Intended for healthcare professionals

CCBYNC Open access
Feature Quality Improvement

Getting more health from healthcare: quality improvement must acknowledge patient coproduction—an essay by Paul Batalden

BMJ 2018; 362 doi: (Published 06 September 2018) Cite this as: BMJ 2018;362:k3617

Read the full collection

  1. Paul Batalden, professor emeritus, paediatrics, community, and family medicine
  1. Dartmouth Institute for Health Policy and Clinical Practice, Geisel Medical School, Dartmouth College, Lebanon, New Hampshire 03756, USA
  1. paul.batalden{at}

Modelling healthcare as either a product or a service neglects essential aspects of coproduction between doctors and patients. Paul Batalden shares his learning from 10 years of studying change

All clinicians experience moments when the healthcare system in which they work makes it difficult for them to deliver good care for their patients.1 Healthcare increasingly seems to include frustrating processes and unmanageable administrative burdens that reduce the time available for patient care, with negative effects on health outcomes.

Clinicians are also increasingly called on to improve the quality of the systems of care that they deliver. Many participate in improvement efforts, from experiencing large scale, top-down organisational change to making small changes that improve the ways their team works and cares for patients. Some will have taken courses on audit, the Model for Improvement,2 Lean,3 and more.

For many clinicians, however, the underlying question, “What is quality improvement, and how can it transform healthcare?” remains unanswered.4 Full appreciation of what it means to get more health from healthcare demands as full an understanding as possible of the systems to be improved. Fortunately, the past decade has afforded many opportunities to fundamentally challenge thinking about how healthcare actually works and how it contributes to health.

Healthcare as a product: an oversimplified model

In 2007, a colleague and I described a frame for thinking and working to improve and transform healthcare.5 This involved a substantial shift in the way we thought about healthcare; the shift became widely used as one definition of quality improvement. Through asking the question, “How might system-wide improvement strategies and efforts usefully improve healthcare?” we began to think in terms of systems and processes, considering how to integrate improvement efforts with daily clinical operations and professional development.

Our models were taken from manufacturing, with products ranging from electronics to cars. …

View Full Text