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Tools and Frameworks for Quality Improvement in Healthcare Essay (Critical Writing)

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Background Information

Kuwait has one of the best healthcare systems in the Eastern Mediterranean region. The system is dedicated to the provision of high-quality and safe healthcare to its people. To achieve these objectives, the system employs expatriate healthcare practitioners from advanced countries such as the United States and United Kingdom (Casey, 2007). In addition, the country’s healthcare system uses advanced information and communication technologies such as the electronic medical records and diagnostic imaging systems. In addition, the country’s healthcare system is characterized by organizational culture of patient safety and quality care. Despite these strengths, Kuwait’s healthcare system is rife with weaknesses which negatively affect the quality of care provided to patients as well as patient safety. These weaknesses include cultural incompetence, inaccessibility of crucial information, cost-effectiveness restraints, nursing shortages and human resources challenges such as high staff turnover rates, low staff morale, and lack of teamwork spirit. The strength of Kuwait’s healthcare system can further be enhanced through the implementation of quality-improvement measures that address the above-mentioned weaknesses. The aim of this paper is to develop a quality improvement program for Kuwait’s healthcare system to address the human resources challenges (high staff turnover rates, low staff morale, and lack of teamwork) using quality improvement tools and frameworks.

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Continuous Quality Improvement (CQI)

The main goal of the quality improvement program is to enhance the quality of care provided to patients by increasing patients’ and staff satisfaction. The following principles will guide the CQI efforts of the healthcare system.

Leadership commitment

The understanding and active dedication of the system’s leadership will provide the platform upon which successful execution of the CQI will be realized. The leaders should therefore share the same vision, support the same principles and motivate those they lead to do the same. The leaders should take the full responsibility of supervising the quality improvement efforts (Gothard and Wixson, 1994). In order to ensure a smooth running of the QI program, a clinical quality improvement committee (CQIC) will be formed (Eubanks, 1994). This committee needs to report directly to the medical executive committee (MEC). The CQIC should be made up of physicians, nurses and other medical staff. The responsibilities of the CQIC will be: to recommend and execute corrective action where needed; to report the results of the QI to the MEC on a regular basis; to determine the variables of quality that need to be measured; to create valid pointers for assessing the quality of care provided, as well as the challenges and opportunities that exist for improving the quality of care; to take part in decision-making processes; and to assess the effectiveness of the measures taken by the healthcare system (Briscoe and Arthur, 1998). The smooth running of the CQIC will be enhanced through various quality improvement tools such as plan-do-check-act cycle, balanced scorecard (BSC), process flow charts, and brainstorming.

Focus on process improvement: the plan-do-check-act cycle

In order to successfully undertake the CQI program, the Kuwait’s healthcare organization needs to adopt the plan-do-check-act (PDCA) cycle. The PDCA cycle is a tool that will help the healthcare system to identify the processes and measure the outcomes for improvement, assess the approach for change, evaluate the data collected, and implement the QI strategy (Motwani et al., 1999). Based on the PDCA, the system can design new products, introduce new services, and change some functions or processes in accordance with the program’s vision and mission as well as the needs and anticipations of clients and employees (Mount, 1996). The PDCA tool used for in particular program is as follows:

The PDCA Cycle.

Plan – The following measures will be undertaken:

Develop a questionnaire that will be addressed to the medical staff to determine the reasons for their dissatisfaction with the organization and their low morale.
Plan for education, training and staff development programs for the employees
Plan for the institution of team-building programs and activities so as to develop the teamwork spirit of the medical staff
Evaluate the remuneration packages of the medical staff vis. a vis. their daily basic needs and make the necessary changes
Plan for activities and measures that would motivate the medical staff such as including them in the decision-making process of the organization and regular reward programs for the productive staff
Do – The above-mentioned recommendations will be put into effect

The questionnaire will be developed and addressed to the medical staff. The responses given will provide the organization’s management with information that can be used for future improvement efforts. The questionnaire will be addressed to both the medical staff and the patients and will be used to collect data that pertain to the problems facing the organization. To this end, several items will be included in the medical staff’s questionnaire namely: the level of morale among the medical staff, the level of cooperation among medical staff, the environment of the organization as far as providing support to the medical staff is concerned, the staff’s satisfaction with the remuneration packages provided by the organization. The questionnaire addressed to the patients will have items such as: the immediacy with which care is provided to them, the level of attention provided to them, the general quality of care provided to them, and the number and frequency of medical errors they have encountered. From the data collected, it is expected that the quality improvement team will find: a low level of staff morale (an average of 15%), a low level of cooperation among the staff (an average of 10%), a low level of staff satisfaction with the organization (an average of 12%).

Start regular education, training and staff development programs to sensitize the medical staff on the importance of providing high-quality care to patients
The organization will engage the medical staff in team-building activities that will be held on a monthly basis until a teamwork spirit among the staff is achieved
The terms of the medical staff’s remuneration packages will be revised to make them more favourable to the employees
The organization will start involving the medical staff in the decision-making processes of the organization. It will also start a bonus program which will reward the employees with bonus payment according to their performance

Check – The effectiveness of each of the recommended measures, activities and programs will be analyzed using questionnaires addressed to the medical staff. The analysis of the data from the questionnaires will enable the organization to determine if: the employees have become more satisfied with the organization; the employees experience enhanced cooperation from their colleagues; and if they have become more motivated in their work.

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Act – The project will be reviewed every month for the next six months following its commencement. Based on the results, the organization will decide whether or not to make the changes permanent or whether to make the necessary improvements. If the results are positive and encouraging, the changes will be made permanent and the review of the project will be reduced from a monthly basis to a semi-annual basis.

Balanced Scorecard (BSC)

A balanced scorecard is a quality improvement tool that focuses on four major elements of the organization: customer, business process, learning and financial. The customer element addresses the needs of the patients particularly as far as their safety and the quality of care they receive. In this project, the opinions of the patients about the quality of care they receive from the medical staff will be collected. The data will help the organization to identify the areas of care provision that need improvement. The business process addresses the areas in which the organization must excel at. In this project, the organization is interested in improving the quality of care of patients by addressing the human resources challenges it currently faces: high staff turnover, staff morale and lack of teamwork. The learning element addresses the activities and programs the organization will undertake to ensure continued improvement. The activities and programs that will be undertaken in this project include: employee education, training, staff development, team-building activities, remuneration program and bonus program. These activities and programs will help the organization to manage its human resources problems. Finally, the financial element addresses the sources of funding of the organization such as its stakeholders (Kaplan and Norton, 1996). The stakeholders of the organization must be satisfied with the project before the project can take off. In addition, cost-benefit analysis of the proposed programs will help the organization and its stakeholders to determine the project’s viability and to provide the financial support necessary for its success.


Brainstorming is one of the tools used in quality improvement. It entails searching for ideas and implementing the most appropriate ones. In this particular case, the CQIC of the organization will hold several regular meetings to discuss the problems currently facing the organization and to search for the solutions. Brainstorming will require total cooperation from all members of the quality improvement team. Generation of ideas can be done in an organized and structured manner in which every member is given a turn to give his/her opinion. This is due to differences in personality which may prevent some members to share their views even if they are of great importance. It is important for members of the CQIC to realize that every idea is valuable and can go a long way in solving the current problems facing the organization. It is also important for feedback to be given to the members of the team (Hoskins et al., 2002).

Data collection and evaluation

Besides the data collection and analysis that was undertaken as part of the PDCA cycle, similar data will also be collected and analyzed six months after the implementation of the project to determine its effectiveness or lack thereof. Specifically, the QI team will collect data concerning: the level of morale among the medical staff, the level of cooperation among medical staff, the environment of the organization as far as providing support to the medical staff is concerned, the staff’s satisfaction with the remuneration packages provided by the organization; the immediacy with which care is provided to patients, the level of attention provided to patients, the general quality of care provided to patients, and the number and frequency of medical errors that patients have encountered. From the data collected, it is expected that the quality improvement team will find: an improved level of staff morale (an average of 65%), a higher level of cooperation among the staff (an average of 60%), and a higher level of staff satisfaction with the organization (an average of 80%) all within the first six months of the project’s implementation. As a result, the organization will record a reduction of 50% in the rate of staff turnover within the first six months. These results from the data analysis will be used to make important decisions such as the continuation of the project and the areas of the project that need improvement or elimination (Calomeni et al., 1999).

Process flow charts

These are pictorial representation of the steps that will be taken in a given process (Carman, 1996). The process flow chart for this quality improvement project is represented below.

Flow chart: Improving quality of patient care.
Involvement of all members

A successful quality improvement program needs to include all the stakeholders of the organization. The organization in this case will include the patients and their care takers, all the employees, and the management in its QI project. This will be achieved by involving all parties in the data collection process in which data will be collected from the patients (and/or their caretakers) as well as the medical practitioners to determine if the project helps in addressing their different needs. Involvement of all these parties will ensure that the QI program addresses their needs and is therefore effective in improving the quality of care provided to patients (Calomeni et al., 1999).

Total Quality Management (TQM)

Like continuous quality improvement, total quality management is part of daily operations for every member of a healthcare organization. Although CQI and TQM are similar, they have a slight difference. While CQI aims at developing new processes and measures to solve the organization’s problems, TQM aims at using the same processes but in a different manner to bring the desired results (Cohen and Lisagor, 2005). The TQM framework for quality improvement that will be used in this particular program will be based on the following principles: management commitment, employee empowerment, fact-based decision making, and continuous improvement.

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Management commitment

The TQM program will require total commitment from the organization’s management (Motwani et al., 1996). The management of the healthcare organization in this case will demonstrate its commitment by developing the strategies for undertaking the project based on the vision and mission of the organization. Management commitment will also be demonstrated through the creation of the TQM team that will oversee the quality improvement project. The commitment of the management is important because it will serve as an example for the rest of the organization’s partners to follow. Commitment from the management will also guarantee the motivation of the entire organization members to work towards the success of the QI project (Narine and Persaud, 2003).

Employee empowerment

The empowerment of the employees is another determining factor of the success of the QI project. Employee empowerment takes various forms such as education, training and staff development (Wong and Chung, 2005). For this QI project, the healthcare organization will empower its employees through regular education and training sessions through which employees will be educated and trained on the importance and ways of providing quality care to patients. Empowerment is important because it will enable the employees to make the right decisions that will serve the best interests of the patients.

Fact-based decision making

Like in CQI, quality improvement through TQM will involve continuous data collection and analysis (through questionnaires and thematic content analysis respectively) to determine the performance of the medical staff as well as the effectiveness of the quality improvement program (Ralston and Larson, 2005). Results from the data collection and analysis will form the basis upon which the organization will make its decisions. In addition, the organization will carry out literature reviews on a regular basis to help it make appropriate and timely decisions.

Continuous improvement

Continuous improvement is part and parcel of TQM. It entails doing the same things but in better ways. The organization will strive to improve the manner in which the healthcare services are offered using the same resources. Continuous improvement will be an undertaking of the entire organization’s team including those who are not directly affected by the current organization’s problems (Narine and Persaud, 2003). Continuous improvement will enable the organization to address the changing needs of its patients and ultimately enhance the quality of care provided to patients.

Structure, Process, and Outcome (SPO)

Structure, process, and outcome are used to measure the quality of care provided to patients. The three elements are interdependent and interact with one another and the environment in which they exist.


Structure refers to the particular organization responsible for providing care. It is characterized by elements such as “staffing patterns, programs, finances, facilities, and size of the organization,” (Wong and Chung, 2005, p. 360). Elements of structure that will support the quality improvement efforts of the organization include: supportive organization’s vision and mission; a committed management (demonstrated through the management’s vision for the organization); open communication lines between all levels of employees (employees on the lower levels should be able to communicate directly with those on higher levels); cooperation among all employees; and adequate resources to implement the project’s recommended measures, including both financial and human resources.


Process entails “examining what must happen when, by whom, and in what sequence,” (Wong and Chung, 2005, p. 361). The processes for the QI project will include: planning, implementing, assessing and revising the necessary changes as discussed above. The planning process will entail planning for the implementation of programs that will enhance employees’ morale (in this case remuneration program, reward system, education, training and staff development programs), and develop their teamwork spirit (through team-building activities). In order to ensure successful planning, the QI team will engage in brainstorming in which all team members will give his/her opinion concerning the problems at hand and the possible solutions. Once the team decides on the most effective solutions possible, it will embark on the implementation process. The implementation process of the programs will be done in accordance with the plans laid down. Regular assessment of the programs will be carried out through data collection and analysis techniques discussed earlier and the necessary changes will be made to them. The process has a great impact on the outcomes of the program and it should therefore be taken into great consideration.


Outcomes refer to the end products of processes. Outcomes of any QI project should be measurable (Urden, 2001; Wong and Chung, 2005). In this particular QI project, outcomes that will be measured include: employee turnover rate, employees’ morale level, teamwork spirit, and quality of patient care as gauged by patients’ opinions and health outcome. It is expected that the quality improvement project will result in: a significantly reduced staff turnover rate (of 50%), a higher staff morale (of 65%), and an enhanced teamwork spirit through improved cooperation (of 60%) within the first six months of the project’s implementation, all of which will lead to an enhanced quality of care provided to patients.

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The quality improvement project undertaken will make use of several quality improvement tools and frameworks namely: continuous quality improvement (CQI), total quality management (TQM), plan-do-check-act cycle (PDCA), structure, process, and outcome (SPO), brainstorming, process flow charts and data collection and analysis. The success of the project cannot be realized without a committed management and leadership hence it is expected that the organization’s management will be supportive of the projected. Generally, it is expected that the project will improve the teamwork spirit of the medical staff, enhance their levels of morale and reduce their rate of turnover. The achievement of the project’s objectives will ultimately lead to improved quality of care provided to patients.

Reference List

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Calomeni, C., Solberg, L., & Conn, S. (1999). Nurses on quality improvement teams: How do they benefit? Journal of Nursing Care Quality, 13(5), 75-90.

Carman, J. et al. (1996). Keys for Successful Implementation of TQM in Hospitals, Health Care Management Review, 21(1): 48-60.

Casey, M. (2007). The history of Kuwait. New York: Greenwood Publishing Group.

Cohen, D., & Lisagor, P. (2005). Medical errors – Is total quality management for the battlefield desirable? Military Medicine, 170(11): 915-918.

Eubanks, P. (1992). The CEO Experience: TQM/CQI, Hospitals, 66(11): 2436.

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Kaplan, R.S. & Norton, D.P. (1996). The Balanced Scorecard: Translating strategy into action. Harvard Business Scholl Press, Boston.

Leape L. (2002). Reporting of adverse events, New England Journal of Medicine, 347: 1633-8.

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Motwani, J., Klein, D. & Navitskas, S. (1999). Striving towards continuous quality improvement: A case study of Saint Mary’s Hospital, Health Care Manager, 18(2): 33-40.

Mount, C. (1996). The Continuous Quality Improvement Process in Dynamic and Rapid Change, Seminars for Nurse Managers, 4(1): 55-59.

Narine, L. & Persaud, D. (2003). Gaining and maintaining commitment to large-scale change in healthcare organizations, Health Services Management Research, 16: 179-187.

Ralston, J. & Larson, E. (2005). Crossing to safety: Transforming healthcare organizations for patient safety, Journal of Postgraduate Medicine, 51(1), 61-7.

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Wong, F. & Chung, L. (2005). Establishing a definition for a nurse-led clinic: structure, process, and outcome, Nursing and Healthcare Management and Policy, 53(3): 358-369.

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