In 1854, Florence Nightingale was sent to Turkey with a group of nurses to help care for soldiers in the Crimean War. Inadvertently, she invented quality improvement in healthcare. The death rate fell from 60% to 42.7% in the first six months and then went down to 2.2% after a year. Considering that Nightingale had no knowledge of viruses or bacteria, let alone how they spread, makes her achievement all the more remarkable.
The history of our knowledge of disease is also the history of quality in healthcare. Since ancient times, humans have tried to win the battle against death through illness. The bubonic plague, or Black Death, blighted societies from around the 13th century.
In the past year, we have been given a glimpse into how awful life must have been for those caught up in the pandemics that raged across Europe. In the first five years of the plague, 20 million people died. The king of France asked the best minds in the country to work out what was spreading the disease. Their conclusion makes for bizarre reading today – the planets Jupiter, Mars and Saturn were aligned along with a lunar eclipse, which caused terrestrial winds to spread noxious air.
A few centuries later this noxious air was given a name: ‘miasma’. Miasma was blamed for infections of all kinds until the discovery of viruses in the late 1800s.
The methods that Nightingale implemented will be familiar to all of us in healthcare but also to everyone else since Covid-19. She distanced the soldiers’ beds three feet apart, ventilated all the wards, made everyone wash their hands, ensured the sewers were flushed and disinfected and she stopped the horses from being stabled in the hospital. Nightingale thought she was keeping out bad miasma but she was actually preventing viruses and bacteria from spreading.
Finally, and most importantly for quality improvement, she kept meticulous records. Not only do we know exactly what actions she took but so did the other nurses who came after her. They could replicate the measures she put in place to keep patients safe. Nightingale loved statistical analysis and had a great aptitude for mathematics. While keeping records in the Crimea, she invented a graphical display to show her results, which she called a ‘coxcomb’ – today we know it as a pie chart.
She kept those records even after she returned to London and used them to improve hospital care, even working with architects to improve hospital building design. The essence of what she did is used in today’s quality improvement in healthcare. The Health Foundation’s guide to quality improvement outlines the following steps to improve quality:
- Understand the problem, with a particular emphasis on what the data tells you.
- Understand the processes and systems within the organisation – particularly the patient pathway – and whether these can be simplified to analyse the demand, capacity and flow of the service.
- Choose the tools to bring about change, including leadership and clinical engagement, skills development, and staff and patient participation.
- Evaluate and measure the impact of a change.
This is also the essence of the Quality Standard for Imaging (QSI). This monthly column is called Why Fronts because one of the most important ways to improve quality is to ask ‘why?’. The question should not just be applied to processes or outcomes that are not working but also to those that are successful. Asking ‘why?’ about everything we do shows that we are thinking and working consciously, which helps to prevent mistakes, especially during repetitive work.
Asking questions is a sign of a healthy working environment. You need to feel free to question what you are doing and why. Nobody should feel that opinions or concerns might be ignored or silenced. If questions are not asked, unsafe practices might be allowed to continue. It is also a chance to share knowledge and to collaborate. Quality improvement requires skills such as perseverance, relationship skills, enthusiasm and optimism.
But one of the most important skills is curiosity. Hari Srinivasan, who leads the Learning team at LinkedIn, says: ‘Curiosity, used strategically, can not only improve the way we work, it can also transform the way we think by allowing us to see creative solutions that may be missed by others, make wiser decisions and increase our influence’. So I encourage you to be curious and ask ‘why?’. This might improve not just your own practice but the treatment of your patients and their outcomes. Also remember to wash your hands frequently and please keep the horses out of the hospital.
If you have any queries, please email me at the address below. Katherine Jakeman, quality improvement partner, RCR/SCoR
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