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“Quality improvement”: noun or verb?
  1. P Batalden
  1. Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, USA

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    Can a collection of activities be categorized as “quality improvement”? Is it research? Practice? Do we need to obtain informed consent from patients if we are soliciting their feedback to change our practices? It started me puzzling on the evolution of our use of language in the field.

    The words we attach to ideas and experiences shape our thinking about them.1 The terms “quality improvement”, “quality improvement project”, “QI tools”, “QI methods”, a “quality improvement activity” and many other examples of using the words “quality” and “improvement” in a noun or adjectival form have helped people to name and understand what was new about some new activities and energies to change and improve health care. I wonder if the way we use these words is changing?

    The words “quality” and “improvement” are not new. From the early 14th century Latin “quālis” and the later French “qualitie”, our modern word “quality” began its modern life as a word that referred to “of what sort?” and, since before 1400, “grade of excellence”. More recently in the 17th century the root “enprowment” of our word “improvement” began by referring to “good or profitable use”. In 1647 the meaning of “betterment” is recorded and relates to a specialized meaning of improving land for better uses.2

    As we used the words “quality improvement” initially in health care, they were associated with some constructs new to health care such as “organization-wide quality efforts” which implied new roles for leaders.3–6 For some there were new ways of understanding health care giving as a process and system,7,8 and for others there were new “tools” such as flow charts or control charts.9,10 Initially it seemed appropriate to me to use the words “quality improvement” to name or define—as nouns do—a new category of ideas, methods, activities, and other phenomena.

    Today we are improving quality by taking actions. “Quality improvement” is no longer an abstract collection of ideas. We have some experience of translating these ideas into the real practice of health care. We act to learn about and integrate the preferences of patients in shared decisions about daily care. We act to understand and try tests of change in the care systems where patients and caregivers meet. We act to measure and learn from the study of variation in process and outcome. We act to integrate caregivers from across disciplines and with information and information technology. Some wish to classify or label these actions as “QI” for other purposes such as for external review or for the purpose of getting informed consent.

    This imperative—relentlessly to study and improve quality—has been part of what it means to be a “health professional” from antiquity to recent times.11,12 The Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) in the US have restated this recently in accrediting and certifying procedures. For example, in the US it is expected that healthcare professionals be competent in “practice-based learning and improvement” and “systems-based practice” as part of their graduate medical education and certification ( and Organizations in the US that seek certification and accreditation as healthcare organizations are expected to be engaged in the continual improvement of the care they offer ( For many, these expectations of professional action are not new, just restated in what seems like a more complex world. As we increasingly calibrate our efforts by measured outcomes, we realize the broad array of actions that may be necessary to improve the quality of health care in complex systems. So, how should we think of the words “quality improvement”?

    When we use language to help give meaning and to make sense of situations, the words themselves take on new nuances to meet our needs. By creating a vocabulary for the field of “quality improvement”, we need to avoid creating a world abstract and unrelated to the practical work of improving quality. We spend valuable energy debating whether or not some activity can or cannot be considered under the noun heading “quality improvement”. More importantly, I suspect, is joining forces to take necessary action to improve the delivery of health services. Let us think about “quality improvement” as a verb, as action that we take to bring about better outcomes (ultimately) for patients. Let us judge our efforts as we evaluate other verbs—by their effects on our patients and our systems.


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