Ten Quality Improvement

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Chapter
Ten Quality Improvement

Initiatives to Standardize
Healthcare Processes
Mohammed M. Albaadani, Adel Omar Bataweel,
Alaa Mahmoud Ismail, Jameelah Mohammed Yaqoob,
Ebrahim Sarwi Asiri, Hesham Ahmed Eid,
Khaled M. Kasasbeh, Mohamed Fathy Shaban,
Nasr Ali Mohammed, Samir Mohammed Bawazir,
Siham Mohammed Saleh and Yasser Sami Amer
Abstract
Quality improvement is a continuous journey to standardize healthcare processes

and structure to reduce variation, achieve predictable results, and improve outcomes
for patients, healthcare systems, and organizations. Improving quality is about making
health care safe, effective, patient-centered, timely, efficient, and equitable. It’s about
giving the people closest to problems affecting care quality the time, permission, skills,
and resources they need to solve them. Patient safety it’s a fundamental principle of
excellent patient care. On the other hand, patient safety it’s a fundamental principle of
excellent patient care. Patient safety also is one of the key components of the Institute
of Medicine’s (IOM) six domains of healthcare quality (Safe, Timely, Effective,
Efficient, Equitable, and Patient-centered) that is used as a metric to evaluate how safe
is the practice. This work aims to highlight the main quality improvement initiatives,
and tools used to standardize healthcare processes and improve patient safety.
Keywords: patient safety, variation, performance improvement, quality initiatives,

standardization, patient outcomes, continuous quality improvement
1. Introduction
The healthcare system is designed to produce health, but it may do the opposite
and cause harm. There are many factors influencing the likelihood of error. These
factors include medical device design, the volume of tasks, the unity and clarity of
guidelines and policies, the behavior of others focusing on strategies that maximize
the frequency of things going right, the dependency of healthcare providers on one
another, the diversity of patients, clinicians and other staff, the vulnerability of
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Contemporary Topics in Patient Safety – Volume 3
patients, variations in the physical layout of clinical environments, variability or lack

of regulations, implementation of new technology, the diversity of care pathways
and organizations involved [1, 2]. These factors not only increase the vulnerability
of patient harm but also make the healthcare system very complex and chaotic.
Therefore, there is an urgent need for feasible solutions to cope with these challenges
and standardize healthcare processes, making the health system safe, effective, and
more efficient. Quality improvement initiatives play a key role in enhancing the
quality of processes in hospitals and improving patient safety outcomes. By imple-
menting evidence-based practices and clinical guidelines, healthcare organizations
can ensure that patients receive appropriate and effective therapies that are tailored to
their individual needs [3]. Quality improvement is defined as a systematic approach
that is guided by data to improve health services and the quality of care and outcomes
for patients based on iterative change, continuous testing and measurement, and
empowerment of frontline teams [4]. It is also defined as the monitoring, assessing,
and enhancement of quality healthcare standards as well as the implementation of
a series of rigorous, systematic, organization-wide processes that result in measur-
able improvement in healthcare services [5]. On the other hand, continuous quality
improvement (CQI) is defined as a progressive incremental improvement of processes,
safety, and patient care [6]. The concept of CQI originated in Japan after World War
II and was used extensively in the industrial and manufacturing sectors and has been
utilized in the health sector [7, 8]. Over several years, continuous quality improvement
has evolved rapidly, and many methodologies have been developed to guide organiza-
tions toward streamlining their processes, reducing waste, and improving efficiency.
There are many quality improvement tools and approaches which include clinical
audit; Plan, Do, Study, Act; model for improvement; LEAN/Six Sigma; performance
benchmarking, process mapping, and statistical process control [9].
2. Methodology
For this chapter, we conducted thorough research using a comprehensive literature

search approach. We explored internet-based bibliographic databases such as Google™
Scholar and PubMed, as well as direct websites of reputable peer-reviewed jour-
nals, books, training courses, programs, and reference websites Joint Commission
International (JCI), International Society for Quality in Healthcare (ISQua), and
Institute of Healthcare Improvement (IHI) related to healthcare quality, safety, and
improvement research. Our specific search terms included but were not limited to
“patient safety,” “healthcare quality,” “health care quality,” “evidence-based healthcare,”
“quality improvement,” “improvement research,” “implementation research,” “quality
of health care,” “practice guidelines,” “clinical audit,” “accreditation,” “care bundles,”
“patient care bundle” “continuous quality management,” “management, total quality,”
and “education.” Initially, we found 230 results and refined our reference list to approxi-
mately 150 highly relevant to our chapter’s focus. Further screening excluded resources
not aligned with the scope, resulting in a final list of 65 citations included in this chapter.
3. What is variation?
Since this chapter seeks to provide some tools to reduce variation that could
affect the outcome of provided care services, it is very important to shed light on this
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Ten Quality Improvement Initiatives to Standardize Healthcare Processes
DOI: http://dx.doi.org/10.5772/intechopen.1004229
concept. Variation means deviation from the norm. In clinical practice, variation
means differences in healthcare processes or outcomes, compared to peers or a gold
standard such as an evidence-based guideline recommendation [10]. Variations in
healthcare are wide-ranging and can include an array of different treatment options,
diagnostic procedures, and medication dosages. Variation is not necessarily bad, and
it can be good as long as it occurs within certain parameters. Clinical variations can be
either warranted or unwarranted. Warranted clinical variation is essentially unavoid-
able, as all doctors, nurses, and other practitioners have a different understanding or
insight into a particular problem and utilize different protocols of problem manage-
ment. On the other hand, unwarranted clinical variation is about the overuse or unde-
ruse of certain therapies, treatments, or diagnosis materials in a way that potentially
hurts patient outcomes or the sustainability of the health system. The second type of
variation is much more problematic in healthcare practice because it can increase the
vulnerability to errors [11].
4. Sources of variation
The major sources of variation can be grouped into two major classes: common
cause variation also called random variation which can happen in stable processes and
special cause variation which is mainly seen in unstable processes. Both types will be
explained later.
5. Contributing factors of the variability of health care
The variability in clinical care practice often stems from two separate issues [12]:
1. Operational variability refers to differences in care delivered directly by different

involved in the patient care process. While each provider delivers care based on
his/her understanding of the patient’s diagnosis and treatment plan, this can lead
to significant differences in the way of delivering patient care.
2. Knowledge variability refers to differences in expertise among medical staff. This

type of variability is often difficult to assess because it’s based on an individual
provider’s educational and experience level.
In this chapter, we will try to highlight the top-quality improvement initiatives

that have significant roles in standardizing healthcare processes, reducing variation in
clinical practice, and achieving predictable results, for patients, healthcare systems,
and organizations. These initiatives include:
1. Clinical practice guidelines and pathways
2. Policies and procedures (P&Ps)
3. Data-driven performance
4. The 5S methodology
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5. High 5s project
6. Clinical audit
7. Quality of thinking
8. Education and training
9. Accreditation process
10. Care bundles
6. Clinical practice guidelines and pathways
6.1 Background
Clinical practice guidelines (CPGs) and integrated care pathways (ICPs) play a
vital role in modern healthcare by providing a framework for standardizing medical
practices and improving the quality and safety of patient care. These evidence-based
tools offer healthcare professionals a structured approach to clinical decision-making,
ensuring that patients receive the most effective and appropriate care. This article
explores the significance of CPGs and ICPs in enhancing healthcare outcomes, quality
improvement, and patient safety.
Clinical practice guidelines (CPGs) are systematically developed, evidence-based
recommendations and statements that guide healthcare professionals in making
informed decisions about the most appropriate healthcare interventions for specific
clinical situations or conditions. CPGs are typically founded on a comprehensive
review of the best available medical evidence, expert consensus, and the consider-
ation of patient values and preferences. They aim to standardize and improve the
quality of healthcare by providing a structured framework for clinical decision-
making, diagnosis, treatment, and patient management [13].
Integrated care pathways (ICPs), also referred to as care pathways or clinical
pathways, are multidisciplinary plans of care that outline the essential steps, activi-
ties, and interventions required for the effective management of patients with
specific medical conditions, across the entire continuum of care. ICPs are designed to
promote collaboration among healthcare professionals from various disciplines and
ensure a seamless and coordinated delivery of care. They often incorporate CPGs and
evidence-based practices into a structured framework that helps optimize patient out-
comes, streamline healthcare processes, and enhance patient and caregiver engage-
ment. They are also considered one of the main types of CPG implementation tools
[14, 15]. ICPs are particularly valuable for managing complex or chronic conditions
by outlining the most appropriate care trajectories and facilitating communication
and continuity of care among healthcare providers.
6.2 Evidence-based medicine and CPGs
Evidence-based medicine (EBM) is of paramount importance in healthcare as

it ensures that clinical decisions and interventions are grounded in the best avail-
able scientific evidence. EBM promotes the rational, efficient, and patient-centered
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delivery of care by systematically integrating rigorous research findings with clinical

expertise and patient values and preferences. It enhances the quality and safety of
healthcare, reducing variations in practice and minimizing the potential for risk or
harm. By adhering to EBM principles, healthcare professionals can optimize diag-
nostic accuracy, and treatment outcomes, reduce unnecessary interventions, and
allocate resources more effectively, ultimately leading to improved patient outcomes,
increased patient satisfaction, and the continuous advancement of medical knowl-
edge and practice [13].
EBM forms the foundation of contemporary and modern healthcare. CPGs and
ICPs are essential tools to apply EBM and Evidence-Based Healthcare in general, as
they translate the latest research findings into practical recommendations for clinical
practice and serve as a bridge between research and patient care.
One of the primary roles of CPGs and ICPs is to standardize care across healthcare
settings which in turn leads to greater consistency, integration, and predictability in
healthcare delivery. When healthcare professionals follow established CPGs and ICPs,
patients can expect a uniform level of care, reducing variations and the potential for
errors. This standardization is particularly critical in complex and high-risk areas,
such as surgery and critical care.
6.3 Improving quality and safety of care
Adherence to CPGs and ICPs can significantly enhance the quality of care provided
to patients [16, 17]. By following evidence-based recommendations, healthcare
providers can optimize treatment plans, reduce complications, and achieve better
patient outcomes. CPGs help identify best practices, allowing healthcare institutions
to measure and improve their performance continuously.
Patient safety is a paramount concern in healthcare, and CPGs and ICPs contribute
significantly to minimizing risks. CPGs have a significant role in aiding the identifica-
tion and mitigation of potential errors and adverse events [15, 18]. They guide infec-
tion control, medication management, and other critical aspects of patient safety,
ultimately reducing the likelihood of harm.
Moreover, by promoting efficient and effective care, these tools can lead to cost
savings for healthcare systems that further highlight the economic benefits of using
CPGs and ICPs. Standardized approaches reduce unnecessary procedures, hospital
readmissions, and complications, resulting in better resource allocation and improved
cost-effectiveness.
6.4 Challenges in guideline and pathway implementation
Implementing CPGs and their ICPs in healthcare settings faces several challenges
[15, 18, 19]. The complexity of CPGs, varying levels of the quality of evidence, and
the need for adaptation to local contexts (i.e., contextualization) can hinder effective
implementation. Additionally, healthcare professionals may experience information
overload, leading to difficulty in staying updated with numerous CPGs for the same
health topics. Barriers to adoption include resistance to change, lack of awareness, and
limited time and resources. Strategies to overcome these barriers involve engaging all
relevant stakeholders in CPG development or adaptation, providing regular training,
involving quality and clinical champions, regular audits and feedback, involving
patients, and integrating CPGs into clinical workflows and ICPs. Successful mod-
els, such as the use of electronic health records for CPG dissemination and clinical
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decision support through automation or digitalization of CPGs and ICPs, have shown
positive impacts on patient care by improving adherence to evidence-based practices.
6.5 Future, innovations, and the way forward
The landscape of CPGs and ICPs is evolving with advances in technology and
methodology. As healthcare moves toward more dynamic, real-time decision-making,
the development and dissemination of CPGs are increasingly incorporating sophis-
ticated data analysis and digital platforms. This evolution is aimed at ensuring that
guidelines are current, evidence-based, and readily accessible to healthcare profes-
sionals, especially with emerging concepts like living CPGs, living systematic reviews,
and living sphere evidence [17].
Emerging technologies, such as machine learning and natural language process-
ing, are revolutionizing the way CPGs are developed and disseminated. These tech-
nologies facilitate the analysis of large datasets to identify patterns and trends, which
can inform CPG development. Additionally, digital dissemination platforms, includ-
ing mobile apps and online portals, are making it easier for healthcare providers to
access and apply guidelines in clinical practice.
The integration of artificial intelligence (AI) and data analytics is expected to pave
the way for personalized CPG recommendations. AI algorithms can analyze patient
data, consider individual health conditions and preferences, and suggest customized
care plans and pathways. This approach aims to enhance the precision of treatments,
improve patient outcomes, and streamline clinical decision-making processes, usher-
ing in a new era of personalized medicine in CPG implementation.
7. Policies and Procedures (P&Ps)
7.1 Background
Policies are defined by the Joint Commission International (JCI) as rules and
principles that guide and inform the organization’s procedures and processes whereas
a procedure is defined as step-by-step instructions for how a task is performed [20].
Delivery of high-quality healthcare services requires up-to-date policies and proce-
dures that reflect the latest good practice, and ensure compliance with the regulatory
and legislative requirements [21]. In addition to their role in facilitating adherence to
healthcare laws, accreditation requirements, licensing, and certification standards,
clinical teams including doctors, nurses, pharmacists, and other care providers who
are involved in patient care, P&Ps can play a vital role in communicating expectations
and standards to staff, set guidelines for day-to-day operations and improvements,
streamline processes and enhance patient safety [22].
7.2 Why policies and procedures are important?
Policies and procedures are essential components of effective quality improvement

and patient safety programs for the following reasons:
1. Assist in carrying out daily patient care by clarifying the roles and responsibilities.
2. Serve as a unique communication tool between the treatment team.

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3. Unify the practices between multidisciplinary teams and reduce the potential
error rate that could happen due to variations in clinical practice.
4. Improve consistency and accuracy of the clinical process.
5. Guide decision-making process.
6. Protect the organization’s reputation and minimize any potential liabilities.
7. Improve confidence and satisfaction in teamwork.
7.3 General guidance for writing effective P&Ps
All policies and procedures should be written in simple and clear language to make
them comprehensible to everyone. Minimize using abbreviations that could inter-
rupt or confuse the reader. It is recommended to avoid using complex sentences with
multiple clauses that would complicate understanding what the policy is about. They
also must state clearly who does what and articulate the roles and responsibilities of
individuals and departments responsible for carrying out certain duties. Finally, all
P&Ps should be accessible to all teams.
7.4 Types of healthcare P&Ps
Healthcare P&Ps can be divided into five major types [23]:
1. Patient care: is related to all P&Ps that guide clinicians to perform daily and rou-
tine patient care operations in the healthcare practice.
2. Health and safety: any kind of policy that helps staff deal with and handle any
safety and health risks that could arise during patient care.
3. Drug handling and management: all types of policies and guidelines that assist in
handling the medication management cycle transfer, storage, prescribing, prepa-
ration, administration, and so on.
4. Information management: all policies that support proper management of sen-

sitive information inside healthcare facilities. They can include topics such as
confidentiality, security, privacy, integrity of information, and distribution of
medical records. It also includes retention time for patient medical records and
other information
5. Administrative and human resources: it pertains to all policies that deal with re-
cruitment, retention, development, and continuing education of staff.
7.5 Management of P&Ps
Policies and procedures must be developed through a standardized and systematic

process starting by addressing the need for them that could stem from new legal
requirements, and then assembling a multidisciplinary team (owners) that will be
responsible for drafting, reviewing, finalizing, and approving the policy. Before
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implementing the P&PSs, the staff should be familiar with them and this can be
achieved through focused training. Adherence of the staff should be monitored and
any challenges or obstacles during implementation should be raised and fixed by the
quality improvement team. Policies and procedures must be reviewed and updated
periodically to ensure their relevancy and effectiveness.
8. Data-driven performance
8.1 Background
Data is a vital and valuable resource in healthcare, it is like a compass or the

dashboard of the vehicle that serves to monitor its performance and alert the driver
of any problem. In the healthcare field, we use Key Performance Indicators (KPIs)
to track the improvement process (observe, analyze, optimize, and transform a
healthcare process) and to make sure that staff are adhering to the standards of care.
These metrics also can be used to compare (benchmarking) the organization’s perfor-
mance to other similar healthcare facilities and identify areas for improvement [24].
Furthermore, they can help to support the effectiveness and efficiency of clinical
care as well as to enhance continuous performance measurement [25]. Finally, these
metrics can enable informed decision-making based on actual healthcare delivery
models, for example, healthcare practitioners and leaders can use accurate, valid,
reliable, timely, relevant, legible, and complete data to proactively adjust the clinical
course of treatment for individual patients [26, 27]. Performance indicators should
not be seen as a quality improvement tool that will provide feasible solutions for how
to fix the performance problems, they act only as diagnostic means and trigger the
organization for any deviation in their process’s performance.
8.2 Sources of data
There are many sources for getting data either internal sources within the
healthcare facility or external from accreditation, government, semi-government,
non-profit patient advocacy, and commercial organizations in the field. The data
collected from internal sources assist in regularly evaluating the performance of
healthcare processes whereas the data used from external sources facilitate compar-
ison with other organizations in the same field and have a similar scope of services
as well as assist in setting performance targets. Table 1 shows the main sources
of data.
8.3 Performance indicators
Performance monitoring is a continuous process that involves collecting data to

determine if a service is meeting desired standards or targets [27]. Key Performance
Indicators (KPIs) are well-defined performance measures that are used to observe,
analyze, optimize, and transform a healthcare process to increase satisfaction for
both patients and healthcare providers alike. These metrics are commonly used by
care facilities to compare their performance to other care facilities and identify areas
for improvement [24]. The performance measures are formulated either based on
standards determined through evidence-based academic literature or the consensus
of experts when evidence is unavailable [27].
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Internal sources External sources
• Occurrence reports/summaries • National registry reports

• Ongoing quality measurement • Communicable Disease Control (CDC) reports
• Surveys, interviews, questionnaires • Research projects/literature (e.g., MEDLINE)
• Direct observation (clinical audit, • Clinical protocols, guidelines, and practice parameters
walkarounds) (medical colleges and boards)
• Clinical records, reports/profiles (phar- • National Guideline Clearinghouse
macy, lab, blood bank, etc.)
• International library of measure
• Infection control reports
• Accreditation bodies reports
• Regulatory and accreditation reports
• Clinical review findings
• Incident reporting system
Table 1.
Source of data.
8.4 Type of performance indicators
According to the Donabedian model, performance indicators are divided into

three types structure, process, and outcome:
1. Structure measure: it evaluates the context in which healthcare is delivered from

two aspects: the capacity of the physical settings (buildings, staff number, cost
per unit, and used equipment, medicines, and systems) and the capabilities of
care providers (staff qualifications, training, and competencies).
2. Process measure: it reflects the way health systems and processes work to deliver
the desired outcome by applying specific actions that are consistent with profes-
sional standards of care and evidence-based guidelines for diagnosis.
3. Outcome measure: it refers to the effects or the outcome of healthcare such as

reduced morbidity and mortality, reduced length of stay, reduced hospital-ac-
quired infections, adverse incidents or harm.
8.5 Balancing measure
Balancing measure is another type of measure that aims to look at a system from
different directions/dimensions. Any changes designed to improve one part of the
system should not cause new problems in other parts of the system. For example, for
reducing the time patients spend on a ventilator after surgery we must make sure that
the reintubation rates are not increasing.
8.6 What is a benchmark?
Benchmark refers to a point of reference that is used to evaluate the performance

or quality of something. It is a standard or a set of criteria against which something
can be measured or compared [28]. Benchmarking can be conducted internally by
comparing the performance of specific processes with similar processes in different
9
areas of the same organization. For example, comparing ventilator-associated pneu-

monia (VAP) rates in different medical intensive care units (ICUs). It can be done also
externally (locally, nationally, or internationally); within healthcare organizations of
similar size and scope, against medical practice literature, or through participation in
national or international databases. Whether internal or external benchmarking the
ultimate aim is to provide clinicians with valuable information that guides them in the
decision-making process.
8.7 Process variation
Variation refers to the lack of uniformity and difference in the performance of the
process compared to the acceptable performance of peers. In clinical practice, clinical
variation can drive poor care quality, wasted resources, and lead to excessive cost of
services [29].
8.8 Types of process variations
There are two types of process variations common cause variation and special
cause variation. Table 2 shows the main differences between them [30].
9. 5S methodology
9.1 Background
The 5S methodology is identified as one of the most common lean management

tools used not only to improve the workplace environment but also to improve the
functional aspects of the process. 5S was developed in Japan and used by Toyota [31].
The 5S methodology is also called lean and it is composed of five Japanese words
Seiri, Seiton, Seiso, Seiketsu, and Shitsuke, which means sort, set in order, shine,
standardize, and sustain. 5S methodology is a set of actions that need to be conducted
systematically in a sequence order one after the other with the full participation of staff
responsible for the process and it should be repeated continuously [32]. The 5S meth-
odology can benefit any organization that is genuinely committed to becoming less
Common cause variation Special cause variation
Caused by natural or ordinary causes Caused by non-ordinary and unnatural causes
Inherent to system or process. Non-inherent to the process design.
Predictable Unpredictable
Affects all the outcomes of a process Affects some but not necessarily all aspects of the
process.
Result in a stable process Result in unstable process
develop and test ideas that might result in Require investigation of the underlying causes of
improvements to the process and system. variations and take correct actions to fix it.
Source: ©2023 Institute for Healthcare Improvement. Used with permission.
Table 2.
Types of process variations.
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wasteful, more efficient, and keen on enhancing safety, establishing goals, and stream-
lining the workflow of the process [33]. Table 3 shows the general principles of 5S.
To facilitate the application of 5S and avoid fall back of the first 3S and conse-
quently long-term implementation for the whole methodology, it is recommended to
divide it into two phases, the initial phase focuses on the achievement of the first 3S
(Sort, Set, and Shine), and the second phase focuses on the last 2S (Standardize and
Sustain) [32]. In the context of healthcare quality improvement, the 5S methodology
has been recognized as one of the lean-quality improvement tools and it was used
to maximize added value by removing all unnecessary factors that do not generate
value [34]. The method had a great impact on the promoting of healthcare services
effectively, and increased staff motivation in healthcare facilities where resources
are scarce and prevailing of other demotivating factors [35, 36]. On the other hand,
applying 5S can enhance patient safety by reducing the rate of errors, improving the
efficiency of healthcare services, reducing waiting time, and creating a safer and
more organized environment for patient care.
9.2 Scope of using 5S in healthcare practice
The 5S methodology can be applied widely in healthcare practice. It can be used,

for example, in the following areas:
1. Error reporting systems: implementing robust systems for reporting and track-
ing errors, near misses, and adverse events can help identify potential risks and
prevent future occurrences.
2. Medication reconciliation: developing thorough processes for reconciling a pa-

tient’s medication history is essential to avoid adverse drug events and ensure
accurate and safe medication administration.
3. Fall prevention programs: implementing protocols to assess and minimize fall

risks for patients, especially those with mobility issues, can prevent injuries and
improve safety.
4. Standardized protocols: developing standardized protocols for various procedures

and care processes, such as surgical checklists and hand hygiene protocols, can
improve consistency and reduce errors.
Japanese English What is it about?
Seiri Sort Eliminate unnecessary items and tools from the workplace area.
Seiton Set Arranging items in the workplace area logically and efficiently.
Seiso Shine Clean the workplace area to maintain a safe environment.
Seiketsu Standardize Standardize the best practices in the workplace area right after implementing the
first 3S.
Shitsuke Sustain Make the already-developed processes part of the practitioner’s daily routine
(self-discipline).
Table 3.
General principles of 5S methodology.
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5. Patient identification protocols: implementing strict protocols for patient identi-

fication, especially before administering medications or performing any proce-
dures, can mitigate the risk of errors.
9.3 Example for applying the 5S in healthcare practice
The 5S methodology can be applied in clinical areas as follows:
1. Sort: this involves removing unnecessary items from the clinical and operational
areas in the hospitals to eliminate clutter and improve efficiency. In healthcare
settings, this can help ensure that essential patient care items are easily accessible
while reducing the risk of errors caused by confusion or clutter, putting in con-
sideration removing the extra unnecessary equipment and supplies will decrease
the chance of mistakes in utilizing the wrong supplies.
2. Set in order: in patient care areas, this can involve organizing medical supplies
and equipment in a standardized and consistent manner, making it easier for
healthcare providers to find what they need quickly and reducing the potential
for error.
3. Shine: in healthcare, this S is a crucial part of infection control programs. By

maintaining a clean and safe environment, the risk of patient harm due to con-
taminated surfaces or equipment will be reduced. If the clinical area is carefully
inspected and all old notices, posters, broken equipment, and unused machines
are removed from the area, the potential hazards and risks can be identified eas-
ily [37]. Shining can be expanded to include cleaning all types of equipment that
are under use like computers, keyboards, monitors, tables, etc. Cleaning should
be conducted periodically with the full participation of all the staff in the area.
Using a simple cleaning checklist can improve the execution of this phase as well
as assist the CQI and the infection control department in the tracing process [32].
4. Standardize: after implementing the first three 3S’s, the next step is to standard-
ize care processes to ensure the consistency and reliability of the care provided to
patients. This S involves creating standardized protocols for handling daily clini-
cal tasks such as medication administration process, patient handoffs, preven-
tion of patient falls, and other critical care processes to minimize any potential
for errors and harm.
5. Sustain: this may involve ongoing training, regular audits, and continuous im-
provement efforts to ensure that patient safety remains a top priority. To ensure
this phase, it is recommended to link this S with a group of Key performance
measures, in which any trend or special variation can be triggered quickly.
10. The high 5S project
10.1 Background
Without a doubt, patient safety has gained considerable global attention and
focus from health leaders, researchers, healthcare providers, and business and
12
management development organizations. It is a fundamental principle of high-quality

patient care [38]. The safety of patients has been incorporated into many healthcare
delivery models developed by various healthcare organizations, for example, is a key
component of the Institute of Medicine’s (IOM) six domains of healthcare quality,
which are abbreviated as STEEEP (Safe, Timely, Effective, Efficient, Equitable, and
Patient-centered).
Furthermore, it is one of the key indicators and measures used to assess the safety
of healthcare practices. Patient safety is defined by the World Health Organization
(WHO) as the absence of preventable harm to a patient and the reduction of risk of
unnecessary harm associated with health care to an acceptable minimum [39]. Within
the context of a broader health system, patient safety is a framework of organized
activities that creates cultures, processes, procedures, behaviors, technologies, and
environments in health care that consistently and sustainably lower risks, reduce the
occurrence of avoidable harm, make the error less likely and reduce the impact of
harm when it does occur [39]. The WHO had declared and adopted several important
patient safety initiatives, to urge and guide member states, particularly in low- and
middle-income countries with fragile health systems to focus and prioritize patient
safety as one of the most important components of healthcare delivery through publi-
cations, capacity building, education, campaigns, tools, and relevant conferences [40].
Clean Hand is Safer Care, Safe Surgery Saves Lives (surgical safety checklist),
Patient Safety research, anti-microbial Resistance, and the multi-professional patient
safety curriculum guide, Global Patient Safety Collaborative (GPSC), and Medication
without Harm are among the WHO global Patient safety initiatives [40]. The 5 s proj-
ect was another WHO patient safety initiative, and it will be the focus of this section.
10.2 What is the high 5s project?
The high 5s project is one of the important global patient safety initiatives that was
launched by the World Health Organization (WHO) in 2006. It aims to address con-
tinuing major concerns about patient safety around the world as well as to facilitate
the implementation and evaluation of standardized patient safety solutions within a
global learning community to achieve measurable, significant, and sustainable reduc-
tions in challenging patient safety problems [41].
10.3 Scope of the 5s project
The five major components of the High 5s project are:
1. Develop and implement Standardized Operating Protocols (SOPs)
2. Create an impact evaluation strategy.
3. Collect, report, and analyze validated data.
4. Develop a collaborative learning community.
5. Disseminating learned lessons globally.
There are five SOPs and associated evaluation instruments were developed
between 2007 and 2009 to address the following challenges: Medication Accuracy at
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Transitions in Care, Correct Procedure at the Correct Body Site, Use of Concentrated
Injectable Medicines, Communication During Patient Care Handovers, and Health
Care-Associated Infections [42].
10.4 Attributes of the high 5s project
There are two unique features of the high 5s project which are [42]:
1. Standardization is the process of developing, agreeing upon, and implementing

technical or uniform specifications, criteria, methods, processes, designs, or
practices that can increase compatibility, interoperability, safety, repeatability,
and quality. Process standardization is the specification and communication of
a process at a level of detail sufficient to permit consistent and verifiable imple-
mentation by different users at different times and in different settings. Stan-
dardization can reduce variation and minimize the tendency of process failure.
It also enables shared learning, facilitates multi-disciplinary teamwork, and
improves efficiency in interactions by establishing optimum conditions.
2. Evaluation: the high 5s project evaluation approach addresses the impact mea-
surement challenge from different perspectives, including qualitative data collec-
tion regarding the SOP implementation experiences, quantitative performance
measurement results, event analysis, and organization culture assessment. These
methods were used to assess the feasibility and impact of implementing stan-
dardized patient safety protocols.
11. Clinical audit
11.1 Background
Audit is a Latin word that means to hear [43]. Clinical audit was defined by the
National Institute for Health and Clinical Excellence (NICE) as a quality improve-
ment process that seeks to improve patient care and outcomes through a systematic
review against explicit criteria and the implementation of change [44]. It is also
defined as a process that seeks to identify where improvements can be made within
healthcare services by measuring them against evidence-based standards [45].
11.2 Audit vs. quality improvement
As we mentioned before in this chapter, quality improvement (QI) is a sys-

tematic approach that is used to study whole processes (clinical and non-clinical)
formulating healthcare systems unlike clinical audit it is mainly clinically oriented.
Although the auditing process is quite longer than some quality improvement
approaches like PDSA and it can take months till completed, both tools have the
same goal which is to look at the current status of healthcare standards and think
how they could be improved. On the other hand, the scope of the audit is broader
than QI approaches, it can be conducted on a small scale, for example, auditing a
specific process in the hospital, or auditing the whole level of care (Primary Care,
Home Care, and a group of Hospitals (trust) and or it can be carried out at national
level (national clinical audits).
14
11.3 What is clinical audit
The audit is one of the key quality improvement measures as well as one of the
main pillars of clinical governance and it allows healthcare organizations to continu-
ally work toward improving the quality of care and optimizing patient safety by
showing them where they are falling short allowing them to implement the required
improvements and repeat the cycle to assess the effectiveness of implemented change
[46]. The main goal of clinical audits is to facilitate the process of quality improve-
ment because that will be very beneficial and will lead to improved outcomes for
patients. Clinical audits can look at care at a national level (national clinical audits)
and local clinical audits can also be carried out locally in trusts, hospitals, or primary
care practices wherever healthcare is provided.
11.4 The cycle of clinical audit
There are six stages of the commonly accepted audit cycle, and each stage is
detailed as follows [46]:
1. Choose the audit topic (identify problem) for example, patients waiting too long
in accident and emergency (A&E).
2. Defining standards/criteria, for example, guidelines recommend that 95% of

patients should wait <4 hours.
3. Collect data, for example, record over a week how long patients wait (determin-
ing that 92% wait for <4 h).
4. Analysis, for example, 92% versus 95% target, areas for improvement.
5. Implementing change, for example, an action plan to help reach the target.
6. Reaudit, for example, do steps 1–5 again until reaching the target then set the
required measures to sustain gained change.
11.5 Audit vs. research
Clinical audit and research can overlap with each other in clinical practice and it is
very important to recognize the differences between them. Table 4 explores the key
differences between these two tools:
11.6 Barriers and enablers factors for effective audit
There are many factors that can influence for conducting a good audit, these
include lack of expertise, inadequate data due to lack of documentation or record
keeping, auditing being conducted subjectively and not based on proven standards,
lack of leadership support, and scarcity of resources due to limited budgets. Quality
of feedback also can limit the benefits of the change that would be brought from the
audit. In contrast, performing an effective audit requires training, allocating the time
for the staff, and having a reliable source of data like electronic health records, an
information technology system that bridges the gap between routine collected data
and auditing as well as the independence of the clinical auditor.
15
Clinical audit Research
It is a continuous cycle of improvement It is a systematic study
It aims to: It aims to:

• Measures the effectiveness of health care against • Answer and analyze various questions and occur-
agreed and proven standards of care for high quality. rences in the field of science.
• Take the corrective actions to align the practice with • Develop hypotheses and test their validity.
these standards.
• Enhance the quality of care by producing
• Implement, monitor, and sustain the changes when knowledge on what constitutes best practice to
indicated. inform the guidelines
Tell us where we are doing it. Discover what should doing
Table 4.
Key differences between clinical audit and research.
12. Quality of thinking
One of the quality definitions is doing the right thing right. However, the right thing
is not determined by quality per se but on a higher level like strategic planning may be
doing our tasks right and free of flaws or harm. Healthcare services can extend beyond
just being safe care to be timely, effective, efficient, equitable, and patient-centered.
Therefore, safety is the number one priority as the patient should not add more
negative health issues than what they already have. Additionally, they need to be
treated for what they came for promptly, with an effective outcome in an efficient
way with the same rights as others and in a nice way. This could be summarized also
in three words devised by IHI (Institute of Healthcare Improvement): be nice to me,
treat me, and do not harm me Figure 1. For this to be achieved there are four factors at
play affecting these dimensions causing less quality of care.
There are four factors of system thinking Patient, Provider, Environment, and
Task, and since we are using an acronym, we might call it PPET for short, Figure 2.
Much work has been put into the environmental factor (sometimes called system
or facility and here it includes all the surroundings from equipment, devices, lights,
flooring, policy & and procedures, pathways, and protocols) as it is believed it will
fail the provider from doing their task right and this is true but proved inadequate as
error rates are on the increase.
Figure 1.
The IHI three principles of care.
16
Figure 2.
Four components of quality thinking.
The patient factor could be out of this chapter’s scope as it needs a complete
chapter on how to communicate well with patients and get the complete information
enabling providers to achieve and reach a proper diagnosis for example.
Task factor is also another important factor where different tasks require different
and higher demands of awareness and mindfulness as in the case of the rule-based
and knowledge-based tasks compared with skill or routine-based tasks. However, the
most important factor that had little attention is the provider factor. Providers could
unintentionally fail to perform their tasks appropriately leading to system failure and
undesirable patient outcomes. Here we want to talk about the quality of the provider’s
thinking in achieving the dimension of Quality STEEEP (Safe, Timely, Effective,
Efficient, Equitable, and Patient-centered).
One would agree that the same task can be done differently by different providers
and even it can be done with variations by the same provider. The same task can be
done incorrectly by certain providers but may be not done by others. Similarly, some
providers will make errors with patients and even not follow the policy and procedure
of the system.
The quality of work or performance is linked and affected by the provider’s think-
ing styles, personality traits, emotional intelligence (EI), and many other intangible
factors like sub-clinical psychopathy when it comes to counterproductive behavior at
the workplace which would compromise patient safety. Therefore, maybe we need to
come up with a new terminology like human internal and external factors to be more
specific so the external factors cover everything outside the provider (e.g., system,
environment, policy & and procedures, patients, tasks, protocols, clinical pathways,
etc.) and internal factors which are intrinsic or brain structure and makeup of
individuals that process internally everything external and produce certain behavior
accordingly.
Organizations should start taking this aspect seriously to understand the varia-
tions among healthcare providers and even within the same service providers to
understand why they behave in certain ways that might expose them to more patient
safety errors and even counterproductive work behavior. For example, the style of
thinking in terms of experiential style (ES, more associated with effect and rapid
response) and rational style (RS, more conscious and analytical) were found to differ
between nurses and physicians. Nurses relied significantly more on ES compared to
physicians and one positive aspect of this is that higher individual scores in ES would
report errors compared to lower ES. However, higher scores in RS were shown to be
linked to lower error rates, but it is better if the individual had higher scores in both
RS and ES to have a real positive effect on lowering clinical errors [47].
17
Another intrinsic factor that affects the quality of work is EI which has many
dimensions. For example, creative thinking was linked to the Sociability factor of the
EI, the higher the score the more creative the person is. Additionally, these factors also
affected the error rate in the person [48]. Another EI dimension that has a positive
impact on the quality of care is self-control where higher scores had significantly safer
quality of care [49].
On the negative side, lower scores in EI are associated with self-harm, and person-
ality disorders that might be harmful to patient safety [49].
Personality traits were shown to predict which individual might be at higher
risk of erring, have negative qualities in the workplace like bullying, and even
how they would care for patient’s needs. Higher scores in the personality trait of
Conscientiousness would lower the risk of clinical errors and in pharmacy staff this
had a positive effect on how pharmacy staff would recommend treatments that are
less likely to cause pain or interfere with the patient’s daily activities hence enhancing
safer care and better quality of patient experience [50].
Agreeableness personality trait had also a positive impact on the quality of
care if the individual had higher scores, however, it has a detrimental effect on the
quality of care from an error rate point of view and provider-patient communica-
tion if the score is low and also it makes the individual at a significantly higher
risk of initiation of bullying and violence. In general individuals with high scores
of agreeableness were found to be friendly, cooperative, and supportive whereas
individuals with low scores tended to be selfish and less caring. Additionally, high
scores in neuroticism were associated with violence, more anxiety, a higher risk of
burnout, and errors [49].
One of the explanations for certain personality traits and EI individuals being
more at risk of lower quality of care from an error point of view, bullying, violence,
less cooperation, and shorter span of attention could be because they tend to be more
anxious than others [51]. Healthcare is a stressful environment of long hours, less
time for proper meals, burnout, lack of sleep, and stressful demands for problem
resolution and patients’ needs. With more anxiety as a normal base for these indi-
viduals then they would feel the stress of work even much more than others. Stress
like this was shown to be associated with a negative effect on the hippocampus and
the amygdala affecting their volume which in turn affects memory, learning, and
accessing information they would be much more emotional and would be caught in a
vicious circle leading them to errors and negative workplace behaviors [52–54].
In conclusion, quality of work depends on external and internal factors surround-
ing the provider which put them at more risk of errors and other negative behavior.
Healthcare organizations must have a holistic approach to quality of care if they want
to reduce harm to patients, staff, and the organization.
13. Education and training
13.1 Background
Training is important in health and social care, to ensure safety for everyone
involved in delivering care and for those receiving it and to maintain the highest
levels of care quality [55]. Quality improvement training programs were defined as
any activity that explicitly aimed to teach professionals about methods that could
be used to analyze and improve the quality of healthcare. In recent years, these
18
programs have grown fast to include ongoing education like workshops, online
courses, collaboratives, and ad hoc training set up to support running specific
improvement projects. This growth in the quality training programs has supported
the participants in improving their knowledge, skills, and attitudes and utilizing
what they have learned in their clinical practice [56]. Education and training can
break down barriers to providing safe care, creating an environment where all
staff learn from error, patients are at the center of care, treated with openness and
honesty, and where staff are trained to focus on patient needs [57]. Quality train-
ing programs can also assist practitioners in complying with local and national
required standards, policies, and practice guidelines and ultimately unifying the
protocols of care.
13.2 How to develop an effective training program?
Developing effective training programs on quality and patient safety requirements

can begin with assessing the existing training needs (gaps: current training and
those required to meet the goal) and this can be done by gathering data from various
sources in the hospital followed by developing the training programs based on the
findings of gap analyses. The source of data includes but is not limited to:
• Key Performance Indicators (KPIs) reports
• Incident reporting system
• Root Cause Analysis (RCA) recommendations
• Accreditation body findings
• Recommendation of quality improvement projects
• Tracing and auditing reports
• Patient safety walk-rounds
• Failure Mode and Effect Analysis (FMEA) recommendations
Table 5 shows some examples of these training programs and their benefits for the
healthcare practitioner.
13.3 Evaluation of training and education process
Training evaluation is an essential component of capacity-building initiatives. It

helps to assess the effectiveness of the training program, identifies areas of improve-
ment, and ensures that the training meets the needs of the participants and that
invested resources in training are being used effectively [57].
Evaluation can be done by one of the evaluation methods such as pre-and
post-training assessments, Kirkpatrick’s Four Levels of Evaluation, CIPP (Context,
Input, Process, Product) model, observation, Surveys, and Questionnaires, or any
other alternative method that is approved by the organization’s education training
department [58].
19
# Education Benefit
1 Data Management It enables the trainer to understand the whole data management process
Process including collection, validation, and analysis as well as tracking the process
performance over time and picking up any deviations.
2 Auditing and Tracing It helps the trainer monitor the adherence of clinicians to the required
Methodologies standards, guidelines, and policies.
3 Performance It assists the trainer in leading the improvement journey by utilizing the right
Improvement quality improvement tools.
Approaches
4 Risk Management Whether is a proactive approach like Failure Mode and Effect Analysis
Approaches (FMEA) or reactive ones like Root Cause Analysis (RCA), the trainer will be
capable of forecasting any potential failure that could happen and any actual
failures already occurred and setting the appropriate risk reduction solutions
5 Standards of Care It provides the trainer with knowledge and skills about the required patient
Requirements care standards and how to meet them through policies, procedures, and
clinical practice guidelines.
Table 5.
Quality training programs.
14. Accreditation process
14.1 Background
Accreditation is about turning the noise of the complex health system into musical
rhythms. According to the International Society for Quality in Healthcare, accredi-
tation is a process “in which trained external peer reviewers evaluate a healthcare
organization’s compliance with pre-established performance standards [59]. In
other words, it’s an approval seal to show to what extent healthcare organizations
are committed to providing safe patient care. Being accredited means the organiza-
tion has met the highest and most excellent standards of care. The Joint Commission
International (JCI) defines a standard as a statement that defines the performance
expectations, structures, or processes that must be in place for an organization to
provide safe and high-quality patient care, treatment, and services [20]. Standards
also are described as the minimum level as the minimum accepted level of practice
and quality. They are also developed in alignment with regulatory requirements,
ensuring that healthcare facilities conform to laws and regulations related to patient
safety. Examples include that healthcare facilities are required to report any medical
equipment-related incidents to the National Food & Drug Authority, and healthcare
providers are not allowed to practice their professions unless the relevant national
regulatory entities license them. A quality management system (QMS), on the other
hand, is a mechanism to ensure that procedures are being carried out in line with
agreed standards and full participation by all staff members [59].
14.2 Accreditation vs. regulations
These two concepts are not identical. Accreditation as mentioned before is an

approval seal to show to what extent the healthcare organizations are committed to
providing safe patient care and it is granted by an independent accrediting body that
20
the organization has met applicable standards and requirements, while regulations
are group of rules that strictly followed, and they enforced by national authorities
and regulators like Ministries of Health, Medical and Nursing counsels, Food Drug
Authorities, etc.
14.3 What are the benefits of accreditation?
Despite the accreditation process emphasizing how healthcare organizations adhere

to applicable standards, the ultimate goal is how continuously improve the healthcare
system and processes. The accreditation can assist the health organizations in:
1. Building up the quality management system (QMS) with required policies,

protocols, procedures, and checklists.
2. Assist in building a quality measurement database.
3. Provide effective comparison with self, and others as well as with best practice.
4. Assisting the organization in developing and disseminating a culture of continu-

ous improvement for all staff.
5. Ensure a safe care environment by reducing the potential risks that could jeopar-
dize care recipients and caregivers alike.
6. Establish an organizational culture of openness, and transparency, speak up, and

learn from past experiences that facilitate improvement initiatives and sustain
change.
7. Assist in Reducing the variations in the clinical practice that could put patient
safety at big risk.
8. Improve the outcomes of healthcare services.
9. Provide a comprehensive framework for healthcare organizations to enhance

patient safety by incorporating best evidence-based practice.
14.4 Accreditation cycle
The accreditation preparation cycle consists of five phases: the first phase is
planning which is about conducting a gap analysis of the current situation to see what
the required documents (what we already have and what we should have). After iden-
tifying the gaps, the next step is to assemble multiple teams to prepare the required
documentation. Then the next phase is to educate and train staff about the required
documents. After that, monitor the compliance of the staff with required docu-
ments by conducting unplanned periodic audits. This cycle should be repeated until
reaching the optimum level of performance. Once the optimum level of performance
has been achieved, the final phase is to maintain this level of practice. Continuous
leadership support, in place-equipped, quality management system, staff vigilance,
and commitment are the key drivers to sustain the gain change.
21
14.5 Standards of patient care
Standards of patient care are those standards related to direct patient-family care.
These standards can vary from one accreditor to another. Below are some examples of
them:
1. Patient care (access, assessment, transition, and continuity of care)
2. Patient safety
3. Medication management
4. Infection control and prevention
5. Anesthesia and surgical
All standards including the care standards are developed with input and informa-
tion from various sources that include [60]:
1. Health care organizations
2. Subject matter experts
3. Scientific literature and industry guidelines
4. Technical Advisory Panels
5. Other key stakeholders
15. Care bundles
15.1 Background
The concept of care bundles has been developed in 2001 by the Institute for
Healthcare Improvement (IHI). A bundle is defined as a set of evidence-based prac-
tices—generally three to five—that when performed collectively and reliably, have
been proven to improve patient outcomes [61, 62]. The Bundle of care is an ongoing
process that’s repeated daily until the patient no longer requires an invasive device or
his or her status has improved. All of the elements of the bundle must be performed
in a sequence of series of steps by one healthcare team within the same time frame to
ensure that clinical improvement occurs. The adoption of ‘care bundles’ can be seen
as a fundamental shift in thinking from the acceptance of some adverse outcomes
as an inevitable result of delivered care to the concept of significant reduction or
even elimination of such adverse outcomes [62]. The theory of care bundles is very
close to the cycle of Deming Cycle of Change Plan, Do, Check, Act (PDCA) where
there is repeated practice as well as careful monitoring for staff compliance with
the care bundle and also the patient outcome to assess the effectiveness. Therefore,
Care Bundles are frequently introduced to clinical practices as components of quality
improvement initiatives [62].
22
15.2 Types of bundles
Care bundles are widely used in clinical practice to manage and prevent certain
health conditions. Table 6 shows the most common types of bundles and the areas
where they can be applied:
15.3 Impact of using care bundles on clinical practice
Care bundles are one of the quality improvement initiatives that enhance the
reliability of the care process which resulted in clinical outcomes improvement.
They have great input on standardizing patient care processes and unifying clinical
practice. In the infection prevention control field, bundles participated in reduc-
ing the negative outcomes that accompany the medical management process like
hospital-acquired infections (HAIs). Antibiotic Care Bundle (ACB), for example,
plays a significant role in implementing the antibiotic stewardship program that
not only improves the proper use of antibiotics and optimizes the course of therapy,
but also goes beyond to slowing the resistance of bacteria, decreasing the length of
stay of patients and ultimately reducing the expenses of health care. Furthermore,
each element of the bundle can be traced to assess the effectiveness of delivered
care hence it provides reliable measures that can be used to see the areas required
improvement.
15.4 Key points to implement successful care bundles
1. To improve effectiveness, bundles of care can be implemented in several

phases: development or adoption, piloting, training, education, auditing, and
feedback.
2. Collected data is used to assess the compliance of the staff or to see how
bundles are effective and should be accessed, have a reliable collection
# Care bundle Where do they apply?
1 WHO Surgical Safety Checklists Surgical theaters
2 Ventilator-Associated Pneumonia (VAP) Intensive care units (ICU’s)
3 Catheter-Associated Urinary Tract ICUs

Infection (CAU-TI)
4 A central line bloodstream infection ICUs

(CLABSI)
5 Peripheral Vascular Catheter (PVC) All clinical area
6 Antibiotic Care Bundle (ACB-Bundle) ICU’s
7 Pressure Ulcer Prevention Care Bundle: All areas of care where a patient is at risk for pressure ulcers.
8 Surgical Site Infection Prevention Bundle ICUs, Surgical departments, isolation wards, etc.
9 Sepsis Care Bundle ICUs, Isolation Wards, and all other areas where patients is
vulnerable to sepsis.
Table 6.
Types of care bundles.
23
measure, validated, and analyzed in due course of time to guide the decision-
making process.
3. Measurement should be accurate, consistent, and ongoing to authentically

reflect hospital practice and, feedback should be delivered frequently (weekly or
monthly if possible) to encourage improvement and sustainability [61].
4. To implement the bundle successfully, each element of the bundle must be

implemented collectively with complete consistency to achieve the most favor-
able outcomes (“all or none” approach) [61].
5. Elements of the care bundle must be concise, simple, and prescriptive and neither
static nor complex and hinder a successful adoption and implementation [63].
6. All of the elements of the bundle must be performed in a sequence by one

healthcare team and within the same time frame.
7. Education, reminders audits, and feedback are the key components for the
implementation of care bundles [64].
8. A flowchart is one of the useful quality tools that can be used to design care
bundles [65].
9. Leadership support and staff commitment are the main success drivers of any
care bundle.
16. Conclusion
Variations in healthcare are wide-ranging and can include an array of different

treatment options, diagnostic procedures, and medication dosages that could jeopar-
dize patient safety. Standardization can reduce variation and minimize the tendency
of process failure. It also can enable shared learning, facilitate multi-disciplinary
teamwork, and improve efficiency in interactions by establishing optimum condi-
tions. Therefore, it is necessary to standardize healthcare processes, reducing varia-
tions in practice and minimizing the potential for risk or harm, this can be achieved
by ongoing training, regular audits, and continuous improvement efforts, using care
bundles, implementing standards of care, and following practice guidelines, policies,
and procedures. And finally, having a dedicated quality culture to implement these
initiatives, and achieve and sustain the desired improvement for the processes and
system is the bedrock of this journey.
Acknowledgements
We thank Allah Almighty who gives me guidance and assistance to complete this
work.
To all our families.
To everyone share their scientific insights and invaluable experiences in the
healthcare improvement field.
24
To our colleagues whom we worked with and enriched our experiences.

And to all those who complete us…without them we are incomplete.
Conflict of interest
We hereby certify that there is not any actual or potential conflict of interest or
unfair advantage at this time, in us providing the offer submission or performing the
services required.
Thanks
We want to express our gratitude to all Intechopen team for their tireless efforts to
guide and help us accomplish this work.
Acronyms and abbreviations
ACB Antibiotic Care Bundle

A&E accident & emergency
AI artificial intelligence
CAU-TI catheter associated urinary tract infection
CDC communicable disease control
CIPP Context, Input, Process, Product
CLABSI Central Line-Associated Blood Stream Infection
CPGs clinical practice guidelines
CQI continuous quality improvement
EBM evidence-based medicine
EI emotional intelligence
ES experiential style
FMEA failure mode and effect analysis
GPSC Global Patient Safety Collaborative
HAIs hospital acquired infections
ICUs intensive care units
ICPs integrated care pathways
IHI Institute of Healthcare Improvement
IOM Institute of Medicine
ISQua International Society for Quality in Healthcare
JCI Joint Commission International
KPIs Key Performance Indicators
NICE National Institute for Health and Clinical Excellence
PDCA Plan Do Check Act
PDSA Plan Do Study Act
PPET Patient, Provider, Environment, Task
P&Ps policies & procedures
PVC peripheral vascular catheter
QI quality improvement
QMS quality management system
RCA Root Cause Analysis
25
RS rational style
SOPs Standardized Operating Protocols
STEEEP Safe, Timely, Effective, Efficient, Equitable, Patient Centered
VAP ventilated-associated pneumonia
WHO World Health Organization
5S Sort, Set, Shine, Standardize, Sustain
Author details
Mohammed M. Albaadani1*, Adel Omar Bataweel2, Alaa Mahmoud Ismail3,

Jameelah Mohammed Yaqoob4, Ebrahim Sarwi Asiri3, Hesham Ahmed Eid5,
Khaled M. Kasasbeh3, Mohamed Fathy Shaban6, Nasr Ali Mohammed4,
Samir Mohammed Bawazir3, Siham Mohammed Saleh7 and Yasser Sami Amer8
1 Health Watch Wigan and Leigh, United Kingdom
2 King Fahad Medical City, Riyadh, Saudi Arabia
3 Prince Sultan Military Medical City, Riyadh, Saudi Arabia
4 Ministry of Health and Population, Sana, Yemen
5 Founder of Quality Education Club, Cairo, Egypt
6 King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
7 Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
8 King Saud University Medical City, Riyadh, Saudi Arabia
*Address all correspondence to: [email protected]
© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of
the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
26
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Ten Quality Improvement

Quality improvement is a continuous journey to standardize healthcare processes

Keywords: patient safety, variation, performance improvement, quality initiatives,

patients, variations in the physical layout of clinical environments, variability or lack

For this chapter, we conducted thorough research using a comprehensive literature

5. Contributing factors of the variability of health care

1. Operational variability refers to differences in care delivered directly by different

2. Knowledge variability refers to differences in expertise among medical staff. This

In this chapter, we will try to highlight the top-quality improvement initiatives

1. Clinical practice guidelines and pathways

2. Policies and procedures (P&Ps)

8. Education and training

10. Care bundles

6. Clinical practice guidelines and pathways

6.2 Evidence-based medicine and CPGs

Evidence-based medicine (EBM) is of paramount importance in healthcare as

delivery of care by systematically integrating rigorous research findings with clinical

6.3 Improving quality and safety of care

6.4 Challenges in guideline and pathway implementation

6.5 Future, innovations, and the way forward

7. Policies and Procedures (P&Ps)

7.2 Why policies and procedures are important?

Policies and procedures are essential components of effective quality improvement

2. Serve as a unique communication tool between the treatment team.

4. Improve consistency and accuracy of the clinical process.

5. Guide decision-making process.

6. Protect the organization’s reputation and minimize any potential liabilities.

7. Improve confidence and satisfaction in teamwork.

7.3 General guidance for writing effective P&Ps

7.4 Types of healthcare P&Ps

Healthcare P&Ps can be divided into five major types [23]:

4. Information management: all policies that support proper management of sen-

7.5 Management of P&Ps

Policies and procedures must be developed through a standardized and systematic

Data is a vital and valuable resource in healthcare, it is like a compass or the

8.2 Sources of data

8.3 Performance indicators

Performance monitoring is a continuous process that involves collecting data to

Internal sources External sources

• Occurrence reports/summaries • National registry reports

8.4 Type of performance indicators

According to the Donabedian model, performance indicators are divided into

1. Structure measure: it evaluates the context in which healthcare is delivered from

3. Outcome measure: it refers to the effects or the outcome of healthcare such as

8.5 Balancing measure

8.6 What is a benchmark?

Benchmark refers to a point of reference that is used to evaluate the performance

areas of the same organization. For example, comparing ventilator-associated pneu-

8.7 Process variation

8.8 Types of process variations

The 5S methodology is identified as one of the most common lean management

Common cause variation Special cause variation

Caused by natural or ordinary causes Caused by non-ordinary and unnatural causes

Inherent to system or process. Non-inherent to the process design.

Result in a stable process Result in unstable process