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| Journal of the New Zealand Medical Association,
23-July-2004, Vol 117 No 1198
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Is New Zealand according too much importance to continuous
quality improvement in healthcare?
Stephen Buetow, Gregor Coster
In September 2003, New Zealand’s Ministry of Health
published ‘Improving quality (IQ): A Systems Approach for the New Zealand
Health and Disability Sector.’1 As part
of a strategy for nationally consistent standards and quality assurance
programmes, it describes a systems approach to help guide and plan improvements
in the sector. It suggests a means of supporting and coordinating quality
improvement activities underpinned by a shared vision of people ‘receiving
people-centred, safe and high-quality services that continually improve and that
are culturally competent.’1
IQ defines quality improvement as including continuous
quality improvement and quality assurance; and signifies ‘a commitment to
supporting continuous quality improvement.’ We commend this focus on
quality improvement. However, we also wish to question the explicit emphasis
given in IQ to continuous quality improvement, alongside the relative neglect of
other approaches to quality improvement.
This discussion is timely because
we,2,3 and others such as the Royal New Zealand
College of General Practitioners,4 have
recently championed continuous quality improvement as a quality improvement
approach. This has reflected to a large degree the influence of Don Berwick. As
President and CEO of the Boston-based Institute for Healthcare Improvement,
Berwick has successfully popularised (within healthcare) the continuous quality
improvement approach developed by Deming, Juran, and others.
Limitations of continuous quality improvementThree sets of difficulties bedevil
continuous quality improvement in heathcare. The first is that, despite
‘pockets of improvement,’ there is little scientific evidence that
continuous quality improvement improves the quality of healthcare among large
numbers of professionals or
organisation-wide.5–7 The effectiveness
of initiatives for continuous quality improvement appears to be highly variable,
possibly reflecting their diversity and changing nature, and differences in
organisational context.7
The second set of difficulties reflects ‘disparities
between the rhetoric and reality of continuous quality
improvement’.8 For example, continuous
quality improvement seeks to ‘drive out’ fear—while promoting
external quality assessments, such as practice accreditation, that can stress
workers and threaten their job security.2,3,8
Expectations on workers to perform with increasing efficiency can produce the
same adverse effects.
Among other examples are a tendency for unequal benefits to
workers, a requirement for leadership, and the dominance of managerial
perspectives and agendas that contradict the ideals of bottom-up participation,
teamwork, and overall commitment.8 The focus of
continuous quality improvement on slow, incremental change to existing
individual processes (through analysis, standardisation, and improvement) tends
to discourage substantial learning and
innovation.9 Continuous quality improvement
requires investment in long-term change, but health services in the public
sector are typically undercapitalised and tend to focus on the management of
short-term crises.8
Thirdly, systematic tools of continuous quality improvement
(such as Shewart’s Plan-Do-Check-Act [PDCA] cycle10) were popularised in,
and for, ‘fairly slow moving industries, such as the automotive
industry.’11 These tools are largely
unsuited to the modern-day environmental conditions of accelerating
technological change: uncertainty, high
complexity,12 and patient
‘bargaining.’13
Questioning the search for processes to reduce and control
medical practice variations that are ‘out of control,’ these
conditions demand health services that can respond
creatively.14 Rather than seek to prevent
errors upstream, this search for (and encouragement of) ‘positive
variation’ recognises that ‘errors’ are
inevitable11 (and indeed desirable) for their
potential to define opportunities for learning and
innovation.11
We support, nevertheless, the use of continuous quality
improvement. The three sets of difficulties are offset by progressive features
of continuous quality improvement. These features include the degree to which
worker involvement is valued and the ability of continuous quality improvement
to help us understand and improve quality rather than merely add to the
proliferation of studies documenting unintended variations and quality
deficits.15
Hence, the need to grapple with the sorts of contradictions
stated above should not deter the use of continuous quality
improvement7,8—rather, this need invites
the use of continuous quality improvement as one of multiple, concurrent
approaches.7,16 This is because
‘continuous improvement is not
enough’9 and other approaches cannot
substitute for continuous quality improvement. They can instead support the
implementation of continuous quality improvement as, for example, a series of
small-scale projects.17 From this perspective,
continuous quality improvement is merely a tool—not the only one, and not
necessarily the most important one—to help healthcare organisations,
teams, and individuals improve quality in healthcare.
Elsewhere, we have discussed other quality
approaches—such as quality assessment, quality assurance, and clinical
audit.2,18 Meanwhile, contemporary, systemic
and practical approaches to management19
include:
Process re-engineeringWe wish to suggest how insights from
process re-engineering can complement the commitment of the Ministry of Health
to continuous quality improvement and quality assurance. Compared with
continuous quality improvement, and its focus on incremental improvements in
performance, the top-down approach of process re-engineering emphasises greater
and more rapid change over a shorter time period. It involves fundamental, not
superficial, rethinking; exploits information technology capability in the
revolutionary redesign of macro-level organisational
processes;21 and can be adapted locally to
incorporate factors that are critical to successful change management in the
public sector.22 Integral to the approach of
process re-engineering is the concept of ‘discontinuous thinking’,
by which is meant a total change in thinking.
Discontinuous thinkingDiscontinuous thinking anticipates
the potential for discontinuous change—including sudden, possibly
catastrophic change. It questions whether continuous improvement is always
possible and desirable in a discontinuous world and challenges linear and
sequential thinking about problems that require solution. It uses a holistic
perspective to catalyse breakthrough processes and then seek the problems they
might solve.
Theoretical support for discontinuous change comes from
biology, quantum physics, and other sciences.19
Organisational cybernetics23 demands that
changing organisations operate discontinuously. Catastrophe
theory,24 complexity
theory,12,25 and chaos
theory26 also reveal how discontinuity
(including unanticipated changes, and predictions that fail to materialise) is
at least as natural as continuity.
Process re-engineering enables organisations to introduce
‘discontinuous improvement’ into their work culture. This overcomes
the problem that change in small, incremental steps may be inappropriate when an
urgent need arises to quickly fix systems that severely compromise patient
safety. For example, the Cartwright Inquiry27
and major inquiries into hospital services in
Christchurch28 and
Gisborne29 suggest such a need, notwithstanding
that radical change can yield incremental improvements and vice
versa.30 Also, Kaitaia provided an excellent
example of the need for process re-engineering (see Box
1).13
Box 1. Case Study: Improving quality (IQ) and process
engineering in Kaitaia
In 2002, an Independent
Review Team (IRT) reported its findings on Kaitaia health
services.31 It found that, although the
presenting issues were retention of 24-hour surgery and caesarean sections at
Kaitaia Hospital, the real issue was system failure underpinning the poor
coordination of services between Northland Base Hospital and Kaitaia Hospital,
poor primary-secondary care integration, and the poor health status of Maori.
The IRT recommended
significant process re-engineering as well as continuous quality improvement.
This involved: Accident and Medical Clinic development; retrieval system
improvement and protocols; increased outpatient clinic services; an Integrated
Health Organisation involving the Primary Health Organisation and hospital
services; integrated care; community governance structures; new systems for
obstetrics, women’s care, and anaesthetics; new investment in information
technology with integrated systems; and numerous other changes.
Signifying more than
continuos quality improvement (CQI), these proposals called for change
management involving systems re-engineering.
Process re-engineering also surmounts the problem that if
what is already done operates predictably at an unacceptable level and adds no
value to a service, improving it incrementally is likely to be a false gain and
a cost to the system.19 This situation can
occur where technology is obsolete, such that the entire process requires
changing through systematic process improvement. Such a requirement is not out
of place in the public sector, where policy and direction can change suddenly
and dramatically.22
In contrast, where ‘special cause’ variation is
present, its origin should be examined and managed; for example, in accordance
with continuous quality improvement. This is necessary to eliminate negative
special causes of the variation, and make positive special causes (such as an
improvement effort) part of the normal process. Continuous quality improvement
can also overcome limitations of process re-engineering. These include the
stress and costs of radical change, and a top-down, business focus on
operational processes, which can weaken the focus on
patients.9
ConclusionWith
exceptions,32 continuous quality improvement
and process re-engineering have seldom been integrated. However, recognition is
increasing that these quality movements can complement and enhance one
another.19 Each focuses on patients and
processes, including training and teamwork, to produce measurable results. Each
helps to address the other’s deficiencies. To keep pace in a
fast-changing, complex and unpredictable world, the Ministry of Health should
thus align itself less exclusively with ‘the small steps of continuous
quality improvement’ and ‘maintaining the
gains.’1
Thornley and her
colleagues33 suggest that, apart from
incremental changes in practice, ‘more radical change is
required’—meaning a need ‘to revolutionise our thinking about
quality’ by focusing more on quality improvement than quality assurance.
While tending to agree—we have indicated in this paper a further need to
delineate and discuss the nature of the quality improvement strategy required
for such ‘radical change.’ This is because, as a means of quality
improvement, continuous quality improvement is itself evolutionary rather than
revolutionary. Furthermore, in our opinion, the Ministry of Health accords too
much importance to continuous quality improvement.
Just as in areas such as guideline
implementation,34 we see a need for the
Ministry to encourage the adoption of a variety and combination of quality
improvement strategies—including the approaches of continuous quality
improvement and process re-engineering.
Which of these approaches is most appropriate depends on the
individual circumstances. However, coordinated within a systems-based framework
such as clinical governance, continuous quality improvement can (and should we
believe) be used continuously between the discontinuities that can occasion a
need to re-engineer core processes for revolutionary, quantum gains in quality
and safety.
Author information:
Stephen Buetow; Deputy Director of Research; Gregor Coster, Professor,
Department of General Practice and Primary Health Care, School of Population
Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland
Correspondence:
Stephen Buetow. Department of General Practice and Primary Health Care, School
of Population Health, Faculty of Medical and Health Sciences, University of
Auckland, Private Bag 92019, Auckland. Fax: (09) 373 7006; email: s.buetow@auckland.ac.nz
References:
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