Quality improvement and measurement: what non-executive directors need to know

An overview of quality improvement and measurement for non-executive directors of health boards.

Appendix 1 - Quality Improvement methodologies

At the outset, it is important to acknowledge that QI methodologies are not the only types of change that bring about improvement. In some cases, wider changes will be necessary. These could include a change of legislation, or professional regulations. Similarly, the introduction of training to existing staff or introducing a new component to pre-registration courses so that new staff entering a system will bring a new skill will bring about change. QI methodologies work within the current legislative, professional and regulatory frameworks and challenging these is beyond the scope of these techniques. Parallel activity may of course work to make these changes.

Skill is required to discern which method is most applicable to the issue being addressed. For example, repeated actions that follow a particular sequence, such as the insertion of catheters, or the issuing of repeat prescriptions, are well suited to being improved through the Model for Improvement that requires rapid hypothesis building, testing and retesting. Redesigning pathways of care that are inefficient and unreliable may lend themselves to lean techniques. An example would be making the distribution of medicines throughout a series of hospitals more efficient.

It is important to recognise that QI usually takes time; the more people who are involved and more complex the environment the longer it will take to make and then embed improvements.

Board members are in a strong position to support wider cultural changes that will be necessary if these QI methodologies and the 'habit' of QI are to become part of the local culture.

The methodologies used most frequently in Scotland are described below.

Understanding the process - Process mapping

'Every system is perfectly designed to deliver the results it produces.'

[Langley et al, 2009]

Although technically not an improvement methodology, since a map is simply a description, process mapping has been included here, since developing a process map is often the first step in any improvement initiative. The sequence of steps in a process are identified and drawn. Quite often this act of investigating and describing a process will immediately show areas where there are inefficiencies or blockages. This can then lead to improvement action to 'unblock' and streamline the process.

To find out more about process mapping, visit:

Model for Improvement

To learn more about the Model for Improvement, and to read about examples of how the Model for Improvement has been used in NHSScotland, visit:


To read about how lean thinking is being applied in NHS England, visit the Lean Healthcare Academy:

To learn how NHS Highland is using lean thinking to implement its Quality in Action work, visit:

To learn how to reduce things that do not add value to patients, visit:

Six Sigma

To learn how Six Sigma can be combined with lean thinking to dramatically reduce waiting times, visit:

For useful tips on how to use the 'five whys' to get to the root cause of problems, visit:

To learn how to reduce things that do not add value to patients, visit:

Demand Capacity Activity and Queue ( DCAQ)

To learn more about Demand Capacity Activity and Queue, visit:

The Vanguard approach

To learn more about the Vanguard approach, visit:

The following link shows how it has been used:

Experience-based co-design

To find out more about experience-based co-design, visit:


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