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Analysis Quality Improvement

Changing how we think about healthcare improvement

BMJ 2018; 361 doi: (Published 17 May 2018) Cite this as: BMJ 2018;361:k2014

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  1. Jeffrey Braithwaite, professor of health systems research and president elect of the International Society for Quality in Health Care
  1. Macquarie University, Australian Institute of Health Innovation, Level 6, 75 Talavera Road North Ryde, NSW 2109, Australia
  1. Correspondence to: jeffrey.braithwaite{at}

Complexity science offers ways to change our collective mindset about healthcare systems, enabling us to improve performance that is otherwise stagnant, argues Jeffrey Braithwaite

For all the talk about quality healthcare, systems performance has frozen in time. Only 50-60% of care has been delivered in line with level 1 evidence or consensus based guidelines for at least a decade and a half12345; around a third of medicine is waste, with no measurable effects or justification for the considerable expenditure6789; and the rate of adverse events across healthcare has remained at about one in 10 patients for 25 years.10111213 Dealing with this stagnation has proved remarkably difficult—so how do we tackle it in a new, effective way?

We need to understand why system-wide progress has been so elusive and to identify the kinds of initiatives that have made positive contributions to date. Then we can ask what new solutions are emerging that may make a difference in the future and start to change our thinking about healthcare systems.

Why change is hard

The overarching challenge lies in the nature of health systems. Healthcare is a complex adaptive system, meaning that the system’s performance and behaviour changes over time and cannot be completely understood by simply knowing about the individual components. No other system is more complex: not banking, education, manufacturing, or the military. No other industry or sector has the equivalent range and breadth—such intricate funding models, the multiple moving parts, the complicated clients with diverse needs, and so many options and interventions for any one person’s needs. Patient presentation is uncertain, and many clinical processes need to be individualised to each patient. Healthcare has numerous stakeholders, with different roles and interests, and uneven regulations that tightly control some matters …

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