QI Hub: Introduction to QI

BGS Clinical Quality Committee
British Geriatrics Society
Date Published:
16 November 2022
Last updated: 
16 November 2022

What is Quality Improvement (QI) and why is it important to consider in the context of older people's healthcare? This section discusses the different origins and approaches to QI.

Healthcare is a highly complex system, full of professional people doing their very best. On a daily basis, clinicians, managers, support staff, and students will come across processes which do not work well. These poor processes can lead to harm, delays and waits, repeated work, frustration and complaints.

Quality Improvement (QI) goes beyond traditional management practices. It is a systematic approach that uses specific techniques to improve quality in health and care. These methods are designed for complex systems, where the problems may not be completely understood, and the answers are not always known. They are used where change is intended to be made at the same time as the continuation of normal work.
There are several QI methodologies, but the approaches most widely used in healthcare are the ‘organisational approaches’. Over the past decade the robust organisational approaches to quality improvement have spread from manufacturing, nuclear and aviation industries to healthcare. The use of these methods is about creating environments in which change and improvement can flourish, where leadership fosters a culture of innovation and provides the tools, techniques and training so that staff can take ownership of improving the quality of care.
Everyone who works in health or care settings understands how complex these environments are; there are numerous processes and pathways and although most of them work well, all staff will be able to identify care processes and pathways which do not work well for staff or for patients.
Quality improvement is about enabling those who work in the health and care system to take responsibility, not just for the care which they provide but for improving the system within which they work. Organisational QI approaches provide the permission, skills and resources for staff to redesign and continually improve care to meet the changing needs of patients and communities so the care system supports delivery of the best care possible.
The BGS webpage on Quality Improvement sets out some of the resources and approaches which provide some additional context and background to its application in the field of older people’s care.
Over the years, several national and international organisations have developed sound reputations for championing the use of these tools and techniques in healthcare. As experience in these settings has deepened, many of the same organisations have developed freely accessible resource sites which act as repositories of their learning and sources of knowledge, learning and expertise.
Through the BGS QI hub we aim to introduce you to methods you can use to create environments in which change and improvement can flourish, where leadership fosters a culture of innovation and provides you with the tools, techniques and training so that staff can take ownership of improving the quality of care. Because after all, “The standard you walk past, is the standard you set.”
In general terms, quality can be improved using either ‘intrinsic’ or ‘extrinsic’ levers. In many settings, including healthcare, both of these methods are used within the same system.
Extrinsic methods include:
  • Centralised government initiatives (eg. statutory duty of quality)
  • Economic drivers (eg .payment for high performance)
  • Professional requirements and mandatory standards
  • External assessment and regulation
Intrinsic methods are typically models and methods that can be put in place by individual organisations. These are known as organisational or industrial approaches.

Organisational Approaches

Most of the original research and QI knowledge comes from three pioneers – Drs Deming, Shewart and Juran, originally working in manufacturing and agriculture (trail-grounds) settings.
During the lifetime of these three thought leaders, the science of improvement moved into healthcare, where others have developed it further. Some of the key concepts are highlighted in the table below:



Further reading

Business process re-engineering


Fundamental rethinking of how processes are designed, with change driven from the top by a visionary leader, and organisations set up around key processes rather than specialist functions

Business process re-engineering - Wikipedia



A quality management system developed by the Japanese car manufacturer Toyota, focusing on value, flow and waste reduction.

What is Lean? - Lean Enterprise Institute

Model for Improvement


An approach to continuous improvement where changes are tested and data collected in small change cycles, in real time.

The Improvement Guide: a practical approach to enhancing organizational performance. Gerald J Langley. Ronald D. Moen. Kevin M. Nolan. Thomas W. Nolan. Clifford L. Norman. Lloyd P. Provost. 2nd Edition 2009. Jossey-Bass.


How to Improve - Institute for Healthcare Improvement


Plan, Do, Study, Act cycles and the model for improvement - NHSE&I

Six Sigma


A process or product improvement approach that focuses on reducing what customers would define as ‘defects’.

Six Sigma - Wikipedia

Statistical process control


Examines the difference between natural variation (common cause) and special cause variation, and enables data to be collected over time to show whether a process is within control limits.

Statistical Process Control: an overview - ScienceDirect Topics

Total quality management (TQM)


Also known as continuous quality improvement. Emphasises the need for leadership and management involvement to understand work processes.

Total quality management - Wikipedia

To learn more about QI tools and methods, when one might be more appropriate than the other, and their pros and cons, the websites below provide advice and guidance:

  • A Guide to Quality Improvement Tools – HQIP
    Healthcare Quality Improvement Partnership’s guide introduces a variety of quality improvement tools used in healthcare and presents case examples and associated tools available to assist with implementation. Also includes an e-learning site with certificate on completion.
  • Royal College of Emergency Medicine (RCEM) provide a practical guide for clinicians undertaking quality improvement projects. It introduces the different tools and specifies: when to use it, how to use it, advantages and disadvantages along with examples.

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