Do we need Quality Insight rather than Quality Improvement? #WILTW

This is the 125th #WILTW

“Paediatricians often think of themselves as clinicians who are always willing to go that extra mile for their patients and that no child will receive less than the best care on offer. Unfortunately, looking at the wider healthcare system, evidence does not bear this out, in terms of overall mortality rates, variance in care and patient experience….[1]”

Prof. Mary Dixon-Woods and Prof. Graham Martin published an article this week entitled “Does Quality Improvement improve Quality“. It is a sobering read and explores the mis-conceptions and mistakes made with the deployment of ‘Quality Improvement‘ techniques in clinical environments. It certainly puts into perspective a passionate, but well meaning piece, I wrote with a colleague Bob Klaber 3 years ago “Quality Improvement: The need to believe it is necessary

“….It may well be that the term ‘quality improvement’ is misunderstood or mistrusted. The concept of evidence-based medicine (EBM) took years to be accepted by the medical profession and it seems likely QI may suffer from similar resistance.

Dixon-Woods and Martin aren’t belittling Quality Improvement’s ability to reverse some of the endemic problems in health systems but pointing out the poor use of methodologies and inadequate reporting of outcomes. The quote that particularly stands out:

The NHS continually loses learning, and this is an urgent problem [2]

They suggest four ways to improve Quality in Quality Improvement

Quality on quality

My interpretation of these suggestions:

i) It is too easy to act in isolation and “allow a thousand flowers of QI interventions to bloom [2]” rather than deliver improvements across ‘sectors’ in a standardised and methodologically robust fashion.

ii) Too often an initiative with some appealing face validity will be picked up and rolled out without any understanding of the environment it was originally developed in.  An intervention may work because of the ethos of the institution it is practiced in not necessarily because of the intervention itself.

iii) Too little time, and resource, is spent understanding the (ii). Monies are directed towards providing quick fixes rather than detailed evaluations involving different specialties and disciplines.

iv) A model has evolved, particularly in education, that rewards involvement in ‘micro’-QI projects delivered over short time periods. Larger programmes, which by their very nature are more likely to fail but provide better learning, are not seen as beneficial for or by trainees.

The challenge is that significant senior leadership will be needed to make these changes happen. What of the healthcare professional wanting to make a difference now? How do we maintain enthusiasm and passion in an increasingly disillusioned workforce when a more organised, and therefore potentially more bureaucratic, improvement strategy may be needed. Healthcare training, particular in medicine, is increasingly dependant on the micro-QI project to develop creativity and provide team work and leadership skills. We may still need a thousand flowers of QI interventions to provide these insights even if they don’t provide improvement.

What have you learnt this week? #WILTW

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[1] Klaber R and Roland D. Delivering quality improvement: the need to believe it is necessary. Arch Dis Child 2014;99:175-179

[2] Dixon-Woods M and Martin G. Does quality improvement improve quality? Future Hospital Journal 2016 doi: 10.7861/futurehosp.3-3-191           


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