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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:

How to Improve Healthcare Improvement? – Only by Improving the Health System “As-A-Whole”

The assay tacitly alludes to the fact that performance outcomes in a system are whole-of-system outcomes [1].

It is rather disappointing that this is not spelled out more loudly and clearly. In a nutshell, the article lists lots of examples that show that health improvement activities in any domain have fail, and the author remains somewhat surprised about it.

It should not come as a surprise if you understand the SYSTEMIC nature of a problem.

As Russell Ackhoff from the Wharton School of Management pointed out a long time ago, a system is a whole that cannot be divided into independent parts, as a system’s properties are not present in its parts. It is not the actions within a part, but the INTERACTIONS between parts, that results in the observable – here undesirable – outcomes [2].

Ackhoff demonstrated that efforts to improve a problem in a system’s parts – the activity of almost all improvement endeavours in any industry – is not going to improve the performance of a system, UNLESS it simultaneously also improves the system-as-a-whole.

A closer analysis would suggest that almost all health systems around the world are now in a state that requires their redesign – improvement efforts to any of its parts is no longer an option, those efforts are now unlikely to get us to where we want to be [3].

1. Dixon-Woods M. How to improve healthcare improvement—an essay by Mary Dixon-Woods. BMJ. 2019;367:l5514.
2. Ackoff RL, Gharajedaghi J. Reflections on Systems and Their Models. Systems Research. 1996;13(1):13-23.
3. Sturmberg JP, Picard M, Aron DC, Bennett JM, Bircher J, deHaven MJ, et al. Health and Disease—Emergent States Resulting from Adaptive Social and Biological Network Interactions. Frontiers in Medicine. 2019;6:59.

Competing interests: No competing interests

21 October 2019
Joachim Sturmberg
A/Prof of General Practice
University of Newcastle - Australia and Foundation President - International Society of Systems and Complexity Sciences for Health
Holgate - Australia