The CQI Toolkit allows users to pick and choose certain aspects of 10 of the following established methodologies and philosophies and combine them to deliver and sustain a successful service improvement project.

Plan Do Study Act (PDSA)

The PDSA Cycle is a systematic series of steps used for valuable learning and knowledge gain for the continuous improvement of a product or process. Also known as the Deming Wheel, or Deming Cycle, the original concept was introduced to Dr WE Deming by his mentor, Walter Shewart of the famous Bell Laboratories in New York, in the 1920s. (The W. Edwards Deming Institute)

NHS Improvement – Plan, Do, Study, Act (PDSA) cycles and the model for improvement

Statistical Process Control (SPC)

Statistical Process Control is a practical statistical approach to understanding and resolving problems. It can help you understand the scale of any problem, gather information and identify possible causes when used in conjunction with other investigation tools, such as process mapping and spaghetti diagrams. You will then be able to measure the impact of any improvement and evaluation its worth. (NHS Improvement)

NHS Improvement – Statistical Process Control

Six Sigma

Six Sigma is a robust data-driven methodology targeting both performance and customer requirements. This methodology helps to identify and eliminate the root cause of problems rather than focusing on treating their effects. Six Sigma’s five stages are to: Define, Measure, Analyse, Improve and Control, allowing for consistent quality of outputs whilst eliminating unnecessary processes and delays.

NHS Improvement – An Overview of Six Sigma


Lean is predominantly about people and processes, eliminating waste whilst maximising customer value. It is the continuous and systematic elimination of waste. Lean is about building the problem-solving capabilities of the team to produce experts who can perform their daily work to the best standard, every day.

The term Lean has been developed in the context of manufacturing from the way in which Toyota and other Japanese motor manufacturers organise their production processes. The approach can be described using the five principles of Lean: Identify customer value, Manage the value stream, ‘Flow’ production, Pull work through the process and Pursue perfection by reducing all forms of waste in the system. Alternatively, this can be summarised as the ‘Toyota Production System’ (TPS), as summarised in the ‘Toyota way: Problem-solving, People and partners, Process and philosophy’.

A variety of tools can be used to support the Lean approach, many of which are common to other approaches and there is no definitive list. Commonly used tools include value stream mapping, rapid improvement events and 5S (Sort, Simplify/Straighten/Set in order, Shine/Scrub, Standardise/Stabilise, Sustain/Self-discipline). 

NHS Institute for Innovation and Improvement – Going lean in the NHS

Business Process Re-engineering

Business Process Re-engineering is the 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. BPR seeks to help companies radically restructure their organisations by focusing on the ground-up design of their business processes.

According to Davenport (1990), a business process is a set of logically related tasks performed to achieve a defined business outcome. Re-engineering emphasises a holistic focus on business objectives and how processes related to them, encouraging full-scale recreation of processes rather than iterative optimisation of sub processes. BPR is also known as business process redesign, business transformation, or business process change management.

Davenport, T. H. & Short, J. E. (1990 Summer). The New Industrial Engineering: Information Technology and Business Process Redesign, Sloan Management Review, pp. 11-27.

Collaborative Working

Groups of hospitals or health economies addressing the same problems as each other and learning from each other’s experience.

Collaboration means to work with each other on a task. It is a recursive process where two or more people or organisations work together to realise shared goals. This is more than the intersection of common goals seen in co-operative ventures, but a deep, collective, determination to reach an identical objective. For example, an endeavour that is creative in nature by sharing knowledge, learning and building consensus. Most collaboration requires leadership, although the form of leadership can be social within a decentralised and egalitarian group. In particular, teams that work collaboratively can obtain greater resources, recognition and reward when facing competition for finite resources. Collaboration is also present in opposing goals exhibiting the notion of adversarial collaboration, though this is not a common case for using the word.

NHS Improvement – Building Collaborative Teams

Total Quality Management

Also known as continuous quality improvement, Total Quality Management emphasises the need for leadership and management involvement to understand work processes.

The main difference between TQM and Six Sigma is the approach. At its core, Total Quality Management (TQM) is a management approach to long-term success through continuous process improvement and customer satisfaction. In a TQM effort, all members of an organisation participate in improving processes, products, services and the culture in which they work.

The TQM concept was developed based on the teachings of American management consultants, including W. Edwards Deming, Joseph M. Juran, and Armand V. Feigenbaum. Originally, these consultants had short-term success in the United States. Managers in Japan, however, embraced their ideas enthusiastically and even named their premier annual prize for manufacturing excellence after Dr. Deming. Based on Statistical Process Control (SPC) techniques, the Six Sigma management strategy was developed in 1986 to support Motorola’s drive towards reducing defects by minimising variation in processes.

Experience Based Design

Experienced based design (EBD) is a method of understanding and improving patient, carer and staff experience by working in partnership. The approach has four stages: capturing the experience, understanding it, improving the experience and measuring the improvement. It involves looking at the care journey in addition to the emotional journey involved when experiencing a particular pathway or part of a service.

This methodology views healthcare processes not only as physically entities but also emotional entities and focusing on both of these aspects creates a positive user experience. Patients, carers and staff work together to determine the desired experience and measure against this intention. By listening to patients and acting on their suggestions, a number of simple improvements can be identified and implemented.

NHS Institute for Innovation and Improvement – the ebd approach. Experience based design

Human Factors

This principle encompasses all factors that can influence people and their behaviour. In a work setting, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work.

Every day in the NHS, tens of thousands of patients are treated safely by dedicated healthcare professionals who are motivated to provide high quality and safe clinical care. For the vast majority of patients, the treatment they receive alleviates or improves their symptoms and is a positive experience. However, an unacceptable number of patients are harmed as a result of their treatment or as a consequence of their admission to hospital.

Examples of common human factors that can increase risk include:

·      Mental workload

·      Distractions and the physical environment

·      Physical demands

·      Device/product design

·      Teamwork

·      Process design

NHS England – Human Factors in Healthcare

Toyota Production System

Toyota Production System blends two philosophies: just-in-time and jidoka. Just-in-time relies on accurately matching system inputs to system outputs, thus minimising inventory and waste. Jidoka refers to a semi-automated control that stops production in the case of an abnormality, it was originally coined to describe a loom which would stop itself upon detecting a broken thread. Together these two philosophies work together to improve quality, reduce the duration and cost through the elimination of waste.
NHS Institute for Innovation and Improvement – Going lean in the NHS
Sakichi Toyoda founded the Toyoda Spinning and Weaving Company in 1918. He developed the first steam-powered loom that could detect a broken thread and stop itself automatically. This innovation led to the wider principle of jidoka, or automation with a human touch – later to become one of the two pillars of TPS. Some years later in 1937, Sakichi’s son Kiichiro founded the Toyota Motor Corporation.
Kiichiro took his father’s concept of jidoka and developed his own complementary philosophy just-in-time – which would become the other pillar of TPS. He visited Ford’s mass production plants in Michigan to study their use of assembly lines. After World War II, the need to be able to manufacture vehicles efficiently was greater than ever. Kiichiro’s younger cousin, Eiji – later to become president and chairman of Toyota Motor Manufacturing – tasked one of Toyota’s young engineers, Taiichi Ohno, with the job of increasing productivity. 
Ohno’s achievement was to marry the just-in-time concept with the principle of jidoka. In 1953, Ohno also visited the USA to study Ford’s production methods, but he was much more inspired by American supermarkets. He noticed how customers would take from the shelves only what they needed at that time, and how those stocks were quickly and precisely replenished. Ohno had the insight that a supermarket was essentially a well-run warehouse, with ‘goods-in’ closely matching ‘goods-out’, and no space for long-term storage. 
On his return to Japan, Ohno developed the same idea into the kanban concept. Ohno also learnt from the American pioneer of quality control, Dr. W. Edwards Deming. The aim of Deming’s method was to improve quality at every stage of a business, from product design, through manufacturing, to aftersales service. Deming taught that each stage in a manufacturing process should be thought of as the previous stage’s customer, which fitted very well with Kiichiro’s just-in-time philosophy, and the principle of kaizen. Today, Ohno is considered the true architect of TPS, having developed it into a practical method and, crucially, having made it work on the shop floor. (Toyota Material Handling Europe)