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A ‘work smarter, not harder’ approach to improving healthcare quality
  1. Christopher William Hayes1,
  2. Paul B Batalden2,
  3. Donald Goldmann3
  1. 1Department of Medicine, St. Michael's Hospital, Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  2. 2The Dartmouth Institute for Health Policy and Clinical Practice, Geisel Medical School at Dartmouth, Lebanon, New Hampshire, USA
  3. 3Institute for Healthcare Improvement, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Christopher William Hayes, Department of Medicine, St. Michael's Hospital, Institute for Health Policy, Management and Evaluation, University of Toronto, 30 Bond St, Rm 1-047 Bond Wing, Toronto, Ontario, Canada M5B 1W8; hayesc{at}

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Over the past 20 years, we have seen increasing activity aimed at achieving reliable, safe and high-quality care. The Institute of Medicine's Crossing the Quality Chasm report collated the evidence of the need for change and provided a framework and a set of key recommendations that challenged providers, organisations, professionals and policymakers to pursue a common goal of high-quality healthcare for all.1

In many ways, the summary of evidence and the accompanying challenge have been accepted and demonstrable improvements have occurred. For example, at the provider level, the rate of central line-associated bloodstream infections has been reduced through directed efforts to implement evidence-based strategies.2 Healthcare organisations are increasingly introducing health information technology to advance the quality and safety of care.3 Professional bodies are influencing the inclusion of safety and quality improvement training in health professional education.4 Policymakers, organisational leaders and legislators have introduced mechanisms to promote and incentivise high-quality healthcare delivery.5–7

Although this degree of change is meaningful, the rate at which healthcare quality is improving has been slower than most would want. Despite a greater understanding of why improvement initiatives fail, including the importance of having the right context and the need for improvement capability,8 ,9 the desire for an increased pace has resulted in more improvement initiatives, greater accountability, tougher accreditation standards and more legislation.5 ,10 ,11 Yet, according …

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