An Opinion Piece: Why quality improvement at scale is hard in healthcare and
what deep action we might take to address the issue.
Over the past 40 years the quality and safety of a wide range of industries have been transformed by
the systematic application of a range of tools and techniques under the banner of Quality
Improvement (QI). It is these approaches that bring us the extraordinary range of high quality/high
value cars and manufactured goods, and allow us to fly safely in our billions.
Healthcare as an industry came somewhat late to this revolution. Led by pioneers around the world,
and in particular by the inspirational work of Don Berwick and colleagues at the Institute for
Healthcare Improvement, and Helen Bevan and colleagues in the UK; hospitals and other parts of
the healthcare systems in many countries began, from the 1990s onward, to modify and apply these
techniques to improving the quality, safety and value of healthcare.
And just as well. Healthcare as an industry is a hugely significant part of the economies of developed
countries, and its spiralling costs threaten its own viability and the economic stability of those
countries. The impact of quality and safety failings is nothing short of disastrous in the lives of
people who use the service – and the nature of healthcare means that it is utilised by almost
everyone in society. In other words, there are few more important missions than the application of
quality improvement approaches to transform the quality and value of healthcare.
So how are we doing? At one level, extraordinarily well. The international efforts outlined above
have led to significant increases in the application of these approaches around the world, measured
improvement in key variables of safety and quality and real and tangible exemplars of excellence in
continuous improvement from individuals, teams and some organisations and systems. To say that
such efforts should be applauded is an understatement. They represent an impact in lives saved and
improved that is of enormous social benefit. The individuals, teams and organisations who are
responsible for it should feel enormous pride and be the recipients of recognition. It is truly great
work.
And yet I am left feeling unsatisfied, for three reasons:
1. the growth in QI activity and its impact has been very significant – but does not represent
the creation of unstoppable momentum towards the creation of a self improving industry.
Spread of great improvement ideas continues to require enormous “push” from the
advocates of change (through pilots, campaigns and spread initiatives) rather than being
“pulled” hungrily from all frontline organisations;
2. the pace of that growth is substantial when measured against the starting point, but remains
insufficient when measured against the need for all healthcare to benefit from
improvements in quality and safety. As users of healthcare we are waiting too long for the
benefits of QI to reach all of us reliably;
3. even where we are working so successfully, we have yet to make significant impact on the
costs of healthcare – a problem so profound that it threatens the future of healthcare
availability in every country of the world. In other QI led industries it is axiomatic that
working on cost reduction and quality improvement are part of the same, positive, process.
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In healthcare, they are still often seen as fundamentally irreconcilable objectives, with the
result that healthcare is slowly destroying itself through its cost growth.
So why is it that we’re being successful in applying QI to get healthcare right and sustainable but, in
my view at least, nothing like as successful as we need to be? I’m pretty sure it’s not for a lack of
smarts – many of the smartest people around are working as doctors, nurses, wider health
professionals and executives. We must be at least as smart as the people running and working in
the car industry. Nor can it be for lack of imagination or effort. Spend a day in the IHI offices in
Cambridge, Mass. or the IQ offices in England and you will be overwhelmed by how much of those
commodities they are bringing to bear on the problem. Purpose can’t be lacking either – making
better healthcare must surely be a more motivational cause than making better widgets. So just
what is it?
As someone who has been working in healthcare quality improvement for over 20 years, seeking to
lead this change as a hospital CEO, running local systems and driving quality and efficiency for the
whole of the National Health Service in England I have come to believe that there are indeed a
number of deep reasons why driving quality improvement at scale in healthcare is particularly
challenging. Moreover, unless these deep issues are tackled with focus and energy then efforts to
drive transformational improvement in quality and cost will continue to demonstrate success – but
at a level below what is required.
So what are these reasons? I am going to suggest four:
1. that the economic drivers don’t work powerfully enough to drive the change;
2. the attempt to jump a chasm from cottage industry to mass customisation in one bound;
3. the three cultural traits of medicine that inhibit large scale QI: Conservatism about change;
independence of practice and love of rescue;
4. the psychological disconnect from purpose.
In each case I will try and make my case about why this feature brings particular challenge – why
without tackling it we are likely to fail to make the move to wholesale transformation – and also
what we might do to begin to address the issue.
Challenge One: The economics don’t work to strongly support QI
It must be arguable that the triumph of QI in other industries was driven by economics. I grew up in
the era where the once great industries of the UK were being trounced by the quality and value
being made available by (initially) Japanese car and electronics manufacturers. No amount of “buy
British” campaigns were sufficient to persuade consumers that they should pay more for inferior
products. In the end local industries had to either change or die – and they did both to a very
significant extent. The power of QI to produce better, safer products and services at a lower price
point meant that the economic systems of most countries drove its adoption with unstoppable
power.
These forces do not seem to work as strongly in healthcare for reasons we all understand. The
complexity of medicine makes it difficult for us as consumers to make simple choices about quality.
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Many payor systems hide the cost from the consumer. Many choices about healthcare are
mediated through the provider of that care. In a service where – in many cases – someone highly
trusted has to lay hands on you – choices are logistically constrained by availability and geography
(in the end half of you needing surgery will have to choose a below average surgeon). Healthcare is
often needed virtually in inverse proportion to economic and social status. For many emergency
services consumer choice becomes a bit of a nonsense concept. This is a powerful list of practical
challenges to the power of economics as a driver.
I have also come to believe that there is a powerful psychological block for us as consumers in
exercising this power. Allowing medical teams to render you unconscious, open your body or ask
you to ingest mind and body altering substances are acts of extraordinary trust. They require great
confidence in those who are going to carry out the procedure. You don't always want to have the
information to make the choice.
So whether it is value or quality, the economics that drive so powerfully in support of quality
improvement in other industries seem to have a weaker effect in healthcare. It is why quality
improvement in our industry has relied so much on intrinsic motivations (which I discuss later). And
why in many countries, there have been efforts to strengthen the role of information, choice and
commercial motivation in driving healthcare improvement. Quality improvers should engage directly
with these efforts, however they present in their jurisdiction.
And in seeking to offset the relative weakness of the economic driver we, as quality improvers
should:
1. participate strongly in efforts to publish information about service quality as transparently as
possible direct to service users. They should seek to influence such programmes to base such
information on measures related to improvement and measurement methods which drive
improvement. They should shape their improvement work to those areas measured in such
quality measurements to amplify its importance;
2. participate strongly in efforts to link measured quality improvement with payment systems. As
above, seeking to influence such systems to focus on areas where there is strong improvement
activity and effective measurement, and shaping QI efforts to support areas targeted by quality
payment systems. Accepting that the evidence for these quality incentive schemes is mixed, see
and contribute to the process of developing such processes as an improvement1 process in itself;
3. when redesigning pathways, maximise the opportunity, working with service users, to inject the
availability of information and the exercise of choice (of treatment, location, clinician and
provider) into those pathways;
4. work relentlessly - relentlessly - on the task of delivering quality improvement and value
improvement together - so that QI becomes the essential tool for delivery of this requirement
given that the overall economics of cost - if not of the market - are likely to be a dominant driver
in all systems over the coming years;
1
The Institute of Medicine (2006): Rewarding Provider Performance: Aligning Incentives in Medicare. National
Academies Press
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5. become the experts (or a core part of the expertise) on the measurement of quality and value
improvement;
Given that, even with the above action, extrinsic economic drivers are always likely to be relatively
weak in health care, we should innovate massively on strengthening the intrinsic drivers. Helen
Bevan's world leading work on using social movements and weak-tie affiliations to create progress2 ,
IHIs spectacular mobilisations of large scale campaigns for specific improvements3, or NHS Scotland's
constant system wide drive for improved safety4 are perhaps the best current large scale examples I
know. The potential of social media is also intriguing - given that they are reshaping economic
drivers in other industries - with Christina Krause's work with BCPSQC to harness this in British
Columbia being a great example5.
Challenge Two: Complexity and mass customisation
It's hardly novel to make the comment that the complexity of delivering healthcare makes its
delivery and improvement difficult. Although the complexity is sometimes (probably often)
overstated almost as an excuse for limited progress - there is no doubt that it is a challenge.
Renee Almaberti,the remarkable international leader on healthcare safety knowledge, is also expert
in aviation safety, and speaks powerfully about how the environment for a pilot, even with weather,
complex mechanical systems and human interaction in the cockpit, is far more controllable and
controlled, than most healthcare environments. We have to make our improvement happen in a
complex world. To do average or good work in QI in health we probably have to have leading edge
capability.
If the complexity is obvious, I want to make a slightly different point - which is that the work to
create and implement improved patient pathways is something that other industries would
recognise as mass-customisation - a set of lean, standardised processes that can be efficiently and
appropriately varied in order to meet individual needs.
Again other industries have cracked this. When I buy a reasonably priced new car today I am offered
an almost bewildering array of options on colour, engine, interior trim and electronics which enable
the car to come off the production line built to my specification. It is impressive, and analogous to
what I am seeking from my healthcare provider when I am a patient.
But it was a long journey for the car industry to get to the point of being able to make that offer.
And of course it started with optimising the production standards around rigid standardisation ("any
colour you want as long as it's black"), then offering limited variation in models, before discovering
that the same tools that were creating lean processes on those standard production lines could also
be developed to allow mass customisation.
2
NHS Institute (2011) Helen Bevan on Social Movement Thinking: A Set of Ideas Whose Time Has Come?
http://www.institute.nhs.uk/quality_and_value/introduction/helen_bevan_on_social_movement_thinking%3A_a_s
et_of_ideas_whose_time_has_come%3F.html
3
Berwick DM, Hackbarth AD, McCannon CJ (2006) IHI replies to "The 100,000 Lives Campaign: A scientific and
policy review. Jt Comm J Qual Patient Saf. 2006 Nov; 32(11):628-30; discussion 631-3.
4
http://www.scottishpatientsafetyprogramme.scot.nhs.uk/about-us
5
http://bcpsqc.ca/blog/events/isqua-webinar-the-bcpsqcs-social-media-journey-thus-far/
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Whereas I often think we are trying to straight from cottage industry to mass customisation in one
leap. Cottage industry may be somewhat unfair - but if you look through the high tech medical
equipment often in large shiny buildings, the clinical management practices that are driving the care
often look more like small scale, informal, craft based practices than highly systemised and process
driven industries. It cannot be surprising that we find it hard to move from where we are to the sort
of systems we want to create in one step.
So to assist in dealing with this complexity, and in particular with the challenge of needing to move
to mass-customisation, we, as QI leaders, need to:
6. move through standardisation in order to allow mass customisation. In my view we need to
reduce unplanned variation before we enable planned variation. The cultural obstacles to this
are discussed later, but QI should relentlessly work to standardise processes (the big cultural
obstacles to this are discussed later);
7. in order to enable mass-customisation in the complex world of healthcare develop the level of
improvement expertise to the highest possible level – because mass customisation requires
expert practice. there is still too much just-good-enough development in this area. It needs to
be a pre-requisite of executives and a core part of the curricula of all healthcare staff pre and
post qualification;
8. in addition to the elements of QI that are focussed on redesign and engagement, further
increase and value the level of technical expertise in logistics, the management of complex
supply chains. The systems expertise to make such complex supply chains work in other
industries is stunning – but massively underdeveloped in health care. When we talk loosely
about integrated or seamless care we are really groping for the ability to manage a complex
integrated supply chain built around the patient’s needs;
9. Engage with information and measurement systems in departments, organisations and systems
to measure and respond to adherence to and deviation from agreed pathways. It is interesting
to me that the long standing international exemplar in this area - Brent James' work at
Intermountain Healthcare6, has been one of the hardest to replicated despite their fantastic
work in training others. I suspect this is because the level of technical expertise, unending focus
on measurement and the desire to tackle the unwarranted variation is so technically demanding
and counter cultural that few others have the skills and commitment that Intermountain have
demonstrated to follow it through. But if mass-customisation in a complex world is the endpoint
then we need to get to that level.
CHALLENGE THREE: THE 3 CULTURES OF MEDICINE
Given that this section includes some critical comments about the culture of medicine that inhibit
QI, I should start by being clear that as a non-clinical executive of almost 30 years, it is working with
doctors and other clinical staff that has been the joy of my career. These overwhelmingly
6
Brent C. James and Lucy A. Savitz (2011) How Intermountain Trimmed Health Care Costs Through Robust
Quality Improvement Efforts. Health Aff June 2011 vol. 30 no. 6 1185-1191
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committed, caring, skilful, hardworking (and occasionally difficult!) colleagues are - of course- the
greatest blessing and potential enjoyed by any industry.
For all that positivity, I have come to believe through experience that the deep culture of medicine
drives much of the culture of healthcare and that there are deeply rooted aspects of that culture
that work against the success of QI efforts - and therefore needed to be addressed by QI leaders.
The first relates to the issues of standardisation outlined above – that medicine has an entrenched
culture of individualism. One of the key rewards of the achievement of a qualification to practice
medicine is seen clearly by many as being the right to independence of practice - that nobody else
should be able to tell you how to practise. Defending this right against outside interference, from
almost any source - is given great energy, with any level of standardisation being dismissed as "cook
book medicine".
I vividly remember a comment made by a great clinical leader in the UK who had lead work on the
implementation of the surgical check list, describing the moment when the spread strategy moved
from encouragement to making its use mandatory. He described how at that point support was lost,
including from many who had already adopted the tool. The cultural norm of individualism had been
breached - and the invader needed to be repelled - even, quite literally, at the cost of lives.
QI in healthcare depends upon the design and implementation of efficient, high value, standardised
pathways, with appropriate variation from those monitored and reviewed. In these terms, it runs
deeply counter to a prevailing element of the culture of medicine.
The second element I wanted to address is a culture of conservatism, that is of basic resistance to
new forms of practice. This has positive roots, in that medicine has moved away from its early days
of allowing doctors to experiment at whim on their patients, to a safer, more ethical and scientific
process of only allowing such experimentation within tightly controlled circumstances. This is surely
right. What is more interesting is how slow dissemination of new practice, even given favourable
results in the scientific process, can be. Given that the results of complex scientific studies are rarely
completely definitive, this conservatism is often couched in a debate about the quality of evidence.
This may be an expression of the culture of individualism described above, but it has often seemed
to me that doctors have become the masters of using debates about evidence to justify their own
treatment preferences.
When this mindset is extended from the clinical intervention to the delivery processes in which the
actual medical treatment is given, the situation becomes even more perilous for QI. Innovation is
something that can only be done in research institutions in carefully controlled big trials - not in the
sort of local small scale change that is a part of the QI method; good ideas which seem to work
cannot be spread unless they are the result of gold standard RCT published studies - something alien
to the QI approach's small scale uncontrolled experimentation; status and reward is given to
invention rather than adoption - completely the reverse of what is required to drive QI at pace and
scale.
Again the QI method runs deeply counter to a powerful and dominant medical culture, with the
defence method in this case being often a somewhat sneering disregard.
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Finally, it is has been my experience that medicine gives great value to a culture of rescue. This is
hardly surprising. I think I can be forgiven a touch of envy when I see the huge personal satisfaction
and acknowledgement medical colleagues receive when they pull off the "great save" with a patient.
A moment when their knowledge, skill and judgement come together to save or change a life. It is
wonderful - and deeply seductive - look how the entertainment industry relentlessly peddles it.
And in my view it has spawned a wider culture in which the against the odds save, the heroic actions
of the individual (that word again) over the system, have precedence. Even planned care often looks
as though it is run in a way which maximises rescue over routine (resistance to the surgical check list
again).
The problem with QI, of course, is that implemented well it creates calm, ordered routine, even in
emergencies. The great save still has its place of course, but in precisely the circumstances that
demand it - not as the norm. We have to learn how to give value to calm, ordered routine care
rather than (or at least as well as) the great save.
Again, in the case of the love of rescue, the deep culture of medicine runs directly against the grain
of QI - and so again we should perhaps not be surprised that it is hard to make QI operate at scale at
pace in healthcare.
In response to these challenges in the culture of medicine, we, the QI leaders should:
1. be focusing on culture change at least as powerfully as they do on process change, implying that
they join up with work on leadership development and the creation and dissemination of values.
In my experience there is an unhelpful divide between QI and leadership development
practitioners and we need urgent work at all levels to create a join between these two
disciplines to effect culture change for quality improvement;
2. take forward the long term work on dealing with the culture of individualism, including selection
at every point of those who recognise the value of team working and appropriate conformance
to standards (commercial airlines grew gradually less attracted to recruiting ex-military pilots,
recognising their different orientation to risk); selected work to drive through standardisation;
and engagement with clinical leaders to develop, communicate and oversee the relevant
standardisation. All this is obvious and often underway. I would add an additional suggestion that QI leaders should engage with providers of medical indemnity insurance providers to set
standards of acceptable practice in terms of conformance to agreed standards that are essential
if cover is to be provided. It is an example of one of the places where "soft" cultural norms are
encoded into "hard" systems - in this case what represents acceptable (and thus insurable)
practice. QI leaders should seek out these encodings and influence them;
3. my recommendation on dealing with the culture of conservatism is, somewhat perversely, to
avoid getting dragged into the mire of evidence debates. This runs counter to work over recent
years by some of the best of the best7 to demonstrate that quality improvement is a science albeit one with more in common with social sciences. I am afraid that, even as a passionate
advocate of QI I don't buy it. It is a set of practices - with lots of great evidence of success that
7
http://www.ihi.org/education/WebTraining/OnDemand/SoupwithFork/Pages/default.aspx
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falls below the standard of science to suggest it is worth pursuing - and we should leave it at
that. Trying to engage with the hard researchers and academics on the science point is just like
wrestling with pigs, you both get dirty but the pigs like it (some of my best friends are academics
by the way...). Focus on leading change through the diffusion of innovation curve, working your
way methodically through from early implementers onward. Get improvements incentivised (as
above) or mandated if you can. Engage like crazy. Just don't wrestle with pigs.
4. we need to deal with the culture of rescue by giving explicit value to calm, ordered routine care.
Just think about those signs on construction sites over recent years, exhorting safety and
displaying the number of days since an accident. Those are exactly that sort of value creation
for safety and conformance to process in an industry that was known for its macho cavalier
attitudes two decades ago. To some extent we are already doing this - in areas like measuring
and celebrating time between infections - but lets have more of these - and how about
developing some measures of calm and order - and measuring and celebrating those.
CHALLENGE FOUR: THE PSYCHOLOGICAL DISCONNECT FROM PURPOSE
When I have discussed elements of these proposals with great healthcare QI leaders, many of them
are concerned with my focus on a fairly tough approach to incentives and culture change. They
point instead to the potential of harnessing the implicit motivations of colleagues who largely
became healthcare professionals with a great moral purpose.
I do not dismiss or minimise this for a moment. Work to engage purpose and commitment (again I
would point to Helen Bevan's seminal work on creating social movements) is powerful, right and
necessary. The arguments above just reflect that this intrinsic purpose does not seem to have been
enough to achieve the results we seek. Of course we should do more to harness our moral purpose
- but it is interesting to reflect on why it has not proved sufficient.
I have come to believe that it may be insufficient to rely on an implicit sense of moral purpose to
drive service improvement, because great professionals are forced to maintain a sense of profound
psychological separation from that purpose. Being a clinical professional is tough. Of course you get
enormous rewards from treatment successes - but you are also forced to deal with tragedy, harm,
death in all its forms and helplessness in the face of desperate expectation from patients and
relatives. Handling this has the risk of being overwhelming, and it seems to me that clinicians are
given profound and largely covert training in maintaining psychological separation from that burden
of emotion. I often wondered whether, in traditional medical training in the UK, new medical
students being given a human cadaver to dissect as one of their first experiences, was as much
about initiating this separation as it was about anatomy. Medical humour, the focus on systems and
disease rather than people, a training culture about toughness and survival - all of these seem to
inculcate and foster that separation.
And perhaps it is necessary to emotional survival. And it does not meant that those people cannot
be and seem professional and caring. But when viewed through the lens of QI it can also mean that
ensuring you are not professionally destroyed by harm to patients creates an understandable
reluctance to acknowledge the harm that is being done as a precursor to reducing it. Perhaps even
that working to provide care inside ineffective systems provides an alternative point of blame for the
impact of those failings on patients (I have lost count of the times I have heard colleagues in the
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National Health Service in England tell patient they could have experienced better care if it wasn't
for the failings of the system).
In other words, the calls within QI to reconnect directly with the patient experience, or to
relentlessly measure performance good and bad - represent a threat to break through the layers of
psychological protection that professionals have built up and that allow them to do their job.
In response to this QI leaders should work to provide systems of explicit psychological support to
those clinicians who are asked to become involved in the work of improvement. Perhaps the
concept in the mental health professions of supervision, acknowledging the impact on the mental
health of the professional of dealing with mental health problems in others and supporting them
through it, has something to offer. But if we are to remove the safety nets of opaque data or failing
processes, and thus bring the clinician face to face with the negative implications of their practice as
well as the positive ones - we need to provide the psychological support that makes that
engagement possible.
CONCLUSION
QI leaders in healthcare have done amazing work over the last two decades. As a result many
thousands of lives have been saved, harm reduced, experience improved and efficiency improved.
But we have not yet, in my opinion, created an unstoppable industry wide drive for improvement. It
could be argued that I am wrong, and that the significant momentum that has been achieved in QI
will mature sufficiently to create this drive. If so, all well and good, but particularly given the
accelerating financial challenge facing all systems, I don't think it's safe to wait and hope.
My conclusion from 20 years seeking to lead QI at a senior level in a large health care system is that
running more and better QI programmes is necessary, but nothing like sufficient. Rather we need to
recognise that there are specific factors - economic, cultural and psychological that make QI work
particularly challenging.
These factors create a somewhat stony soil into which our QI work seeds fall. Good farmers work on
the soil. As QI leaders we need to work on the deeper environmental factors at least as hard as we
work on the QI programmes themselves, or we will continue to find good results hard to sustain, and
spread hard to drive. The fifteen suggested actions for QI leaders in this opinion piece may or may
not be the right ones (although I think there are some potentially important avenues for work here) but I would suggest that all QI leaders reflect on the issues in the environment they need to change
if our work is to have the lasting effect it needs to have.
In making these recommendations I am conscious that the action suggested is not all in the gift of
most QI leaders - or even or organisational CEOs. The actions fall in the realms of payor policy,
information systems, indemnity insurance, recruitment, leadership development, measurement and
market development to name a few. Which leads to perhaps to my most important
recommendation - which is that QI leaders need to get everywhere - wherever these policies are
being formulated or enacted, QI leaders need to get themselves onto advisory panels, influence
decision makers, permanently or temporarily take leadership roles in these areas, write articles and
make presentations, lead pilots - in short, on this broader canvas, do what they do best - and lead
change.
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Jim Easton
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