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Novel quality improvement method to reduce cost while improving the quality of patient care: retrospective observational study
  1. Kedar S Mate1,2,
  2. Jeffrey Rakover1,
  3. Kay Cordiner3,
  4. Amy Noble4,
  5. Noura Hassan5
  1. 1 Research and Development Department, Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
  2. 2 Medicine, Weill Cornell Medical School, New York City, New York, USA
  3. 3 Respiratory Unit in Raigmore Hospital, NHS Highland, Inverness, Highlands, UK
  4. 4 Respiratory Unit, Raigmore Hospital, Inverness, Highlands, UK
  5. 5 Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
  1. Correspondence to Jeffrey Rakover, Research and Development, Institute for Healthcare Improvement, Boston, MA 02109, USA; jrakover{at}


Background Healthcare cost management strategies are limited in number and resource intensive. Budget constraints in the National Health Service Scotland (NHS Scotland) apply pressure on regional health boards to improve efficiency while preserving quality.

Methods We developed a technical method to assist health systems to reduce operating costs, called continuous value management (CVM). Derived from lean accounting and employing quality improvement (QI) methods, the approach allows for management to reduce or repurpose resources to improve efficiency. The primary outcome measure was the cost per patient admitted to the ward in British pounds (£).

Interventions The first step of CVM is developing a standard care model. Teams then track system performance weekly using a tool called the ‘box score’, and improve performance using QI methods with results displayed on a visual management board. A 29-bed inpatient respiratory ward in a mid-sized hospital in NHS Scotland pilot tested the method.

Results We included 5806 patients between October 2016 and May 2018. During the 18-month pilot, the ward realised a 21.8% reduction in cost per patient admitted to the ward (from an initial average level of £807.70 to £631.50 as a new average applying Shewhart control chart rules, p<0.0001), and agency nursing spend decreased by 30.8%. The ward realised a 28.9% increase in the number of patients admitted to the ward per week. Other quality measures (eg, staff satisfaction) were sustained or improved.

Conclusion CVM methods reduced the cost of care while improving quality. Most of the reduction came by way of reduced bank nursing spend. Work is under way to further test CVM and understand leadership behaviours supporting scale-up.

  • continuous quality improvement
  • healthcare quality improvement
  • lean management
  • management
  • quality improvement

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  • Funding IHI received funding from NHS Scotland to complete this pilot, via an existing strategic partnership relationship.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.