Paul Batalden and Frank Davidoff of the Dartmouth Institute describe quality improvement as:
“The combined efforts of everyone – health care professionals, patients and their families, researchers, commissioners, educators – to make changes that will lead to better patient outcomes, better system performance, and better professional development.”
Quality improvement is a key mechanism to reducing errors and every error is an opportunity to improve, but we first have to recognise errors and understand why they occur.
Errors most often occur as a result of flawed processes or systems of care, rather than negligent or irresponsible individuals and errors that lead to harm are not usually the result of just one thing going wrong.
The Institute for Healthcare Improvement (IHI) asked Dr Lucian Leape from the Harvard School of Public Health about people that suffer from mistakes in health care, how these mistakes happen and how to prevent them. In the video, Dr Leape describes how errors occur and how we should respond to them.
“Errors are not caused by bad people, but by bad systems”
“If you want to prevent mistakes, you recognise that humans will always be error-prone”
“Try to error-proof your systems”
“Every system is perfectly designed to get the results it gets.“
Paul Batalden, M.D
Both intended and unintended consequences are designed into our systems; therefore, in order to change the results we must change the system.
Quality improvement enables us to design processes and systems that make it easy to do the right things and, therefore, harder to do the wrong things.
Reducing errors and improving patient safety are just a couple of reasons why we should do QI. There are countless examples of successful quality improvement initiatives that are focused on improving efficiency and improving patient care and experience.