Putting improvement at the heart of health care

The need to improve the quality and safety of health care has never been greater.¹,² Two notions are central to good medical practice. Firstly, doctors continually monitor the care they offer, checking this against what they actually do and learning what they need to do differently.³ Secondly, in the words of the NHS Modernisation Agency, best care wraps around the patient, rather than the patient fitting the care that is offered.

Therefore it seems paradoxical that resistance by doctors towards activities promoting quality assurance and improvement is claimed to be found across all countries and health systems.⁴ Many reasons for such opposition have been suggested. One conclusion is that this will continue until role models emerge that are shown to work.⁴ In fact, such models already exist, for both improvement practice and medical practice.

The recent increase in reported improvement activity using the principles and methods of continuous quality improvement offers evidence of one approach that may deliver lasting changes.⁵,⁶ Continuous quality improvement can be described as the continual improvement of processes designed to meet patients' needs typically using a framework such as the “plan-do-study-act” cycle to test out changes in practice and to learn from results.

Measures to introduce revalidation of doctors will require them to improve continually their own medical practice. In the longer term this could be supported by current improvements in approaches to student learning in medical schools—for example, by using Kolb's learning cycle.⁷ Helping them discover how they learn, and enabling them to map those principles on to their clinical work (and vice versa), offers simple tools that will empower their clinical practice, as well as prepare them to be lifelong learners. This meets the challenge for educators to enable competence and capability, ensuring that care keeps up with its ever changing context,⁸ and fosters attitudes for students to sustain quality improvement throughout their medical career.

A crucial challenge is to help medical students learn the knowledge and skills needed for improvement during their undergraduate education at the same time as they learn their professional knowledge and skills.⁹ Continuous quality improvement is usually an interprofessional endeavour, and stories of improvement in practice are inevitably stories of people learning together. The plan-do-study-act framework is analogous to Kolb's learning cycle, and this congruence between continuous quality improvement and reflective approaches to learning makes learning about continuous quality improvement fundamental to a student's early experiences in the undergraduate curriculum. What is needed is an integration of best educational practice with best improvement practice.

The worlds of service providers and educators are changing rapidly. It is incumbent upon medical schools to ensure that students' learning matches what providers are actually doing in clinical practice, or a new gap between theory and practice may emerge. In the United Kingdom measures to improve quality—such as the promotion of clinical governance, individual initiatives using the principles of continuous quality improvement, and the national investment in collaboratives based on these principles—require a parallel investment in undergraduate learning. Such measures also provide important new opportunities for students to learn about improvement in clinical placements gaining crucial insight into the interrelationships between individual, team, and organisational factors.⁵

Continuous quality improvement is emerging as an academic discipline in its own right with a body of knowledge, experience, and skills, and a growing volume of published evidence that allows it to be construed as a scholarly activity rather than merely a loose collection of heuristics and methods.¹⁰ Its place in the curriculum of medical schools needs examination, and because of its pertinence to the work of tomorrow's doctors it needs to be included in core curriculums.¹¹ This will have knock on effects for the roles and skills of academic staff¹² as well as career paths. It may be best served by the establishment of new academic departments of healthcare improvement in medical schools¹⁰ to build students' understanding and practical improvement skills through the processes and the content of their learning. Such departments will not succeed unless they work across and alongside all other departments rather than merely adding burden to already overfilled curriculums.

We therefore propose three challenges for medical schools if they are to really start students on a lifetime of continual improvement of practice. Firstly, they should adopt continuous quality improvement principles early into the way students learn and help students map these principles into their practice. Secondly, they should narrow the gap between theory and practice so that students link their practical experience with their own personal development; a skill that will serve them well as clinicians. Thirdly, and this is perhaps the biggest challenge, they should show commitment by establishing academic departments of healthcare improvement that will teach, and continue to research, this vital area of clinical practice.

This will not be easy and will require much open dialogue about how best to achieve the desired results. What is not open to debate, however, is the need to prepare new doctors with the personal and professional skills necessary to make a significant contribution to improving health care in the 21st century.