The nature of improvement

Quality improvement is often narrowly identified with a set of techniques adapted from industrial settings. They include the US Institute for Healthcare Improvement's Model for Improvement, which, among other things, combines measurement with tests of small change (plan–do-study–act cycles). These techniques provide a useful toolkit and are applicable to many problems, but more mature improvement organisations will draw on a much wider suite of methods when the occasion demands.

The most immediately effective quality and safety improvements have been those with a strong focus on a core clinical issue or a specific clinical process or pathway, often using checklists and ‘care bundles’ of interventions that increase the consistency of care.^{Reference Shekelle, Pronovost, Wachter, McDonald, Schoelles and Dy7} Many other types of intervention can be employed to help staff to work more effectively.^{Reference Vincent and Amalberti8} For instance, medication errors have been reduced by standardising formularies and protocols, by including pharmacists in ward rounds and by introducing computerised prescribing. Errors can also be reduced by improving working conditions, for instance by minimising the interruptions and distractions that greatly increase propensity to error.^{Reference Vincent9}

Centres of improvement

Quality improvement is often a small-scale, local activity in which each team painstakingly works out its own solution for each problem.^{Reference Dixon-Woods10} The core quality improvement methods are aimed at the engagement of frontline staff, who are empowered to address problems in their own environment. This is certainly valuable but not sufficient to address complex, entrenched problems. Working in this isolated way means a lack of critical mass to support the right kinds of expertise, such as the technical skill in human factors or ergonomics necessary to engineer a process or devise a safety solution.^{Reference Dixon-Woods10}

Larger organisations can build improvement capacity and skills by developing permanent multidisciplinary centres to provide sustained inspiration, research, training and practical support for implementation and innovation.^{Reference Vincent, Batalden and Davidoff11} Small units exist within many hospitals and other healthcare organisations, but are often mainly concerned with regulation and compliance. The centres described in the series of papers on quality improvement in this issue of BJPsych International have a wider vision, however. They aim to systematically improve the safety and quality of care provided to patients and the working lives of their staff. While they are very different in size, scope and in their place in the healthcare system, they share some common characteristics. First, they are led by people who are passionate about improving healthcare. Second, they have support from senior managers and executives in their organisations or region. Third, they all provide education and training programmes in quality and safety improvement, which range from short introductory courses to deep programmes of study. Fourth, they are all open to wider learning both within and outside their organisations. Finally, they have all built trust within their teams and organisations to enable open discussion of safety and quality issues. In the longer term, organisations must also build an infrastructure for quality improvement that includes an information system to track change, dedicated improvement leads across the organisation, and an education programme and a department or an institute to support improvement.^{Reference Ovretveit and Staines12}

Making a start

Many reading these papers will admire what has been achieved in Jönköping, Tuscany or other centres but think that this could not be achieved in their own environment. All these centres, however, began with a small group of enthusiastic people who tried to tackle immediate local problems. From such small beginnings, they eventually built the established centres described. Wherever you work and in whatever system, we hope these papers and these centres will inspire you and support you on your improvement journey.