So, what does quality improvement mean for me?

I’ve been working in mental health for 20 years and, in all this time, I can’t remember hearing as much about quality of the care we provide as I have in the last five years.

Early in my career, I saw patients in clinics, wards and their homes, without consciously thinking about the quality of my work. I just assumed that if I did my best for my patients, they would be happy with what they got. And indeed, they were. Or, so I would want to believe anyway!

Many years ago, if someone had asked me to define quality, I’d have struggled to do so without resorting to a lengthy and convoluted explanation of the concept – in terms of how something looked, felt and worked. Quality was something you used to gauge a consumer product that came in a package, such as a TV set or a pair of trousers. Not something you thought about when helping people in distress – perhaps because the very act of helping others overcome their distress was noble enough. And in any case, you were so busy doing things that you had no time to think about how you did them.

Well, not anymore.

In the mid-1990s, clinical governance was still a relatively new concept, defined as ‘continuous quality improvement by NHS organisations in an environment in which excellence in clinical care will flourish’. I remember having read about clinical governance before job interviews as it was a stock question in most of them. It did not mean a lot in practice. Some ‘difficult’ interviewers even asked probing questions like what it meant for me! I had some well-rehearsed answers that did the trick.

Clinical audit was a big part of quality improvement and it still is. One way to improve quality was to benchmark my practice against some externally-defined standards. But no matter how many audits we did, presented, disseminated and implemented changes from, the standards would ultimately ‘settle down’ to a background level which was not much higher than the pre-audit standards. Somehow, the magical step-change from recommendations to implementation of change was hard to sustain. I found this process exasperating and often wondered about the point of it all.

In a clinical context, I’m struck by how an individual’s perspective on quality can change depending on which side of the table they are sitting on. I did a reflective teaching session with some doctors in training and asked them to describe their own experiences as a patient. Every one of them said how apprehensive they were about not knowing what to expect and about not being given enough information about tests or treatments. All of them rated people skills higher than the technical competence of healthcare staff and described how their doctor could have done much better had they known what the patient wanted from the interaction. What amazed me was that when we become patients, our expectations and behaviours tend to be very similar, no matter who we are and what we do.

People have defined quality in terms of safety, experience, effectiveness, person-centred care, timeliness, access etc. But the longer I’ve thought about it, the more complex it got and the more difficulty I had fully grasping what it meant. Perhaps this uncertainty is not so bad after all, as it helps me discover its new meanings and dimensions all the time. What I now know is that it means different things to different people – whether you are a clinician or a patient. The context and the setting are as important as standardised measures of quality.

What really matters is that I’m conscious of the quality of my work all the time and attempt to improve it compared to the last time I did something similar. For this, I need to have an open and honest dialogue with my patients and acknowledge what is important to them and why. And I need to keep checking that my assumptions about what they want are indeed correct.

Kallur Suresh is a Consultant Psychiatrist for Older People at the North Essex Partnership NHS Foundation Trust. He is a GenerationQ 2012 fellow.