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This study demonstrates how becoming a high-reliability institution in health care is a priority, given the high-risk environment in which an error can result in harm. Literature conceptually supports the need for highly reliable health care facilities but does not show a comprehensive approach to operationalizing the concept into the daily workforce to support patients. The Veterans Health Administration closes the gap by documenting a case study that not only demonstrates specific actions and functions that create a high-reliability organization (HRO) for safety and improvement but also created a learning organization by spreading the knowledge to other facilities.

The authors instituted a methodology consisting of assessments, training and educational simulations to measure, establish and operationalize activities that identified and prevented harmful events. Visual communication boards were created to facilitate team huddles and discuss improvement ideas. Improvements were then measured and analyzed for purposeful outcomes and return on investment (ROI).

HRO can be operationalized successfully in health care systems. Measurable outcomes verified that psychological safety was achieved through the identification and participation of 3,184 process improvement projects over a five-year period, which yielded a US$2.8m ROI. Documented processes and activities were used for educational teachings, which were disseminated to other Veteran Affairs Medical Center’s through the Truman HRO Academy.

This case study is limited to one hospital in the Veterans Health Administration (VHA) network. As the VHA continues to deploy the methods outlined to other hospitals, the authors will perform incremental data collection and ongoing analysis for further validation of the HRO methods and operations. Hospitalists can adapt the methods in the case study for practical application in a health care setting outside of VHA. Although the model is rooted in health care, the methods may be adapted for use in other industries.

This case study overcomes the limitations within literature regarding operationalizing HRO by providing actual activities and demonstrations that can be implemented by other health care facilities.

In the recent climate of consumerism and consumer focused care, health and social care needs to be more responsive than ever before. Consumer needs and preferences can be elicited with accepted validity and reliability only by strict methodological control, customerisation of the questionnaire and skilled interpretation. To construct, conduct, interpret and implement improved service provision, requires a trained work force and infrastructure. This article aims to appraise various aspects of consumer surveys and to assess their value as effective service improvement tools.

The customer is the sole reason organisations exist. Consumer surveys are used worldwide as service and quality of care improvement tools by all types of service providers including health service providers. The article critically appraises the value of consumer surveys as service improvement tools in health services tool and its future applications.

No one type of survey is the best or ideal. The key is the selection of the correct survey methodology, unique and customised for the particular type/aspect of care being evaluated. The method used should reflect the importance of the information required.

Methodological rigor is essential for the effectiveness of consumer surveys as service improvement tools. Unfortunately so far there is no universal consensus on superiority of one particular methodology over another or any benefit of one specific methodology in a given situation. More training and some dedicated resource allocation is required to develop consumer surveys. More research is needed to develop specific survey methodology and evaluation techniques for improved validity and reliability of the surveys as service improvement tools. Measurement of consumer preferences/priorities, evaluation of services and key performance scores, is not easy.

Consumer surveys seem impressive tools as they provide the customer a voice for change or modification. However, from a scientific point‐of‐view their credibility in service improvement in terms of reproducibility, reliability and validity, has remained debatable.

This artcile is a critical appraisal of the value of consumer surveys as a service improvement tool in health services – a lesson which needs to be learnt.

The purpose of this study is to benchmark the use of process improvement techniques among US health care organizations that won the Malcolm Baldrige National Quality Award.

The applications from 13 Baldrige award winning health care organizations were researched to determine which process improvement techniques were used most frequently to guide their operations.

The results from this study identify several best practices in process improvement techniques. Furthermore, the study pinpoints in which aspect of performance that a process improvement technique is most likely to be used.

Only applications from organizations winning the Baldrige award have been studied. The identity and application for organizations that do not win the award are not released to the public. Statistical analysis of the data is limited to the relatively small number (13) of award winners.

The results clearly show that there are certain process improvement techniques used by a majority of the Baldrige winners. It is not possible to guarantee that the use of these same techniques by other health care organizations will result in performance improvement, only that the winners used the techniques and have achieved a high level of performance. The results identify processes for further benchmarking studies.

The process improvement techniques identified in this study have been used by successful health care organizations. This information may be useful to other health care organizations when deciding on which process improvement techniques to pursue in order to improve their own performance. While the Baldrige award process has driven benchmarking efforts, this study uses the Baldrige process to identify benchmarking opportunities for process improvement in health care organizations.

A conceptual model of health care, a theory of quality improvement in health care and the role of patient, physician and employee judgements as part of organisation‐wide improvement are introduced. The conceptual model of health care shows how the practitioner, the locus of care‐giving and the social context interact to meet the needs of patients and highlights potential sources of unwanted variation in outcomes. This theory of quality improvement stresses the continuous improvement of processes throughout the entire organisation to meet the needs and expectations of customers. Basic building blocks for continuous improvement ‐ knowledge of customers, knowledge of work as processes, and statistical and scientific thinking ‐ are discussed along with the need to transform the entire organisation. A method for gaining customer knowledge and for monitoring hospital quality, based on measuring quality from patients′, physicians′, and employees′ judgements of quality, is introduced. The method, called the Hospital Quality Trend (HQT) family of quality measures, is described and its uses to promote organisation‐wide quality improvement are illustrated. Health care work is complex and unique. Careful analysis of the way that work is done and knowledge of the customers in defining and improving quality is essential for achieving better quality and value from the health care system.

This paper aims to explore patient to care provider reverse exchanges to improve the care processes and service supply chain using an online feedback platform. This paper demonstrates how a better understanding of timely and unsolicited feedback (“voice of the patient as a customer”) stimulates local interventions to improve service delivery and enact the essential characteristics of highly reliable organisations (HRO).

A realist approach involving an exploratory hospital case study using user feedback from an IT patient feedback platform. The methodology included interviews, secondary data and access to thousands of patient feedback narratives.

The findings show that a systems approach to the supply chain, using real-time feedback to enact process improvement is beneficial and a fruitful source of innovation for professional services staff. The setting of the improvement focusses on a true “voice of the customer” rather than attempting to improve arbitrarily internal process efficiency has major benefits for staff and their engagement with the right interventions to support higher performance.

The findings show major positive benefits for the adaptation and constant reflection of staff on the service provided to patients. The approach provides a means of reflecting as to whether the current supply chain and service provision are fit for purpose, as well as reliable, efficient and of value to the consumer.

This study is one of a few that adopt the consumer orientation needed to fully exploit the concepts of patient-centric improvement by including dynamic feedback in the supply chain and systems approach to care.

The EFQM model for organisational excellence is used in the health care sector as a tool to diagnose and assess the starting position for an effective QM programme. Feedback reports cover the fields of acute medical care, rehabilitation and ambulant care and contain strengths areas for improvement. Building on the EFQM feedback reports, the Modular Concept for Quality in Health Care (“Heidelberg Model”) improves QM both holistically and specifically by implementing so‐called “Modules for Excellence”. The implementation process follows principles of project management covering medical, nursing and managing issues and the performance is periodically evaluated against targets. QM projects that are designed in the dichotomic way follow three goals. Organisational diagnosis and therapy lead to numerical health care improvements in “Prevention of nosocomial infections” and “Optimising out‐patient treatment”. Different assessment approaches lead to a diagnosing feedback report for QM in health care. The Modular Concept for Quality in Health Care (“Heidelberg Model”) clusters, prioritises, implements and evaluates the organisation’s key areas for improvement.

Continuous quality improvement (CQI) programmes have been taken up widely by indigenous primary health care services in Australia, but as yet there has not been a systematic assessment of their focus and achievements. A scoping review of the literature from studies of CQI in indigenous primary health care services was undertaken to explore impacts on service systems, care and client outcomes with the aim of providing guidance on future evaluation efforts. The paper aims to discuss these issues,

Searches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews to December 2016 and handsearching of key websites and publications. Studies of CQI programs or activities in Indigenous primary health care services which demonstrated some combination of CQI characteristics, as described by Rubenstein (2013) were included. A two-stage approach to analysis was undertaken. Stage 1 identified the range and scope of literature, and Stage 2 investigated impacts to service systems, care and client outcomes. The Framework for Performance Assessment in Primary Health Care was used to frame the Stage 2 analysis.

The majority of Aboriginal community controlled health services have been involved in CQI but there are gaps in knowledge about uptake in general practice and government clinics. There are as many baseline studies as studies on impacts over time. Of the 14 studies included for further analysis, 6 reported on impacts on service systems; all 14 reported on impacts on care and 6 on client outcomes. Changes to services systems are variable and studies of impacts on care and client outcomes show promising though uneven improvements. There are no economic studies or studies addressing community engagement in CQI activities.

To supplement existing limited knowledge about which service system change strategies are effective and sustainable for which problems in which settings, there needs to be investment in research and development. Research needs to be grounded in the realities of service delivery and contribute to the development of CQI capacity at the service level. Knowledge translation needs to be built into implementation to ensure maximum benefit to those endeavouring on a daily basis to constantly reflect on and improve the quality of the care they deliver to clients, and to the stewardship structures supporting services at regional, state/territory and national levels.

Improved approaches, methods, data capture and reporting arrangements are needed to enhance existing activity and to ensure maximum benefit to services endeavouring to reflect on and improve quality of care and to the stewardship structure supporting services at regional, state/territory and national levels.

Although there is a growing body of research evidence about CQI both nationally and internationally, and considerable investment by the federal government in Australia to support CQI as part of routine practice, there has not been a systematic assessment of the achievements of CQI in Indigenous primary health care services. Many unanswered questions remain about the extent of uptake, implementation and impacts. This is a barrier to future investment and regional and local programme design, monitoring and evaluation. The authors conducted a scoping review to address these questions. From this, the authors draw conclusions about the state of knowledge in Australia with a view to informing how future CQI research and evaluation might be intensified.

The purpose of this paper is to describe a quality improvement collaborative conducted in 33 Nigerian facilities to improve maternal and newborn care outcomes by increasing compliance with high‐impact, evidence‐based care standards. Intervention costs and cost‐effectiveness were examined and costs to the Niger Health Ministry (MoH) were estimated if they were to scale‐up the intervention to additional sites.

Facility‐based maternal care outcomes and costs from pre‐quality improvement collaborative baseline monitoring data in participating facilities from January to May 2006 were compared with outcomes and costs from the same facilities from June 2008 to September 2008. Cost data were collected from project accounting records. The MoH costs were determined from interviews with clinic managers and quality improvement teams. Effectiveness data were obtained from facilities' records.

The average delivery‐cost decreased from $35 before to $28 after the collaborative. The USAID/HCI project's incremental cost was $2.43/delivery. The collaborative incremental cost‐effectiveness was $147/disability‐adjusted life year averted. If the MoH spread the intervention to other facilities, substantive cost‐savings and improved health outcomes can be predicted.

The intervention achieved significant positive health benefits for a low cost. The Niger MoH can expect approximately 50 per cent return on its investment if it implements the collaborative in new facilities. The improvement collaborative approach can improve health and save health care resources.

This is one of the first studies known to examine collaborative quality improvement and economic efficiency in a developing country.

This paper aims to compare and contrast quality improvement in the domain of health care disparities with quality improvement in other domains.

The author provides a descriptive essay and review to put forward the findings of their research.

In the USA, health care quality improvement systems have largely been accepted and institutionalized. Most if not all hospital and health care systems now have quality monitoring and improvement teams. In contrast, despite a plethora of stark reports in the literature showing that the US health care system has failed to deliver health care with equity when the care of Whites is compared with that of racial and ethnic minorities, there is not a parallel health care disparities improvement system in most health care settings.

Paralleling many steps that have been taken to improve quality in general, health care workers and health systems must take steps to improve structures and processes of care to reduce health care disparities.

Pinpoints some important distinctions between improving structures and processes of care related to health care disparities, and those related to other aspects of quality improvement. Doing so will save lives, and in the process improve overall quality.

The importance of culture is often emphasized for continuous learning and quality improvement within health care organizations. Limited empirical evidence for cultivating a culture that supports continuous learning and quality improvement in health care settings is currently available.

The purpose of this report is to characterize the evolution of a large division of physical therapists and occupational therapists in a pediatric hospital setting from 2005 to 2018 to identify key facilitators and barriers for cultivating a culture empowered to engage in continuous learning and improvement.

An ethnographic methodology was used including participant observation, document review, and stakeholder interviews to acquire a deep understanding and develop a theoretical model to depict insights gained from the investigation.

A variety of individual, social, and structural enablers and motivators emerged as key influences toward a culture empowered to support continuous learning and improvement. Features of the system that helped create sustainable, positive momentum (e.g., systems thinking, leaders with grit, and mindful design) and factors that hindered momentum (e.g., system uncertainty, staff turnover, slow barrier resolution, and competing priorities) were also identified.

Individual-level, social-level, and structural-level elements all influenced the culture that emerged over a 12-year period. Several cultural catalysts and deterrents emerged as factors that supported and hindered progress and sustainability of the emergent culture.

Cultivating a culture of continuous learning and improvement is possible. Purposeful consideration of the proposed model and identified factors from this report may yield important insights to advance understanding of how to cultivate a culture that facilitates continuous learning and improvement within a health care setting.