Quality Writ Small

A thoughtful friend sent me a recent editorial by Don Berwick in the May 16^th JAMA in which he makes some observations about quality improvement that I find truly profound. To tell the truth, I barely glanced at the study Berwick is writing about (heart attacks are not my thing), and on some level Berwick’s commentary completely fails at its purpose, if that purpose is to interest me in the original study, but it’s a masterpiece nonetheless.  Consider this quote:

 “I think it is a disservice to the sciences of improvement to reify the term “quality improvement” as if it were a device or even a stable methodology. Making patient care better is always a good idea, and there is no harm at all in using the term “improvement” to describe that quest. However, treating the pursuit of improvement (no initial caps) by searching for a boxable, boundable formula, let alone canonizing it with a proper-noun label—“Quality Improvement” (initial caps)—is misleading. The ways in which people and organizations try to overcome the destructive forces of entropy in complex systems and to continually improve the work that they do on behalf of patients are numerous and, thank goodness, will forever evolve.”

With that, Berwick gets right to the heart of what has really been eating me about the academic-ization of quality improvement.  Don’t get me wrong, I think it’s a good thing from the 10,000 foot view, but lately I feel the loss of something.  A while back I started using the phrase “meaningful quality work,” as if I could make people understand my perspective by simply changing the label.  I didn’t realize I simply needed to wait for Don Berwick to uncapitalize it. What I meant by meaningful quality is any sort of work where the primary focus is improvement for the sake of improvement and nothing else (though publication of such work should not be precluded in my opinion).   There have been so many calls for rigor in designing quality improvement projects and so much discussion of what is quality vs. what is research that we are undoubtedly losing something in the process. Nimbleness? Disruptive innovation? I can’t quite put my finger on it, but I’ll fall back on one of the most clichéd phrases in the language and say that when we engage in the “reification” of quality (to use Berwick’s term), our thinking is squarely inside the box, and the box is shrinking daily.

The shrinking box affects us outside of what we read in journals, particularly with things like maintenance of certification (MOC). While it’s clearly important for specialty boards to provide significant oversight on what can be claimed as credit for MOC, I’ve begun to suspect that the maintenance of paperwork has taken precedence over the pursuit of true improvement, at least in pediatrics.  Consider the text of a recent email I got from one of the most energetic and innovative young pediatric hospitalists I know (full disclosure: I happen to be her boss): “I am looking through the MOC stuff and it is making my brain implode…Do we have to do a QI project from the list provided, or can we provide proof/data of one of our own QI projects? “  Now the answer to that is the former, unless you’d like to pony up serious bank to have the board evaluate and possibly approve your own project  - provided it meets their fairly rigid definition of QI (all caps).  So the hospitalist in question, who has won an award for one of her several quality projects from the corporate parent of our hospital, will completely fail to get any credit for her existing work as she pursues MOC and will, no doubt, eventually  do one of the brief and meaningless online projects approved by the ABP.  Lucky for us, she will continue her extensive and meaningful work on a local level because she is just that kind of person, and it will be done with the sole purpose of overcoming “the destructive forces of entropy in complex systems.”  It will remain QI uncapitalized, in both senses of the word. 

Now, none of my carping is intended to take anything away from QI done with academic intent. I love it - but the powers that be might want to clear a space for lowercase quality as well.  There must still be a few things left to learn out there that are not rapid PDSA cycles, right?   Let me end with Berwick again, because it is so eloquent and because what else is there to say after this:

“Human spirit, liberated, seeks growth, learning, and joy in work. That is the fuel for improvement. It energizes the quest for methods that will evolve, as they always have. Quality improvement is not a single, testable answer; like so much else that is important in human life, it is a continuing and wonder-filled question.”

Berwick DM. The question of improvement. JAMA. 2012;307(19):2093-4.