Applying quality improvement approaches to health care

Martin Marshall's excellent exposition of the challenges and
opportunities
faced when applying quality improvement methods to healthcare that are
derived from manufacturing and service industries only obliquely engages
with a crucial practical issue. Hospitals are amongst the most complex of
all
human organizations. Quality improvement programs are necessarily as much
social, as technical, interventions. They touch closely on the
sensitivities of
the staff, who are generally confident that they know their own business
better than anyone external who is attempting to change things.

For the last seven years, we have been struggling with a program of
quality
improvement, based on Lean Thinking1,one of the weird and wonderful
approaches described by Marshall. Over time, we have learnt to separate
out
issues of authorization from permission. A quality improvement program of
any substance has to be authorized by the management and governance
structures within a hospital. These are the people who have to say 'yes'.
But
merely being authorized to improve things cuts no ice with the staff on
the
ground. They have to give permission for their own work to become part of
the quality improvement process. They can say 'no' to quality improvement,

and when they do, there is not much that anyone else can do.

It is vital to begin any program of quality improvement by ensuring
that the
work is properly authorized. But then an extensive program of engagement
has to begin that builds permission. Permission can never be taken for
granted. Our own practice is to start by conducting a large scale mapping
exercise in which staff from all levels in the service or settings where
improvement is sought, come together and explain what it is that they do,
at
each step of the process to be improved. If patients can be directly
involved
in such sessions, so much the better. These sessions are always a
revelation
to all involved. The experience of allowing all levels of staff to speak
and be
listened to is as important as the technical aspects of the mapping
process. It
is a beginning that engages with the social system without ignoring the
more
familiar biomedical technical components of healthcare.

1. Ben-Tovim DI,Bassham J, Bolch D, Martin M, Dougherty M, Swarcbord
M.
Lean Thinking across a hospital, Redesigning Care at the Flinders Medical
Centre Aust Health Rev 2007;31:10-15

Competing interests:
None declared