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There is increasing evidence that the structured use of the principles and methods of continuous quality improvement (CQI) in healthcare settings will have a positive effect on improving care.1–3 Recognition of this in the UK can be seen from frequent references to CQI in Government publications driving the “modernisation agenda”. Government support of centrally funded initiatives such as the National Breakthrough Collaboratives4 provides additional evidence, although it is not clear whether a common understanding exists of what are its key elements. For example, these should include a focus on improving the way we understand and meet the needs of patients/users; a focus on improving the processes by which their care is delivered; and the application of improvement methodology that enables us to learn as we go. Finally, it is essential that the delivery of care is improved by the interprofessional teams who provide it.
It is still early days and the limited availability of knowledge and expertise in these methods means that improvement projects often have to rely on the use of external facilitators for their successful conclusion. It has been suggested that it is unlikely that success will be achieved without such facilitation,5 although it is also true to say that such dependency may itself sow the seeds of future failure. Resourcing such facilitation in the long term is not sustainable if we really want to see improvement become a routine part of everyday practice.
We therefore have to consider how to develop the necessary knowledge and skills within health care itself and, in particular, how to help practitioners learn improvement skills alongside their professional and technical skills.6 In this issue of Quality in Health Care Kyrkjebø et al7 describe an educational project that addresses this crucial question and, in doing so, they make an important contribution to the work of others in the field.8–10
This work is beginning to integrate understanding about best improvement practice with knowledge of best educational practice. Making them both practice based and relevant to patients and students produces the best improvements and the best learning. Such an aim underlies the project reported by Kyrkjebø and colleagues.7 They tested out a student experience that was carefully designed to have a patient focus, to link theory and learning in practice, and to introduce students to improvement methods that could make a real difference to the quality of care. Although they were unable to provide a formal interprofessional team experience, the students were able to develop insight into skills needed to work jointly with colleagues.
As the study infers, such learning must go beyond simply learning the mechanics of improvement tools. Stories of successful improvement are inevitably stories of people learning together and, in health care, this means within clinical and other practice based settings. We need to establish creative learning strategies that involve students in real work as a learning medium so that they may leave something behind as well as take something away.11 They need to develop a personal understanding that, to be continuous improvers, they must be continuous learners. In educational terms this reflects the difference between “deep” and “surface” learning,12 and reinforces the need for deep learning that develops each student's self-concept and self-confidence as a lifelong learner if they are to contribute effectively to continuously improving practice.13 If their learning about improvement does not achieve this, it will soon become a distant although interesting memory as they cope with the stresses and turbulence of everyday work. The use of “active learning” by Kyrkjebø et al7 is an important attempt to address this need and gives us clues about creating opportunities for practice based learning in mainstream education.
Their work raises many challenges of implementation for both education and service providers. With regard to the former, there is a particular need to develop the interest and skills of the academic staff who must themselves gain experience of facilitating improvement projects in practice. Unless they do so they will never be able to underpin their teaching with the personal feeling that is critical for helping students to learn.14 With regard to service providers, Kyrkjebø et al express the hope that their students' experience “will enable them to take part actively in quality improvement when they are qualified”. This is unlikely to happen by chance and raises significant questions about the environments in which students must learn and will have to practise.7 In particular, practice based learning requires the creation of opportunities for students to participate in work settings where clinical teams are using systematic approaches to improve their care as part of their everyday work. After qualifying, they require opportunities to develop themselves and their improvement skills within routine organisational staff development programmes. Continuous improvement needs to be integral to both educational and healthcare institutions.
The final message that can be taken from the paper by Kyrkjebø et al is perhaps the most profound. Integrating our basic human enjoyment of learning with deep feelings about providing the best possible care for our patients provides an enormously powerful driver for improvement. It creates the demand for health profession educators and service providers to understand that they are part of the same system of care delivery with a shared underlying purpose. Put another way, how can we provide services that continuously improve care and education at the same time? This requires a sophisticated dialogue between employers and academics that will establish partnerships between healthcare providers and higher education and will provide benefits for learners, providers, and the wider community.13