Quality improvement methods to study and improve the process and outcomes of pediatric cardiac care

Quality improvement methods offer an approach, a set of tools, and a powerful way of thinking about how to transform clinical operations to achieve better results for patients and healthcare teams. Quality improvement methods are ideally suited to improve the safety and quality of pediatric cardiac surgery (PCS). We review five quality improvement tools that are relevant for improving PCS: checklists, process maps, Ishikawa diagrams, run charts, and control charts. Checklists have received the most attention and the evidence supports the greater adoption of checklists in surgery as well as other medical specialties. Process mapping or flowcharting is an important quality improvement tool that helps clinicians reflect on their mental models – how they understand their environment. Process maps provide insight into how to improve the process or overcome barriers, by soliciting the activities of the care process from the clinical team, coupled with visual representation of the care process. Ishikawa diagrams, also known as cause and effect diagrams or fishbone diagrams, are a graphical representation of the sources of variation in a process. The run chart is a simple plot of a measurement over time with a line drawn at the median; data displayed on the run chart can be related to patients, organizations, or clinical units. Control charts are similar to run charts in that they both provide data displayed over time, however, control charts provide upper and lower control limits that allow the determination of whether a process is stable. Values outside control limits may be an indicator of special cause variation. Each of these five tools can help facilitate tracking and analysis of single and groups of patient process and outcome data and should be become part of the routine manner in which clinicians and healthcare systems deliver care.