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Quality Improvement in a Complex World.

Everyone in healthcare really has two jobs when they come to work every
day: to do their work and to improve it.

                                    --Batalden and Davidoff (2007, p. 3)

In the seminal article "What Is 'Quality Improvement' and How Can It Transform Health Care?" this concluding statement charged all health care professionals to engage in the practice of quality improvement (QI). At the time of publication in 2007, quality improvement were buzzwords, promising administrators less waste in the system and providing leaders a framework to methodically spur and track change while inviting front lines to be part of the solution.

The Agency for Health care Research and Quality (AHRQ) defined quality improvement in health care as "the framework to systematically improve the ways care is delivered to patients" (AHRQ, 2013). Since then, health care organizations have embraced a variety of QI methodologies to identify and close the gap between desired and actual results. LEAN, Six Sigma, Total Quality Management, and Institute for Healthcare Improvement (IHI) Model for Improvement are all defect-based approaches, whereas Positive Deviance and Appreciative Inquiry are examples of asset-based approaches, to name a few.

W. Edwards Deming, an engineer and mathematician, authored many of the foundational concepts of QI (Best & Neuhauser, 2005). Gleaned from decades of research in manufacturing settings, Deming drafted a "system of profound knowledge" articulating four tenets that act as supporting columns for QI methodologies: (a) appreciation for a system, (b) understanding variation, (c) a theory of knowledge (how new knowledge is generated in a system), and (d) understanding psychology and human behavior (Best & Neuhauser, 2005, p. 311). When these tenets are applied to health care, access to care, as well as the effectiveness and efficiency of that care, can improve, especially when "appreciating" the interconnectedness within the system. Identifying the waste caused by variation can recoup the time, material, and personnel energy lost in an uncontrolled system.

Having a theory of knowledge can ensure organizations grow and adapt to change. Understanding psychology and human behavior can help guide individuals through the emotional aspects of change, as well as provide guidance for effective team membership and meaningful contribution to the change initiatives. Examples of small improvements began to present in the literature. Eventually larger systems, like Virginia Mason for example, began branding their own versions of QI and sharing their QI journey, so that others may benefit from the lessons learned. QI was like a guiding light out of the wilderness.

As a clinician desiring improved outcomes for my patients and a better working environment for myself and the teams I work in, I fully endorsed QI. I committed to a second residency devoted to training physicians with leadership and quality improvement skills. I embraced my role as a QI disciple preaching its virtues to all who would listen. This message was warmly received, bolstered but stories of QI success entering the literature. As results of local QI projects demonstrated reduced emergency department utilization among high utilizers and reduced hospital readmission, it seemed QI would deliver on its promise and that I had found my place in health care. I would provide individual care as a family medicine physician, and I would improve the system not just by engaging in QI myself but would also teach QI to others to assist the system in achieving the Quadruple Aim (Bodenheimer & Sinsky, 2014). Teams were ready to engage in projects using a formalized methodology that QI offered, and the use of QI was growing in the organization as it was in the wider field of health care. Like the case in many hospital systems today, I was part of the newly formed QI committee, until eventually a department was created to centralize and coordinate the projects. QI had established itself within health care, and the opening quotation felt true. Everyone did have two jobs, whether they wanted to or not. However, this became the problem, because the warmly lit house of QI began showing some cracks under the harsh light of a demanding health care system.

Deming's above tenets act as four foundational support columns that all QI is to build upon. When they are not set soundly, all that rests upon them is in jeopardy. The success story of QI led to its widespread adoption, yet the banner of QI was often coopted and its implementation incomplete or otherwise inappropriate, deviating from QI science. In an effort to more rapidly obtain the results needed in health care, to bend the cost curve, and to maintain margins, aspects of QI were being employed in isolation or inappropriately. For example, variation was "solved" by the adoption of standardized protocols without an underlying understanding of the system, and improvements were implemented as quickly as they could be made into policy without engagement of those stakeholders who would be impacted. Has the sense of urgency to create change come at the expense of critically appraising whether the change is indeed an improvement? And has that distortion resulted in so-called QI being done to health care workers rather than with them?

Although the story of QI, combined with a drastic urgency for change, may have created the current state in its misapplication in health care, it is the QI tenets put forth by Deming that can redeem its promise. In this way, QI is a fractal, similar in makeup and application on various scales. This speaks to the universality of Deming's four tenets; the same tenets used for a successful QI project need to be employed in building the QI capacity of an organization.

I believe the Collaborative Family Healthcare Association (CFHA) and its members can play a significant role in this regard. CFHA was founded with an understanding of complex systems. As an organization, we have come together to determine how we, as providers in a health care system, can deliver health and health care for and with the whole person, and our current focus is on the deployment of integrated behavioral health interventions. In taking on this improvement work, we have learned how important Deming's tenets are in creating positive change. Although organizations like IHI can provide very effective teachings and methodologies for the application of QI science, who better than the members of CFHA to implement these. We are the experts on systems thinking (it is in this journal's name), on generating new knowledge for improvement (evidenced by the articles published in our journal), on interdisciplinary teams, on inclusion and integration, on human behavior and psychology. We can all address the inappropriate variation in how "QI" is wielded within the system, by engaging, and owning, the process as it was intended. Perhaps then we will embrace our dual roles as health care providers and health care improvers, rather than feel burdened by them.


Agency for Healthcare Research and Quality. (2013). Module 4: Approaches to quality improvement. Retrieved from

Batalden, P. B., & Davidoff, F. (2007). What is "quality improvement" and how can it transform healthcare? BMJ Quality & Safety, 16, 2-3.

Best, M., & Neuhauser, D. (2005). W Edwards Deming: Father of quality management, patient and composer. BMJ Quality & Safety, 14, 310-312.

Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12, 573-576.

Received October 7, 2019

Accepted October 10, 2019

Andrew S. Valeras, DO, MPH

Concord Hospital Family Health Center, Concord, New Hampshire

Correspondence concerning this article should be addressed to Andrew S. Valeras, DO, MPH, Concord Hospital Family Health Center, 250 Pleasant Street, Concord, NH 03301. E-mail:
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Author:Valeras, Andrew S.
Publication:Families, Systems & Health
Date:Dec 1, 2019
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