Health care organisations share a range of generic characteristics that make them particularly challenging for quality improvement programmes: complex care processes; multiple stakeholders; long-standing inter- and intra- professional ‘turf wars’; an emphasis on individual proficiency rather than team-working; a history of challenging relationships between managers and health professionals; varying standards of data and infrastructure support for data collection/analysis; and a long history of successive top-down reorganisations and change programmes. These characteristics need to be borne in mind when considering which approaches to quality improvement will have greatest application in health services.
Importing quality improvement techniques from outside health care may have the benefit that the tools and approaches have been tested to some degree, but the complexity of
health care and the contingencies of the particular local and organisational circumstances can combine to overwhelm these potential advantages.
Nonetheless, the accumulated knowledge from more than two decades of research, evaluation and experience has highlighted that, whatever quality improvement methods or approaches are used, there are core conditions that need to be met. Health care organisations need to:
• Apply methods consistently over a sufficiently long timescale with demonstrated sustained organisational commitment and support
• Involve doctors and other health professionals in a wide team effort while providing adequate training and development
• Seek active involvement of middle and senior managers, the board (including nonexecutive directors) and, most obviously and visibly, the chief executive
• Integrate quality improvement into the organisation’s other activities (so that it is part of the organisation’s strategic plans and priorities, targets etc)
• Tailor the selected methods to local circumstances
• Create robust IT systems that enable the measurement of processes and impacts, iteratively refining the approaches used
• Acknowledge – and ameliorate as far as possible – the impact of competing activities/changes.
The review of the models and system-wide approaches shows that there are strong commonalities between them: although they may have different emphases, many share similar underlying objectives, and the distinctions between the approaches are often blurred in practice. Moreover, each of the approaches and the data used to underpin them can be used either to enable quality improvement by ‘inspiring and developing’ or to mandate quality improvement through ‘policing, punishing and rewarding.’
Despite the many insights into implementation that can be drawn from the studies, it remains hard to assess the overall impact of specific programmes in individual organisations
or to make comparisons of approaches across a range of studies. What is clear from this review and from the broader literature on organisational change is that there is no one
‘right’ quality improvement method. Instead, successful implementation may be more about the interaction between any given programme and its implementation in the local context. This suggests that the following inter-linked processes are important:
• the thoughtful consideration of local circumstances and selection of the approach (or combination of approaches) that is the ‘best fit’ (however imperfect) for the local organisation;
• the adaptation of the approach so that it best reflects the local circumstances at the outset and responds to emerging developments as implementation unfolds; and
• the careful and sustained application of the approach in a way that is congruent with current knowledge on key considerations in change management in health care.
Thus quality improvement programmes – of whatever hue – will place simultaneous responsibilities on front-line health professionals and on managers at all levels. Managers
need to be actively involved with quality improvement for both symbolic and practical purposes: to ensure that quality improvement activities are aligned with the strategic objectives of the organisation and are resourced effectively; to address system barriers to changes; to embed effective practice into routine processes; and to ensure that the organisation makes full use of the external resources available to support local quality improvement.
Finally, so that quality improvement work contributes to its own evidence base, it is essential to put in place some form of ongoing evaluation (both qualitative and quantitative): “in
a sense we should view every quality improvement programme as a kind of experiment, and design it to be ‘auto-evaluative’ so that the programme itself produces information about its own effectiveness.” (Walshe and Freeman 2002: 87).