE-AIM planning and evaluation framework21 to determine the effectiveness of the QI programmes and the willingness to adopt the MFI as the common improvement language: specifically reach, effectiveness and adoption.
Reach: overall percentage of staff trained
Reach was defined as the absolute number of individuals who willingly participated in the initiative. For JHC, this was tracked by the overall percentage (%) of staff trained in QI programmes, calculated by dividing the number of staff trained in QI programmes by the total number of staff in JHC and multiplying the result by 100. The number of staff trained in JHC QI programmes was tracked through staff registration via the human resources (HR) portal (myHR) and attendance during the training sessions. In addition to the three levels of training provided, staff who had completed the IHI Open School modules attended prior QI training such as the Clinical Practice Improvement Programme or were sent for external QI training such as the Improvement Coach or Improvement Advisor Professional Development Programme were also included. The total number of staff in JHC provided by HR, included full-time employees, medical residents, seconded clinical HODs and cluster-level administrative/support staff working within JHC. Visiting consultants, locums and staff from other agencies were excluded.
The target was to achieve at least 25% of JHC staff trained in QI programmes based on the dosing formula. This target was backed by research that established that social conventions could be altered when a committed minority group reached a critical mass of approximately 25%.22 Staff feedback was collected after each training session using a digital programme evaluation form, aimed at understanding staff’s learning experience. Average scores for overall course rating and programme effectiveness were tracked across sessions.
Effectiveness: outcomes of organisation-wide improvement projects
Effectiveness was defined as the impact of an intervention on important outcomes. The effectiveness of the MFI framework was assessed through improvements in the two organisation-wide projects as mentioned earlier. First, the DCBN project monitored the monthly percentage calculated by dividing the number of patients discharged before 12pm by the total number of inpatient discharges. Second, the 30-day inpatient readmission project calculated the monthly rate determined using the number of emergency readmissions within 30 days of initial discharge divided by the total number of inpatient discharges.
Adoption: number of QI projects completed and presented
Adoption was defined as the number of individuals actively engaged in QI projects at work. QI initiatives completed at JHC were collated to a central repository and presented through project posters during the annual Quality Month event to recognise and showcase the improvement efforts for staff.
Results
Reach: overall percentage of staff trained in JHC QI programmes
As of March 2024, a total of 16 QI beginners, 32 QI fundamentals and 1 QI leadership workshop sessions were conducted. Additional improvement capabilities were built by sending 16 staff to the IHI Improvement Coach Professional Development Programme, with one staff advancing to the IHI Improvement Advisor Professional Development Programme. The overall percentage of staff trained in at least one of the QI courses increased from 11.3% (470 staff) in January 2020 to 22.0% (909 staff) in March 2024 (shown in figure 2).
(A) Number and percentage of JHC staff trained as well as their ratings on JHC QI Programmes starting with (B) overall rating of QI beginners course; (C) rating on skills and knowledge before taking QI beginners course; (D) rating on skills and knowledge after taking QI beginners course; (E) overall rating of QI fundamentals course; (F) rating on skills and knowledge before taking QI fundamentals course; (G) rating on skills and knowledge after taking QI fundamentals course. The ratings were averaged based on the trainings conducted from January 2020 to March 2024. JHC, JurongHealth Campus; QI, quality improvement.
Feedback from staff revealed an average overall rating of 4.58 out of 5 (with 5 being excellent) for QI beginners (SD=0.54) and 4.58 out of 5 for QI fundamentals training (SD=0.55) (figure 2). Programme effectiveness ratings for QI beginners increased from 3.14 (SD=1.34) before the course to 4.29 (SD=0.60) after (shown in figure 2), and for QI fundamentals from 2.88 (SD=1.23) before the course to 4.23 (SD=0.55) after (shown in figure 2).
Effectiveness: outcomes of organisation-wide improvement projects
The baseline performance for the DCBN project was 21.52% between January and May 2017. This figure increased to 25.84% over time, as indicated in figure 3. When the performance declined from January 2018 to June 2018 marked by 6 points below the centre line, new strategies were implemented to improve the performance. Evidence of improvement was confirmed through positive trends, indicated by six consecutive points in the upward direction thereafter. Similarly, for the 30-day inpatient readmission project, the baseline data showed a 13.92% readmission rate between January and December 2018. Through a series of interventions tested,23 the readmission rate decreased to 12.96% between January and December 2019, as depicted in figure 3. Evidence of improvement was again verified by a consistent shift with 12 points falling below the centre line. Though both indicators could not be tracked for sustainability with the COVID-19 pandemic from 2020 to 2023, staff shared positive sentiments regarding the QI framework as it created the feeling that there was an organisation-wide effort and not merely the herculean effort of isolated individuals trying to ‘do a QI project’.
Demonstrated outcomes from two organisation-wide improvement projects that applied the model for improvement framework: (A) discharge before noon (DCBN) and (B) 30-day inpatient readmission. ED, emergency department; EDD, Estimated Date of Discharge; LCL, Lower Control Limit; NTFGH, Ng Teng Fong General Hospital; UCL, Upper Control Limit.
Adoption: number of QI projects collated and presented
The annual count of QI projects collated and presented during our Quality Month events ranged from 15 to 26 between 2011 and 2018. There was a hiatus from 2014 to 2016 due to the relocation of JHC to its new campus. Since 2019 this number has increased 2–3 fold ranging from 38 to 71 QI projects, which correlated with a heightened awareness of QI initiatives among the staff.
Discussion
Effectiveness of QI training programmes
The seminal articles ‘To Err is Human’24 and ‘Crossing the Quality Chasm’25 highlighted that errors in healthcare were systems based rather than the result of individual negligence or incompetence. The publications implicitly drew on QI principles and focused on systems improvement driven by data. Over the past three decades, it has become common for nearly every healthcare organisation to implement a QI framework. In setting up our framework, it became evident that having a common language to describe QI activities was essential, and thereafter identify the roles and responsibilities at all staff levels. This clarity translated to the training doses required and the development of an organisation-wide QI Training Programme.
The journey over the past few years demonstrated the progress made to design and then train JHC staff through various QI programmes. Staff generally expressed satisfaction with the training provided with improved ratings in their skills and knowledge after attending the training courses. The increasing number and quality of QI projects submitted and increased use of QI language at meetings to measure success and make decisions also seemed to suggest positive learning outcomes. However, a standard method of measuring the application of QI learning would give more objective data. According to Kirkpatrick’s Four Levels of Training Evaluation,26 the current JHC programme evaluation form only captures elements of level 1 (reaction) and level 2 (learning). Enhancing the evaluation form to encompass the remaining level 2 elements (attitude, confidence and commitment) and including level 3 (behaviour) and level 4 (results) components would substantiate the application of learning from the training programmes.
One key challenge to address was the retention of staff trained in QI programmes. It was discovered that out of a total of 840 staff trained over three years, 439 staff were currently employed at JHC (52.3% remaining in the organisation). A similar observation was made in ELFT’s capacity and capability journey, where 1274 graduates from their improvement leaders programme over 9 years yielded 693 graduates currently employed at ELFT (54.4% remaining in the organisation).14 The QI training programme must take this into consideration in attempting to reach the critical mass of QI-trained staff in the organisation.
Impact of QI projects on the organisation
The increased number of QI projects completed and presented was indicative of staffs’ interest and commitment to improving their work for the patients; and the success of their projects in improving the process or outcomes they were working on. The success of the projects could also be attributed in part to the QII team’s provision of additional resources to support QI projects. These resources included the creation and internal distribution of a guidebook titled ‘A Clear Path for Improvement’, QI templates and previous projects. These resources were published on the intranet for easy access to aid staff in initiating their improvement endeavours at their preferred pace.
Despite building a database of over 350 QI projects, the impact of these projects on organisational key performance indicators (KPIs) has not been established. This highlighted that projects were primarily ‘grassroots’ initiatives and a potential next step could involve aligning QI projects with organisational KPIs or vice versa, cascading the organisation’s priorities to ensure subsequent projects are aligned for greater impact. This integration of QC, QI and quality planning into a holistic, organisation-wide and customer-centric strategic approach to quality is termed ‘whole system quality’. In addition, the improvements gained in the QI projects need to be monitored after its completion to ensure that the gains are sustained over the long run.
Implementing QI programmes into practice
Establishing the effectiveness of the improvement framework does not ensure its integration into routine practice within the organisation. Therefore, there remains a need to continually cultivate a culture where QI is deeply rooted and sustained consistently throughout the organisation. A key factor in this endeavour would be for staff to incorporate the learnings from QI training programmes into their daily work, as demonstrated by the journey of building capacity, capability and sustainability for organisational excellence.9
Conclusion
Through the JHC quality journey of building QI capacity and capability, four critical elements for systematically establishing an improvement framework were identified: (1) establishing a common language for improvement; (2) defining distinct roles and skills for improvement; (3) adopting a dosing approach to QI training and (4) building a critical mass of committed staff trained in QI. This case study substantiated the evidence of practising a consistent improvement approach with staff playing their respective roles in improvement across the organisation. While the initial results showed positive outcomes, using the Kirkpatrick framework could provide a more comprehensive evaluation of the effectiveness of the QI training programmes. In the next phase, JHC would be focusing on objectively measuring the application of the QI knowledge gained into daily work and ultimately making a tangible impact for better organisational performance.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Acknowledgments
We acknowledge the JHC staff who enthusiastically participated in QI training and diligently applied skills and knowledge through various QI projects. Our gratitude extends to our QI coaches and quality champions, whose passion for quality and dedication to coaching QI project teams have been indispensable. Lastly, we want to thank JHC senior management including LSQ for their steadfast commitment to quality. Their support was critical in embedding a QI culture in JHC.
Footnotes
Contributors YJN and KSML developed the overall organisational strategy and executed initiatives to build QI capacity and capability within JHC. KSML accepted full responsibility as the guarantor for the finished work and controlled the decision to publish. CHH provided invaluable guidance to the team in developing the strategy and secured leadership commitment throughout our capacity and capability-building efforts. AUY lent his expertise to draft our quality journey presented through this publication.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.