The difficulties with Quality Improvement in health and social care

The focus on industrial quality improvement (QI) and teamwork emerged in the 1940s in response to the need for high quality, low cost materials for World War II.  The quality improvement approach was subsequently popularised in the Japanese automobile manufacturing industry in the 1960s and 1970s.  Supported by influential organisations such as the Institute for Healthcare Improvement (IHI) and the Joint Commission for Accreditation of Healthcare Organizations (JCAHQ), quality improvement principles have been widely employed in the US over the past decade or so, among a growing variety of health and social care providers.  This expansion has also been witnessed in a number of other countries’ health and social care systems, including Australia, Canada, and the UK.  Arguably, the use of QI approaches within health and social care context can be problematic.  As QI approaches are rooted in private sector organisations whose aim it is to offer a relatively limited range of services and products, with a narrow range of variability in quality, at a competitive cost to consumers who can choose among many suppliers, they do not necessarily match the more variable processes of care delivery.  This is not to say that there are no activities in the health and social care which are amenable to QI processes.  Laundry services, laboratory specimen processing and catering, for example, can more easily be organised in more standardised, efficient and reliable fashion.  But providing care involves a range of complex professional, economic and organisational factors.  In addition, unlike consumers, patients are usually unique, with differing co-morbidities and social conditions, different values and personal support systems, all which challenge the ethos of QI.  

(Scott Reeves, Editor-in-Chief)

To read more see: Reeves S, Zwarenstein M, Espin S, Lewin S (2010) Interprofessional Teamwork for Health and Social Care. Blackwell-Wiley, London. 

Challenges with Crew Resource Management

One of the foremost efforts by the aviation community to develop safe teams is the training program known as CRM.  This approach originated from work undertaken by  NASA who identified that the primary cause of the majority of aviation accidents was human error, and that the main problems were failures of communication, leadership and decisions making in the cockpit.  CRM training was subsequently adopted by the aviation industry. It is now a mandated requirement for commercial air crews working under most regulatory bodies worldwide.  Despite a paucity of evidence, CRM has been widely adopted by many health care organisations.  In many respects, this approach has a good fit with a number of care settings such as emergency rooms, intensive care units and operating rooms/theatres.  In these locations, the interprofessional team takes responsibility for the patient’s defined problems and deals with them in priority order, under the leadership of a physician or surgeon.  There are (usually) standardised procedures, protocols and algorithms that can be followed.   However, with more than 90% of health and social care provided in less structured, low intensity settings like clinicians’ offices, patients’ homes, hospital outpatient departments or inpatient wards, the applicability of CRM may be more limited.  The differences between health and social care and the airline industry also extend to the nature of tasks.  While most patients have common diagnoses, every case is rendered unique by the interaction of multiple problems and with personal and social situations.  As a result, a standardised CRM approach to delivering care in these situations is inappropriate.  Indeed, the challenge for delivering care is that patient care tasks can be complex, evolving and difficult to specify.  Moreover, with severely ill patients, there is variability in the kind of teamwork they need.  Variability is also linked to where the patients are in their care trajectory.  The complexity in a single patient hospital stay may, for example, fluctuate back and forth over time in terms of medical need in the early days to social need in the latter days, and back again. 

(Scott Reeves, Editor-in-Chief)

To read more see: Reeves S, Zwarenstein M, Espin S, Lewin S (2010) Interprofessional Teamwork for Health and Social Care. Blackwell-Wiley, London. 

Why we need to problematise the interprofessional field

Established academic fields such as education and sociology have regularly problematised a range of common place issues.  However, to date, within the interprofessional field there has been little effort to problematise key interprofessional concepts, the interprofessional activities (courses, workshops) that have been produced, or the evaluative approaches employed.  The lack of problematisation within the interprofessional field may be due to its relatively recent arrival as an area of academic inquiry.  Indeed, both interprofessional education and practice are still relatively newcomers as areas of scholarship in comparison with disciplines like sociology or education.  The unproblematised nature of this field may also stem from the fact that so much of what we do interprofessionally is usually undertaken on top of profession-specific responsibilities and workloads.  As a result, one could argue that much of the work which has been undertaken in this field has been done so by interprofessional enthusiasts.  While we clearly need enthusiasts to initiate and (attempt to) sustain a range of interprofessional education and practice activities, arguably, the result is a tendency to accept, at face value, a range of interprofessional concepts and activities, which have now become normalised into our everyday thinking.  This uncritical approach can generate a number of difficulties in our work as we fail to understand the nature of interprofessional phenomena as they are designed, implemented and evaluated.

(Scott Reeves, Editor-in-Chief)

To read more see: The need to problematize interprofessional education and practice activities.
Journal of Interprofessional Care; 24:333-335.