Background The Plan-Do-Study-Act (PDSA) method is widely used in quality improvement (QI) strategies. However, previous studies have indicated that methodological problems are frequent in PDSA-based QI projects. Furthermore, it has been difficult to establish an association between the use of PDSA and improvements in clinical practices and patient outcomes. The aim of this systematic review was to examine whether recently published PDSA-based QI projects show self-reported effects and are conducted according to key features of the method. Methods A systematic literature search was performed in the PubMed, Embase and CINAHL databases. QI projects using PDSA published in peer-reviewed journals in 2015 and 2016 were included. Projects were assessed to determine the reported effects and the use of the following key methodological features; iterative cyclic method, continuous data collection, small-scale testing and use of a theoretical rationale. Results Of the 120 QI projects included, almost all reported improvement (98%). However, only 32 (27%) described a specific, quantitative aim and reached it. A total of 72 projects (60%) documented PDSA cycles sufficiently for inclusion in a full analysis of key features. Of these only three (4%) adhered to all four key methodological features. Conclusion Even though a majority of the QI projects reported improvements, the widespread challenges with low adherence to key methodological features in the individual projects pose a challenge for the legitimacy of PDSA-based QI. This review indicates that there is a continued need for improvement in quality improvement methodology.

The Danish government launched a new National Quality Programme (NQP) in healthcare in 2015. It has changed the focus from old public management in terms of accreditation, regulation, rules and standards to new public governance focusing on delivering high quality healthcare and outcomes of value for the patients, health professionals and the Danish healthcare system. The NQP aims to strengthen the focus on continuous quality improvement and the launch of the programme was accompanied by a decision to phase out accreditation of public hospitals. The NQP includes 1) eight specific national quality goals, 2) a national educational programme for quality management, and 3) establishment of quality improvement collaboratives. Since the establishment of the NQP the indicator results have improved in several important clinical areas. However, causal conclusions related to the effect of the NQP cannot yet be made. This perspective on quality paper aims to give a short introduction to the NQP and documented outcomes.

Quality problem Patient care pathways should be organized according to the needs of the patients. This requires methods to assess whether the specific pathways ensure the right care for the right person at the right time and in the right setting. Initial assessment Previous investigations indicate that approximately 25% of the patients in Danish hospitals experience inappropriate elements in their care pathways. Choice of solution This study applied the Patient Inventory method to identify inappropriate elements in care pathways in 15 psychiatric in-patient wards in Denmark. Implementation The pathway for 201 patients was systematically evaluated by the clinical staff to identify whether the admission of the patient was avoidable, the hospitalization was unnecessarily prolonged, or if the patient could receive more relevant treatment elsewhere. A subsequent meeting between the clinical staff and management qualified the assessment and identified possible solutions to problems. Evaluation A total of 54 (26.9%) of the included patients were assessed to have inappropriate elements in their care pathways, some with more than one type, resulting in a total of 65 episodes. Eight of these episodes (13.1%) were admissions considered to be avoidable, 26 (42.2%) were unnecessary prolongation of admissions, and 31 (58.1%) were patients assessed to be able to receive more relevant care elsewhere. Lessons learned One out of four assessed patients admitted to a psychiatric ward was exposed to an inappropriate element in their care pathway. The Patient Inventory tool can assist in a structured dialogue between clinical staff and management to identify focus areas for improvement efforts.

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