A Health Foundation review reports that active involvement of clinicians with quality improvement remains largely unrealised. With the challenge of having to do more with fewer resources, engagement becomes ever more critical yet the NHS “often relies on overly simplistic rational-linear approaches to change that:

 end in disappointment which could be predicted by the ‘person on the street [Ovretveit]

Definition of quality

The Health Foundation defines quality as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’.

The evidence base

The authors examined published and grey literature on primary, secondary and tertiary healthcare in the UK, 1990-2009. Most studies rely on self-reported attitudes, with the risk of social desirability bias.  The review encompasses 100 or so empirical studies to broader literatures eg. evidence-based practice and change management, each with substantial bodies of research

The findings

The review highlighted 10 questions :

1. Do different healthcare professional groups define quality in the same way?

No. Different professional groups often define quality in different ways. Within a profession, thinking on what constitutes good or quality practice may be contested.

2. Do healthcare professionals think that the quality of care needs to be improved?

Yes (and No). There is agreement that it needs to be improved and clinical staff are  well able to identify important deficits in care yet many believe that quality is provided bacause it is a central tenet of professional codes of practice

3. What are healthcare professionals’ attitudes towards initiatives aimed at quality improvement?

They are reluctant to engage. Partly they believe initiatives are driven to reduce costs or that these will be ineffective. They may be concerned about harmful effects on staff and patients.

4. Do healthcare professionals have a clear understanding of the concepts and methods of quality improvement?

No. The authors describe healthcare as “replete with concepts, methods and programmes … which healthcare professionals struggle to understand.”

5. Where do healthcare professionals think that responsibility for quality improvement should lie?

Doctors see that defining and assessing healthcare quality is a medical responsibility. “Managers may struggle … against entrenched attitudes, and they may have to devise strategies to circumvent considerable opposition. There is an increasing recognition … of organisational or systems approaches….” Patients have a role

6. What do healthcare professionals think about clinical guidelines and ‘evidence-based practice’ (EBP) as routes to quality?

There may now be an acceptance of these as concepts, if not in daily practice. Many  view EBP as just one tool; many perceive guidelines as hampering clinical freedom

7. What are healthcare professionals’ attitudes to the measurement of healthcare quality for quality improvement purposes?

Clinicians have strong concerns that indicators are flawed; data are inaccurate, difficult to interpret and may be used to cut costs and impose constraints. Also, that patient surveys may focus on aspects that clinicians do not regard as important.

8. What are healthcare professionals’ attitudes to measures of quality being made public and used for external judgement and accountability?

They are concerned that certain data provide a skewed picture and wary about effects on clinicians, on public understanding and confidence, and on healthcare organisations.

9. What do healthcare professionals see as the barriers and enablers to quality improvement?

Lack of time and resources, competing priorities, and policy overload are barriers. Since the problems of working effectively between and across health professions are well documented the authors conclude that while more time and more resources may be needed or helpful, these are “unlikely to be sufficient in overcoming the substantial barriers to clinicians’ active engagement in successful quality improvement”.

10. What trends are discernible from the literature that may or may not relate to clinicians’ views of engagement with quality improvement?

Four trends were identified relating to involvement that stops short of full engagement, the separation of quality and safety, increased patient involvement, ger focus on systems approaches

Conclusions

Lack of engagement in quality improvement is a long-standing, multi factorial and international problem. Achieving substantial and sustained clinician engagement is likely to remain difficult.

References

Wilkinson, J.E. et al. Are clinicians engaged in quality improvement? A review of the literature on healthcare professionals’ views on quality improvement initiatives [PDF], Health Foundation, May 2011