Healthcare professionals’ views on clinician engagement in quality improvement

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.

Introduction

• Healthcare professionals express strong support for the principle of quality patient care, but this may not reflect a clear understanding as to how quality might be defined, recognised or improved.
• Healthcare professionals’ espoused beliefs about quality may not translate into changes in everyday practice. Instead, clinicians have shown a variety of responses to quality initiatives, ranging from apathy to outright resistance.
• Our reading of the wide literature documenting how healthcare professionals have responded to various quality initiatives in the UK since 1990 prompted a series of ten inter-related questions, which we have used to structure this summary and the main report.

Methods

• In searching for published papers, policy reports and ‘grey literature’ relevant to the review, we used a comprehensive range of sources including key databases, a wide range of medical, nursing, allied health professional and management journals, and websites of relevant Government bodies, professional organisations and research centres. We also searched reference lists of retrieved papers and consulted individuals with knowledge of the field.
• Eighty-six significant empirical studies were uncovered, reported in around 100 different papers. It is largely the findings from these that are summarised and integrated using the ten key questions as an organising framework (the studies are also listed and summarised in the Technical Appendix).

Ten key questions emerging from the literature

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

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.

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

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.

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

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.

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

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.

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

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.

6. What do healthcare professionals think about clinical guidelines and quality?

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.

7. What do healthcare professionals think about evidence-based practice (EBP) and its contribution to quality?

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.

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

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.

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

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.

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

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.

Concluding remarks: setting the findings in context

• This review is necessarily broad, moving out as it does from the 86 empirical studies to broader literatures. Many of the areas touched on have their own substantial bodies of research (eg, evidence-based practice, management of change or professional identity).
• The review draws predominantly on studies that rely on self-reported attitudes; inevitably there is a risk in such studies of social desirability bias (ie, individuals may wish to present themselves or their organisation in a favourable light). Nevertheless, studies like this provide a rich picture of perceptions. Such perceptions arise from, and contribute to, the shared meanings that are part of local organisational cultures.
•  Studies of healthcare professionals’ perceptions cannot show the extent to which these perceptions accord with actual circumstances and so they need to be used with care in identifying what may be needed to promote engagement with quality improvement. Nevertheless, such perceptions are an important part of setting the context for change and constraining what may be achieved.
• Attitudes towards specific quality initiatives are influenced by the political and local contexts and by other events occurring at the same time. Three contextual features that have been particularly influential in shaping healthcare professionals’ attitudes to quality and quality improvement in the period covered by the review are: the substantial and sustained organisational turbulence in the NHS; the conflict between quality assurance and quality improvement; and the sustained and largely critical attention the NHS receives from politicians and the media.
• Increasing clinician engagement is likely to be difficult: non-engagement of clinicians is a long-standing, multifactorial and international problem. Nevertheless, a detailed understanding of the diverse perceptions of healthcare professionals in relation to quality and quality improvement, which this literature review and the research that will follow contribute to, is a vital part of planning and implementing such change.