Best Practice Improvement Informatics Thoughts and Musings

Bringing 100 year old technology to Healthcare -Part 2

Statistical Process Control (SPC) is a technique that has been widely used in industry for many decades. But is it useful in Healthcare.
Part 2 of 4

In part 1 of this extended blog I introduced Statistical Process Control and set the scene for considering whether it has a role to play in the complex context of healthcare. Thus this blog explores how SPC has risen to favour within the NHS.

What about Healthcare?

Manufacturing is all very well, however, it might seem that healthcare is very different. People aren’t manufactured widgets and medicine is arguably as much an art as a science; regulatory, organisational and clinical conditions are very different to those found in industry. People are more complex still, whether physiologically or otherwise… Clearly, there are many processes in healthcare that would benefit from being maintained in a stable state, by systematic elimination of the special causes of variation. However, the notion that SPC is a useful tool when applied to non-repetitive, knowledge-intensive processes common in healthcare management does seem to be up for debate.  

According to the Institute of Healthcare Improvement (IHI), SPC is a key component to support its Model for Improvement[i]. Similarly, NHS Improvement[ii] and NHS England[iii] advocate for the use of SPC. On the ground, many NHS Trusts have adopted SPC, to a greater or lesser extent, within their Quality Improvement Programmes, while dozens of SPC in Healthcare events have been run[iv]. Foremost amongst these is the Quality Improvement (QI) department at East London NHS Foundation Trust (ELFT), who have achieved the remarkable feat of taking the whole trust, from Executive Board to frontline staff, on the journey from RAG-based metrics to control charts as their default approach.

“Improvement is in the fabric of the trust”

Forid Alom, the Head of Improvement Analytics, East London NHS Foundation Trust

I spoke to Forid Alom, the Head of Improvement Analytics at ELFT; he described how the trust’s journey to SPC started with the unexpected. In 2014, the Trust Board was confident that their organisation was doing well; their board report, based on established Red-Amber-Green (RAG) performance indicators, showed Green against every metric and things seemed to be in as-good-a-place as a complex health provider could expect. Then they had not one, but two serious incidents that their RAG-based metrics suggested shouldn’t have happened. Whatever the cause, their RAG report hadn’t been effective. Their RAG indicators had very little predictive power and while they might have been easy to understand at a glance, they failed to provide the actionable intelligence which could have averted the incidents. So began a multi-year programme to accelerate their Quality Improvement Programme, based on the IHI Model for Improvement. A key insight was that static indicators didn’t tell enough of the story and the data need to be assessed and analysed over time.  This in turn introduced a comprehensive adoption of SPC. Executives were all trained in the understanding of SPC and the Board Report was comprehensively re-engineered to show SPC charts instead of RAG. IHI delivered initial training courses to the trust, until the training team developed the expertise to deliver them internally. Five years later, there are 10 fully formed training programmes, ~30% of trust staff have had  QI training including SPC, 184 qualified QI coaches have been created, and there are a further 12 certified Improvement Advisers. The Executive Team now rely on control charts and demand them instead of RAG. Improvement of this approach is a core element of the Trust’s Five Year Strategy. In that time, 177 projects have seen an improvement and the Care Quality Commission (CQC) has awarded them the coveted ‘Outstanding’ rating.

As Alom states, “improvement is in the fabric of the trust”, and “improvement thinking has had a significant impact, which includes SPC”.

Figure 2 ELFT publish their QI progress and successes

ELFT is considering what to do next. As Alom says, “You can’t do improvement projects forever. At some point it needs to become Business As Usual”. There is a recognition that projects seek to deal with large, visible needs and often take 6 months. The danger is in overlooking the little things, the ‘grit in the machine’ as it were. There are improvements that could happen in a day, and it is this mindset that the trust has adopted, by introducing a daily improvement process founded on the same Marginal Gains concepts that led to overwhelming success for the British at the 2008 and 2012 Olympics[v].

ELFT are very keen to spread the word. Bolstered by multiple awards, they now support multiple  organisations, to help them move from RAG to SPC. They have made their resources available on a publicly accessible microsite[vi] and promote their take on QI at conferences and beyond.

From the ELFT experience, it is clear that SPC is an excellent technique to use when implementing change. It enables organisations to understand whether changes being made result in actual improvement and can give early warning when things are heading out of control – for those skilled enough to use the techniques.  The latter comment is important. Many organisations simply set the control limits based on 3 Standard Deviations (SD) from the mean. As NHS Improvement are very keen to point out, this is incorrect; sigma should be used instead (though the rationale requires a detailed statistical explanation beyond the scope of this article). Getting this wrong can lead to inappropriate control limits.

Thomas Nicholas and Alex Starks, Analysts at NHS Improvement, discuss the importance of setting process limits for SPC charts correctly

Part 3 will take a sidewise look at SPC in Healthcare and ask it it really is the next big thing, or just another bandwagon

When part 4 comes along it will be about how to use SPC with your current data tools, namely Excel and Power BI. I’ll reach some kind of a conclusion too.

If you want to find out more about how Cloud2 helped ELFT then please contact them, I’m sure that they will be only too pleased to help.

References and Sources







If you are interested in #SPC, #QualityImprovement and the #NHS then you might find this multipart article interesting

By Simon Hudson

Simon Hudson is an entrepreneur, health sector specialist and founder of Cloud2 Ltd. and Kinata Ltd. and, most recently, Novia Works Ltd. He has an abiding, evangelical interest in information, knowledge management and has a lot to say on best practice use of Microsoft Teams, SharePoint and cloud technologies, the health sector, sustainability and more. He has had articles and editorials published in a variety of knowledge management, clinical benchmarking and health journals. He is a co-facilitator of the M365 North User Group Leeds and is Entrepreneur in Residence at the University of Hull.

Simon is passionate about rather too many things, including science, music (he writes and plays guitar & mandola), skiing, classic cars, technology and, by no means least, his family.


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