The need for expertise in quality improvement at every stage of a healthcare worker’s career

The quality improvement in healthcare movement has been around for the past 25 years with variable degrees of success. The focus on quality and safety commenced with the publication of a few seminal reports: Crossing the Quality Chasm and To Err is Human in the USA, and Organisation with a Memory in the United Kingdom. In 2018, just prior to the pandemic, two international reports, Crossing the Global Quality Chasm, a follow up of the initial report, and the Lancet Commission reported on the quality and safety of healthcare world-wide. These reports demonstrated that in lower middle income countries there was a challenge to improve safety and quality in the context of delivering universal health coverage. The quality of healthcare in upper income countries has improved but is variable. In 2021, the World Health Organisation published the Global Action Plan for Patient Safety, starting the decade with a focus on patient safety. All the reports documented the need to improve quality and safety of patient care. The COVID pandemic added to this imperative, and added new dimensions, such as the wellbeing of all.

Academics often focus on writing such reports, which are called for by policy makers who use them to develop strategic plans for action. The NHS and other health systems are littered with strategies that come and go with each leadership change. Strategies result in setting standards with a system of inspection and regulation. The reports and standards should be an impetus to change, but they are far removed from the realities of working on the frontline of healthcare. Standards and strategies to implement change do not necessarily improve the quality of care. The real question is how do we get smart people, i.e. doctors and nurses and other health professionals, to deliver safe, high quality care all of the time. An ongoing challenge has been spreading successful improvement outcomes at scale. Partly, this is due to a lack of sound implementation processes; partly, due to a lack of data on what works; and finally to a simplistic view that what is successful in one context can be applied elsewhere.

Healthcare policy planners have stated they want to have safe and person-centred healthcare services that are efficient and effective. The desired outcomes have not been widely achieved for several reasons including:

• the theories and methods are not understood or accepted by clinicians,
• there is limited published evidence that they are effective ,
• implementation is dependent on context,
• improvement initiatives may not have been applied in a logical and consistent manner,
• and there are competing demands and resultant time constraints.

The lack of uptake within the medical profession, and to a lesser degree by nursing and other healthcare workers, has been a specific challenge. This may be the result of jargon, the variable evidence base, and their lack of knowledge of the new sciences of improvement and implementation. The study of improvement theory and method is not an integral part of the medical curricula. We train healthcare workers to have excellence in subject matter knowledge but do not provide them with the education to apply that knowledge equally. If one adds the complexity of professionalism it is difficult to decrease the widespread variation that exists in the delivery of healthcare.

The understanding of what is required to improve healthcare and to be safe and person centred is now well understood. However, implementing what we know works is not easy. Setting standards is essential and can be regarded as Quality 1.0. Unfortunately, many see this as the solution when in fact it is only the start of the quality journey. Learning technical skills using the theories and methods of improvement can be termed Quality 2.0. This is where the focus has been for the past 25 years. Most interventions to improve quality of care have focussed on teaching healthcare workers patient safety or quality improvement methodology. This is essential but will not achieve quality care at scale. One must add ideas of implementation science and make quality relevant to the workforce in an age of pressing issues—such as climate change and the delivery of equitable care. This leads to a different approach to achieving quality.

The future of quality in healthcare is the coproduction of solutions and interventions, Quality 3.0. This process may use standards and improvement as well as safety theories and methods, but will be owned by the patients as well as doctors, nurses, or other healthcare workers. The transfer of power is challenging and complex. Yet if not adopted, it will be difficult to achieve high quality care at scale. Every healthcare worker requires the power, agency, and/or courage to improve care, supported by knowledge and expertise. Only then can there be a difference for the people receiving care.

_{Feature image via Freepik.}