Please note: This review was updated in 2011 and a new publication, Are clinicians engaged in quality improvement?, was launched.
It is widely accepted that the active involvement of staff is an essential requirement for quality improvement, yet such initiatives in the NHS have not generally secured the full engagement of clinicians. This literature review seeks to clarify what is already known about the views of UK healthcare professionals in this area.
Different health professional groups largely inhabit separate hierarchies and networks, often with surprisingly little inter-communication. Thus, different professional groups often do not define quality in the same way. Moreover, the processes of determining what constitutes good or quality practice within an individual profession are complex and sometimes divergent between different professional groups.
Healthcare professionals may assert that high-quality care is already being provided, and may need substantial local data to challenge this conviction. Paradoxically, however, they are often well able to identify important deficits in care that they believe need to be addressed.
Although some studies show that healthcare professionals may respond positively to involvement in certain national quality initiatives, overall, healthcare professionals are reluctant to engage. In part this is because they perceive that the initiatives will be ineffective and a waste of scarce personal and organisational resources; in addition, healthcare professionals may be concerned about harmful effects that may result from quality initiatives.
Overall, clinicians and managers seem to have a limited understanding of the latest concepts and methods underlying quality improvement, and many show relatively little interest in learning about them. However, new initiatives, such as the online resource saferhealthcare.org.uk, may help them to enhance understanding and share experience about quality improvement activities.
Quality improvement is often the scene of ‘turf battles’ between different professionals. Nevertheless, within the clinical professions, many healthcare professionals will readily devolve responsibility for quality-related issues (such as pain management, or infection control) to a designated individual or team if a suitable candidate exists. Quality improvement is also the subject of conflict between doctors and managers. Doctors think that responsibility for defining and assessing healthcare quality should rest with the medical profession rather than managers, and quality improvement initiatives that appear to erode this and to give what is seen as undue power to others (eg, managers or non-clinical assessors) are often vigorously resisted. Managers may struggle to implement quality improvement initiatives against sometimes-entrenched attitudes, and may have to devise strategies to circumvent considerable opposition.
Managers support greater systematisation of clinical work through the use of such tools as clinical guidelines. However, despite some positive orientations, many clinicians do not regard clinical guidelines and related initiatives (eg, National Service Frameworks) as useful tools in providing quality care, and may resist them because they are perceived as hampering clinical freedom and impeding local practice.
Evidence-based practice is a controversial issue, with enthusiastic supporters and equally vociferous detractors. For many clinicians, evidence-based practice is seen as, at best, only one tool in a range of approaches to providing quality care and, at worst, an impediment to providing individualised and holistic patient care.
Clinicians have strong and diverse concerns about the measurement of healthcare quality, even when these indicators are only being used for internal quality improvement purposes. There are concerns that: the indicators are flawed and do not reflect the care provided; they are based on inaccurate data; and they are difficult to understand and interpret. In addition, there are fears that the data will be used for managerial and cost-cutting purposes that may impose significant constraints and control on healthcare professionals.
Clinicians are generally wary about the effects of publicising measures of healthcare quality, and can see these processes as divorced from, and often inimical to, local clinical priorities and local quality improvement. For managers, such initiatives may prove useful as levers to bring about change in specific areas of care, but they are also concerned about the limited picture shown by quality measures and about the potential for adverse consequences.
Healthcare professionals describe a wide range of barriers to quality improvement, and give only a more limited list of enablers (eg, effective training, modern medical records systems, and structured programmes). Lack of time and resources are most commonly cited by all healthcare professionals, but other barriers include: lack of expertise or advice on project design and analysis; problems with group dynamics; lack of a coherent overall plan; and organisational impediments (eg, clinician–manager battles; organisational mergers). Many of the identified barriers arise from the well-documented problems of working effectively between and across health professions. This means that although more time and more resources may be necessary or helpful (directly and in their explicit recognition of healthcare professionals’ concerns), they are unlikely to be sufficient on their own to overcome the substantial barriers to clinicians’ active engagement in successful quality improvement.