Staff in hospital departments, mental health and community services should be engaged in efforts to improve systems and the quality and efficiency of services.

This type of quality improvement (QI), or service improvement involves a study of the way systems work and may involve a study of alternative ways of organising: but is not “research” as understood by academics.

Indeed it is important to resist the efforts by academics to turn quality improvement into an academic pursuit, or one carried out by specific separate QI departments and handed down to staff at the front line.

A recent BMJ ‘essay’ by a high-flying Cambridge academic, How to improve healthcare improvement is undermined from the outset by getting this wrong.

The author, Mary Dixon-Woods, appears to set off in a promising direction, warning of the inadequate focus on quality improvement, on learning from failures and seeking to ensure systems have “the preconditions for high quality, safe care: funding, staff, training, buildings, equipment, and other infrastructure.”

But she goes on to question the effectiveness of quality improvement in improving quality – not by comparing the performance and outcomes of departments and trusts before and after initiatives have been implemented, but on the basis of an absence of randomised control trials.

US quality expert Don Berwick made clear back in 1996 that this was not a useful way to assess such work:

“When we try to improve a system we do not need perfect inference about a pre-existing hypothesis: we do not need randomisation, power calculations, and large samples. We need just enough information to take a next step in learning.

“Often a small series of patients or a few closely observed events contain more than enough information for a specific process change to be evaluated, refined, or discarded, just as my daughter, in learning to ride her bicycle, sometimes must fall down only once to learn not to try that manoeuvre again.”

Much QI work takes place on a day to day basis within well-managed departments seeking to improve their performance, and is not written up into peer-reviewed academic papers.

The starting point must be what Berwick describes as the Central Law of Improvement: “every system is perfectly designed to produce the results it achieves”.

So if we want to improve the quality of care delivered, we have to improve the system, and address any gaps, delays, confusion and other weaknesses that impede or undermine patient care.

Moreover if a quality improvement exercise results in a reduction in hospital-acquired infection – perhaps by improved and more frequent cleaning of doctors’ stethoscopes, for example, or similar measures – there is no sense in then adopting a randomised control trial in which some patients are put at greater risk by research in which some doctors act as the “control” by not cleaning their stethoscopes.

The process for quality improvement advocated by Berwick, by the US Institute for Healthcare Improvement and by British advocates (including the 1000Lives Plus initiative in Wales) is the implementation in the workplace of a “plan-do-study-act (PDSA) cycle”.

Berwick sums this up as inductive learning – “he growth of knowledge through making changes and then reflecting on the consequences of those changes.”

He argues that “… the enterprise of testing change in informative cycles should be part of normal daily activity throughout an organisation.”

If it’s a part of normal daily activity, it’s not academic research. Berwick says this method represents a democratisation of scientific method.

This is very different from the way academics seek to find a role for themselves and subject any area of inquiry to their own assumptions.

Ms Dixon-Woods argues some QI efforts, “perversely, may cause harm—as happened when a multicomponent intervention was found to be associated with an increase rather than a decrease in surgical site infections.”

Had this intervention adopted a PDSA approach it would have been stopped as soon as there was any evidence of harm being done.

She also cites a study by a team including Lord Darzi that attempts to assess peer-reviewed publications of PDSA cycles but which complains that they show an “inconsistent approach” but “does not conclude whether better application of the PDSA method results in better outcomes.”

Academics are unhappy with an approach that shows academics and their methods to be unnecessary and even unhelpful.

Even Dixon-Woods admits that “not all improvement needs to involve a well defined QI intervention, and not everything requires a discrete project with formal plan-do-study-act cycles.”

Indeed the second page of her essay is considerably more constructive than the first, noting that “many high performing organisations, including many currently rated as outstanding by the Care Quality Commission … use structured methods of continuous quality improvement.

“But studies of high performing settings … indicate that although continuous improvement is key to their success, a specific branded improvement method is not necessary.”

She also criticises mental health and learning disability services for paying much less attention than acute hospitals to quality and safety improvement.

So the essay serves as a useful spur to discussion of how services can be improved for patients through the involvement of the staff who care for them and addressing systemic problems rather than individual skills and behaviour.

Some of the right answers are included for those who stay the course and plough through a first page which is littered with the wrong ones.

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John Lister
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