Introduction

That improvements are possible in many areas of clinical care has become increasingly clear. The different players within health care, however—clinicians, epidemiologists, health services researchers, educationalists, social scientists, economists, health authorities—often have different ideas on the best strategies to improve practice and the best way of making changes.

An example

Let us assume that aggregated data, collected by health authorities, disclose that the rate of caesarean section in a specific district is exceptionally high. A committee is formed with experts and representatives of various interests to develop plans for improving obstetric care. Hearing the problem, all are worried.

The clinician either denies there is a problem or proposes setting up a well designed course to increase clinicians' knowledge and skills.

“OK,” says the clinical epidemiologist, “but we first need to know what the evidence is on the indications for a caesarean section. We should perform a meta-analysis and come up with evidence based guidelines to disseminate among the obstetricians.”

“No,” says the educational expert: “that is a top down approach and such strategies will usually fail. Form small groups of doctors and let them discuss the problem, using cases and experiences from their own practices as the basis for local arrangements on new routines.”

“We should take a look at the facts first,” says the health services researcher. “Let us set up a multicentre audit first and collect data on actual variation between hospitals and include data on casemix. Feeding this information back to the hospitals will probably stimulate improvement.”

“You are all focusing too much on the individual doctor,” says the management expert. “The problem is not the doctor, but the system. We should analyse the process of decision making and performing the caesarean sections and see what structures determine the process. Next we need a quality improvement team.”

“This is …