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Rapid response to:

Feature Quality Improvement

How to improve healthcare improvement—an essay by Mary Dixon-Woods

BMJ 2019; 367 doi: (Published 01 October 2019) Cite this as: BMJ 2019;367:l5514

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Rapid Response:

Improving quality improvement - a reply to an essay by Mary Dixon-Woods

Dear Editors

We thank Mary Dixon-Woods for her thought-piece on the improvement of healthcare improvement. While we appreciate that the topic ´effectiveness of quality improvement efforts´ is being discussed in a general medical journal, we feel the need to highlight that many of the ideas formulated have been extensively discussed in the more specialized journals in the past and perhaps some important ideas are missing.

We would like to add four points.

First, since Donabedian’s seminal publication on ‘evaluating the quality of care’ [1], substantial literature on tools to assess and improve the quality and safety of health care has evolved [2]. It is true that it is only more recently; however, that the effectiveness and impact of quality improvement strategies themselves are subject to evaluations through implementation science and that the design of many quality improvement studies have methodological flaws as we have highlighted in the past [3].

Much of these flaws relate to the complexity of the health care environment and of the professional-patient encounter, multifaceted interactions to improve outcomes, the time lag in which some outcomes occur, and the nature of health and disease themselves all interact and contribute to the epistemology of quality improvement research.

Perhaps one of the missing components in advancing quality improvement research is a unifying model of quality improvement systems, beyond the archetypical Dona-bedian style structure-process-outcome model. Quality improvement research frequently establishes a causal link between distal factors (improvement strategies) and quality and patient safety outcomes. These causal links are very complex as we could show for the relationships between hospital quality management strategies, their adaption in different hospital departments and their impact on clinical and pa-tient-reported outcomes [4, 5].

Second, most quality improvement initiatives focus on institutional settings, the majority on hospitals, but also ambulatory care and other settings. However, health outcomes are not just the effect of a set of interventions in one setting, but rather the result of a complex care pathway, including primary, secondary, self-care and other contributors. Quality improvement approaches in integrated care settings; however, are rare, yet this is probably where a much larger impact on a range of outcomes can be achieved, given the predominant failures to ensure timely referrals, continuity of care and follow-up care in the community after discharge [6].

Third, and linked to the previous point, quality improvement in institutional settings (or integrated care settings if it were) can´t be easily disentangled from the wide range of national quality strategies and contexts in which they are being implemented. For example, in OECD countries outcomes for avoidable hospital admissions vary by a factor of nearly 10 – measuring the effect of quality improvement in the presence of very strong contextual factors that confound any relationship between quality improvement and outcome is a challenge [7]. Similar gradients exist within countries.

Finally, it is gratifying to see the importance of patient-empowerment and co-production being highlighted in a general medical journal. These are issues of vast importance given the challenges today´s health systems face. It is worthwhile high-lighting that these issues have been studied intensively in medical sociology and health psychology for decades, in particular the role of co-production in human service organizations and the principle of saluto-genesis as opposed to the dominant focus on understanding pathological processes [8, 9]. We would encourage readers however to understand the patient not just as a contributor to quality outcomes but to embrace patient empowerment also as a right and as an opportunity to introduce more reflexive learning and feedback about the nature of medical care [10].


[1] Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarter-ly1966;44:166–206
[2] Groene O, Kringos D, Sunol R on behalf of the DUQuE Project. Seven ways to improve quality and safety in hospitals. An evidence-based guide. DUQuE Collaboration, 2014,
[3] Groene O. Does quality improvement face a legitimacy crisis? Poor quality studies, small effects. J Health Serv Res Policy. 2011 Jul;16(3):131-2.
[4] Sunol R, Wagner C, Arah OA, Kristensen S, Pfaff H, Klazinga N, Thompson CA, Wang A, Der-Sarkissian M, Bartels P, Michel P, Groene O; DUQuE Project Consortium. Implementation of Depart-mental Quality Strategies Is Positively Associated with Clinical Practice: Results of a Multicenter Study in 73 Hospitals in 7 European Countries. PLoS One. 2015 Nov 20;10(11):e0141157
[5] Groene O, Arah OA, Klazinga NS, Wagner C, Bartels PD, Kristensen S, Saillour F, Thompson A, Thompson CA, Pfaff H, DerSarkissian M, Sunol R. Patient Experience Shows Little Relationship with Hospital Quality Management Strategies. PLoS One. 2015 Jul 7;10(7):e0131805
[6] Groene O, Pimperl A, Hildebrandt H. The role of integrated care and population health. In: Aase K, Waring J, Schibevaag L (eds). Researching quality in care transitions: international perspectives. Pal-grave Macmillan, Cham: 2017, 259-279
[7] Busse R, Klazinga N, Panteli D, Quentin W (eds). Improving healthcare quality in Europe Character-istics, effectiveness and implementation of different strategies. World Health Organization/OECD, Copenhagen, 2019
[8] Antonovsky, A. (1979): Health, Stress and Coping, San Francisco
(9) Hasenfeld Y. Human services as complex organizations. 1st edition. Sage, Los Angelos, 1992
[10] Groene O. Patient centredness and quality improvement efforts in hospitals: rationale, measure-ment, implementation. Int J Qual Health Care. 2011 Oct;23(5):531-7.

Competing interests: No competing interests

10 October 2019
Oliver Groene
Honorary Senior Lecturer
Rosa Sunol
London School of Hygiene and Tropical Medicine
Tavistock Place 15 - 17