“Every system is perfectly designed to achieve the results that it achieves”.

Don Berwick has called this the Central Law of Improvement.¹ One might reasonably paraphrase Berwick’s Central Law to apply to QSHC as: “Every journal is perfectly designed to achieve the results that it achieves”. New editorial leadership provides a timely opportunity to reflect on what results QSHC might achieve going forward in advocacy for more reliable and safe patient care.

Fiona Moss has provided highly effective, expert editorial leadership over the last 13 years. During her tenure as Editor-in-Chief, the journal has made significant contributions to worldwide healthcare improvement and patient safety. In particular, it has set high standards for rigorous, sensible, and critical thinking in these emerging scholarly fields. In that spirit, her editorial in the most recent issue of QSHC forcefully challenged us to work even more effectively to integrate the roles of the patient, the clinician, and the organization for more reliable and safe care.² I want to echo her call for urgency.

Momentum is building. “To Err is Human”³ and “Crossing the Quality Chasm”,⁴ two frequently cited reports issued by the Institute of Medicine of the US National Academies of Sciences, established compelling arguments for change. I am increasingly optimistic that we are near the tipping point where the pace of change will build its own momentum. QSHC will contribute to that momentum.

I propose three questions to help focus the journal’s strategy for that contribution.

• How can QSHC foster ever more rigorous scholarship in the fields of healthcare improvement and patient safety?

• How can QSHC speak effectively to a broader readership—that is, a general medical audience, other health professionals, as well as the public?

• How can QSHC serve to heighten awareness of the knowledge for improvement and safety for the next generation of health profession students and trainees?

How can QSHC foster ever more rigorous scholarship in the fields of healthcare improvement and patient safety?

Healthcare improvement and patient safety are positioned as scholarly fields in the academic community in much the same way health services research was 2–3 decades ago—not orphans, but not widely acknowledged as full members of the academic family either. Early on, many scholars, schooled in the laboratory, found it difficult to acknowledge as scholarly health services research fields such as clinical epidemiology and evidence-based decision making. But that misperception has given way in the wake of careful application of statistical methodology and rigorous definition of new knowledge.

It is appropriate that quality improvement and patient safety appear to be undergoing a shorter trial as academic fields. The societal imperative to make health care better and safer is too great to tolerate a meandering pace. Moreover, information technology provides tools that support its development—tools that were just emerging two decades ago. It is incumbent upon this journal to contribute to the definition of the highest standards of scholarship. It can do this even more effectively if fortified by advice from authors who have a stake in the discussion and an innovative editorial board that has a responsibility for the journal’s outcomes.

Such standards should be as explicit and transparent as possible, both to assure the development of valid new knowledge and also to help define the opportunities for those who envision their scholarly careers in this rewarding and important work. Every effort should be made to guide young scholars toward this end. While the research focus of medical schools and teaching hospitals—the discovery of new knowledge—makes these settings appropriate test beds for new ideas for improvement and safety, academic doctors cannot hope to build their scholarly careers until their important contributions are properly acknowledged by their peers. It is fitting that the editorial board should re-examine regularly the criteria that constitute rigor and new knowledge in the field.

How can QSHC speak effectively to a broader readership—a general medical audience, other health professionals, as well as the public?

New knowledge for quality improvement and safety is too vital to the welfare of patients to be focused on a specialized medical readership. This places new obligations on scholarly journals to make such knowledge compelling and accessible. This journal can serve the medical profession—and the patients that the profession serves—by the active pursuit of a diverse readership which includes not only the broad specialties of medicine, but also nursing, pharmacy, health systems management, and information technology experts.

Patients also should be brought into this discussion as active participants. The authors of “Crossing the Quality Chasm” put heavy emphasis on the role of patient centred care as a path to closing the gaps in quality. It is noteworthy that scholars have begun to validate the patient’s unique role in improving care. Examples include shared decision making as a tool to reduce variation,⁵ the patient’s central role in high performance clinical microsystems,⁶ and the role of the informed activated patient in the improved outcomes produced in the chronic care model.⁷ In this regard, QSHC could do well to make its content as accessible as possible to patients and their families.

How can QSHC serve to heighten awareness of the knowledge for improvement and safety for the next generation of health profession students and trainees?

Medical students and residents—as upcoming stewards of the healthcare system—must learn clinical medicine in medical settings that reflect the best patient care achievable if they are to fulfil their future roles in directing needed improvement in the healthcare system and delivery of high quality, safe health care. Systems improvement and patient safety must be integrated into medical education at all levels.^8,9 But formal courses in these fields will have little value if students and trainees do not find these elements implemented when they arrive at the clinical setting. QSHC must provide a forum by serving as the source for the scholarly innovative work of medical educators who focus their work on educating for healthcare improvement.

We at the BMJ Publishing Group plan to use the coming months to review these questions—and others that will inevitably emerge. We will be mindful that an important tenet of improvement is transparency. We will seek advice everywhere we can find it—including advice from clinicians, healthcare managers, and scholars in healthcare improvement and safety as well as health profession students and patients around the world. We will also seek consultation from colleagues in journalism and other medical journals. A principal source of advice will be the current QSHC readership. In this regard, a survey for readers is available at the QSHC homepage (http://www.qshc.com). I invite all readers to take advantage of this opportunity to offer advice, either via the website or personally to me by email.