Understanding what works—and why—in quality improvement: the need for theory-driven evaluation

Abstract

Clinicians who are asked to participate in quality improvement programmes in healthcare organizations are often heard to ask for the evidence that they ‘work’. By that, they often mean they want randomized controlled trials, which show that accreditation, or credentialing, or criterion-based audit, or adverse event monitoring, or continuous quality improvement programmes, or whatever approach is being used cause meaningful and worthwhile improvements in the quality of care [1]. When they learn that there are relatively few experimental studies of quality improvement interventions [2], and those which do exist often show weak or moderate effects at best, this state of affairs is sometimes used to argue that it is not worthwhile investing time and effort in quality improvement. After all, the argument goes, we should not embark on using a new clinical intervention such as a drug or a surgical procedure without solid experimental evidence of its effectiveness, so why should we have a lower threshold for the adoption of organizational interventions like quality improvement programmes? Surely, they too should be proven to ‘work’ before they are adopted or implemented widely? This point of view needs to be challenged. It is founded on a fundamental misunderstanding of the place of experimental methods in investigating and understanding complex social interventions, which is commonplace particularly among clinicians and biomedical researchers and which can seriously hamper those both researching …