Box 1.

How to improve the quality of quality improvement

  1. Act like a sector.

    Allowing a thousand flowers of quality improvement (QI) interventions to bloom is not a sensible or efficient way of going about fixing healthcare and it introduces new risks. As we have argued elsewhere, many of the quality challenges that confront healthcare need to be solved at the level of entire systems,22 not hospital by hospital, practice by practice, care home by care home. Healthcare needs to take itself seriously as a collective whole or sector-like entity capable of agreeing standard operating procedures and systems that are designed with the right expertise, tested properly, implemented with professional leadership at the core, and remain open to innovation. Where technology or external standardisation is the issue – for example, the ongoing failure to address issues of alarm fatigue, incompatible devices or drug-naming and packaging practices – political leadership will be needed, although professional advocacy and involvement will be essential. However, much can be achieved by coming together voluntarily; the key will be to find the right structures for enabling this. A key principle is that such structures should be properly inclusive and include patients, carers and multiple professional disciplines, as well as other sectors and other workers as appropriate.

  2. Stop looking for magic bullets – focus on organisational strengthening and learn from positive deviance.

    When healthcare has sought to learn from other industries, it has not always done so in thoughtful or well-informed ways. It has instead tended to adopt specific interventions (eg checklists) and tried to treat them as magic bullets that are then implemented with little fidelity. Too little has been spent on the organisational strengthening needed to make improvement. Once the search for magic bullet interventions is abandoned, much can be learned from the characteristics, practices and behaviours that are implicated in the performance of demonstrably safe and high-quality settings. This is the approach used, for example, in studies of high-reliability organisations.31,32 The increasingly popular positive deviance approach similarly seeks to learn from exceptionally good performance.33 Sometimes, this approach can help to identify processes that promote high-quality care;34,35 sometimes, it will identify characteristics of context (values, behaviours, structures and so on) that need to be propagated. What is clear already is that organisations need to develop clear goals, manage people and resources effectively, foster a sense of moral community, develop their information and intelligence systems, and ensure that they have the capacity to engage in problem solving.4,36

  3. Build capacity for designing and testing solutions, and plan for replication and scaling from the start.

    Developing solutions to many quality and safety problems may require high-level skills and expertise from multiple disciplines, and highly sophisticated development processes. It is clear that we need to get better at developing or selecting interventions that have a high likelihood of success, testing them rigorously in different contexts, and offering organisations solutions (the technical and operational issues they need to tackle and the ‘hints and tips’ on the things they will need to do to make the change happen). Much more attention is needed to develop high-quality prototypes of possible solutions in laboratory-like conditions – which may be a designated hospital or network of hospitals that agrees to act as the lab – and undertake modelling and simulation before they are tested for real. The goal of such testing should be to identify, among other things, how the solution might work in different scenarios and conditions, and to work out what are the core, non-negotiable elements and what can be locally customised. Testing should also support intelligent replication and scaling. It is now clear that a simple description of the components of an intervention is not enough; what matters is likely to be the activation of mechanisms, even if precise activities undertaken to activate those mechanisms differ across contexts. Fidelity will lie in the mechanisms rather than fussy adherence to specific forms.

  4. Think programmes and resources, not projects.

    QI projects are sometimes the right answer – for example, where there is a specific, bounded problem to be solved, and particularly if it is one where experience and evidence suggest a plausible solution – but where they are undertaken it should be with a commitment to sharing. In general, thinking and planning long-term programmes of work that are coordinated through some central hub, and that doctors-in-training and others work on for particular periods of time as part of a contribution to a bigger effort (for instance, they might be involved in some of the testing activities described above or on data analysis), may be more productive than individual, short-term projects. Many people who do improvement work are not trained academics and the reports of their work are not traditional academic outputs. However, not being able to publish and share diminishes the attractiveness of improvement work in terms of career rewards and satisfaction. Healthcare needs to do for QI what it has done for research: build an infrastructure that enables learning about successful and less successful efforts to be curated and searched by others. An open-access, peer-reviewed curation model that provides a searchable database of improvement resources that people have developed or used in their organisations is one possibility worth exploring. Authors should be offered guidance on the aspects of the intervention, context and implementation process they should cover to make this resource as accessible, comprehensive and useful as possible.