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Views And Reviews Acute Perspective

David Oliver: Should practical quality improvement have parity of esteem with evidence based medicine?

BMJ 2017; 357 doi: (Published 30 May 2017) Cite this as: BMJ 2017;357:j2582

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Quality Improvement and ethics

This Acute Perspective by Dr David Oliver (1) has our interest, in part because we all embarked on our career in medicine around the same time.

We very much share Dr Oliver's advocacy for "the actions and engagement of frontline practitioners and the real world context in which they work" and agree that these "are critical to success."

We would like to contribute in the spirit of critical thinking (2) regarding the place of ethics in Quality Improvement (QI).
Dr Oliver states that QI can deliver “tangible outcomes” and that it has “a methodological and theoretical rigour and peer community of its own”.

As far back as 2007 Brent et al identified that "ethical issues arise in QI because attempts to improve quality may inadvertently cause harm, waste scarce resources, or affect some patients unfairly."(3)

Dr Oliver states that “ethical approval is less burdensome” for QI. We are of the view that ethics must be one of the necessary starting principles for any QI work and would argue that any attempt, however well intentioned, to demote ethics from this role might result in outcomes that may not be described as “improvement”.


(1) Oliver, D. Acute Perspective: Should practical quality improvement have parity of esteem with evidence based medicine? Published 30 May 2017. BMJ 2017;357:j2582

(2) Sharples et al. Critical thinking in healthcare and education. Published 16 May 2017. BMJ 2017;357:j2234

(3) Brent, J et al. The Ethics of Using Quality Improvement Methods in Health Care. Ann Intern Med. 2007;146:666-673.

Competing interests: No competing interests

04 June 2017
P.J. & S.F. Gordon
Psychiatrist for Older Adults and General Practitioner
Bridge of Allan