Article Text


All change
Quality and safety in health care: plus ça change, plus ça ne reste plus la même chose
  1. F Moss
  1. Correspondence to:
 Dr F Moss
 Quality and Safety in Healthcare, BMJ Journals, BMA House, Tavistock Square, London WC1H 9JR, UK;

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In the 12 years since QSHC was launched as QHC (Quality in Healthcare) attitudes to quality improvement have changed enormously. Then, in the United Kingdom, quality improvement work largely consisted of medical audit. Results of audit work were usually discussed in clinical meetings with little management involvement. Now there is corporate responsibility—shared between clinicians and managers—for the quality of care, quality improvement, and risk management. The links between improvement in clinical practice and organisational change are widely acknowledged. Quality improvement is less an optional extra, it is more a part of routine practice. And much more is known about the extent of error than 12 years ago. Shocking revelations from public inquiries into the circumstances of scandals have illustrated the frailty of many parts of care systems. Data quantifying the extent of adverse events within many healthcare systems indicate that error is endemic. And, although health systems may differ, many of the circumstances of error and the lessons that emerge from investigations apply in any country. Worldwide, people are trying to find ways of making health care safer and less damaging to patients.

This journal has changed too. Changes in the content have reflected developments in quality and safety improvement. Organisational change and team functioning have become important and recurring themes. Human factors, clinical microsystems, and decision making are some of the topics covered in the past two years that may not have made as much sense 12 years ago as they do now. Many more authors are from outside the United Kingdom and we hope that all papers have generalisable messages accessible to readers worldwide.

Two years ago, too, the journal changed in appearance; a new cover, a new layout, and a new title. But more importantly the journal became available electronically, making it accessible from anywhere in the world and providing opportunity for readers to respond to published papers. Also, since 2002, all the editorial processes are web based.

Journals are like all systems, they are “perfectly designed to get precisely the results that they get” and any improvement requires a change in the system. But sometimes change requires a catalyst, usually an individual. Two of this journal’s change agents, Richard Grol and Paul Barach, have now stepped down from the editorial team. An early editorial aspiration was that the journal should become international. But in this matter the journal’s beginning was not auspicious. Launched as QHC by the BMJ Publishing Group in the wake of the introduction of medical audit in the United Kingdom, this was a very British enterprise that looked very medical and, despite early editorial intentions, was of particular interest to people working within the United Kingdom National Health Service (NHS). Richard Grol, viewing the journal from the other side of North Sea, was able to show the editorial team just how British we were, and just how difficult it was for others to glean generalisable messages from papers that assumed a working knowledge of the NHS. Unless we changed, he said, we would attract neither readers nor authors from outside the United Kingdom. Now all authors are asked to include relevant aspects of their healthcare systems to enable their work to be accessible to readers from other countries. A little extra work for authors perhaps, but it should widen the impact of their work. Richard has served the journal well for many years and his suggested series, Quality improvement research, will be published in a book later this year.1

Another early assumption was that the safety of care was integral to good quality care. This is a crucial subject: if all healthcare systems were safer, lives would be saved. But, despite a focused issue on clinical risk management and a few other papers, it was not clear either to authors or readers that QHC was interested in papers on the safety of care. Paul Barach had the inspiration to put the “S” into QHC. Since then many more papers on a wide range of topics relevant to safety improvement have been published. Paul has contributed hugely to the journal but has decided to step down from his active editorial role in order to devote more time to his new and demanding role as Director of the Miami Center for Patient Safety.

Many thanks to Richard and Paul for their important contributions and for stimulating change.

The editorial team can influence the content of a journal by commissioning papers. But as a peer reviewed journal we are dependant, too, on submitted papers. So, the content will reflect the range of topics covered by submitted papers. We now receive more than three times more unsolicited papers than we did 12 years ago. As a result QSHC was able easily to expand from a quarterly to a bimonthly journal. Papers that report original research are an important part of this journal and we now publish many more: only 16 in 1993, but 33 in 2003. Maybe more research on quality and safety is being done, or perhaps more of it is being submitted to QSHC.

One unfulfilled editorial aspiration is to increase the number of quality improvement reports, but very few are submitted. In 1993 we published six quality improvement reports (all from the United Kingdom), but only one in 2003. As there is both more concern about the quality and safety of care and more energy expended trying to do something about it, it might be supposed that more people are attempting change and gaining the sort of insight into what it takes to improve care that would be helpful to others. And perhaps too we might have expected to receive more quality improvement reports for consideration. We realised that the standard structure for reporting research is not helpful for writing about a process of improvement that involves several cycles of reflection and action. So, in 1999, to help authors construct quality improvement reports, we put together a structure that we thought might encourage people to write about and submit them. The editorial outlining that structure is reprinted in this issue.2

Although only few quality improvement reports have been submitted to this journal, more have been submitted to and published by the BMJ. And so, to encourage more people to write about their quality and safety improvement work we will re-publish at least one BMJ quality improvement report in each issue of QSHC. The first of these describing criteria based audit in Ugandan maternity units is on page 49 of this issue.3 But we want to make this an iterative process and are interested in your views on both the content and the structure of quality improvement reports. (This might help us fulfil another unfulfilled editorial aspiration: to encourage exchange of ideas through the rapid response connection on the QSHC website.) We are asking readers to respond to three questions about each quality improvement report by using the rapid response facility available through the website (

  • What else would you like to know about this work?

  • Do you encounter similar problems in your practice?

  • Was the structure helpful?

Please use the rapid response button and let us know your views and your suggestions.

The world is now much more knowledgeable about the quality and safety of health care. It is not clear that it is yet any wiser. Many people are working to improve care and some of the lessons they are learning may be of use to others. Tell us about your experiences. If you don’t have the time, inclination, or energy to write a quality improvement report then respond through the new “Quality Ideas” button and post your idea on the web ( Web based publishing has changed journals. Already readers can now contribute their views on published papers in real time and enter debates on the web. Much more interaction is likely in the future. We have set it up! So, be part of this change and let us know what you think.


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