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Navigating adaptive challenges in quality improvement
  1. Peter J Pronovost
  1. Correspondence to Dr Peter J Pronovost, The Johns Hopkins University, 1909 Thames Street, 2nd floor, Baltimore, MD 21231, USA; ppronovo{at}

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Many quality improvement (QI) projects often fail to achieve their goals. Some fail for technical reasons, such as invalid measures, inattention to key contextual factors that determine the intervention's effectiveness, or not pilot testing the effort to identify and remove implementation barriers. But, an even larger number of projects fail because of adaptive challenges. ‘Adaptive challenges can only be addressed through changes in people's priorities, beliefs, habits, and loyalties.’1 2 A challenge for leaders is engaging people in deciding the change is needed, while also accepting that there may be things people want to preserve. For example, convincing physicians to include nurses during patient rounds, but letting them work out the logistics. Technical challenges are issues for which there is knowledge to implement a solution. For example, prescribing a β blocker to treat patients following an acute myocardial infarction, or installing computers outside patient rooms to quickly access electronic medical records. A common mistake is to treat an adaptive problem as a technical one. QI work has to address both technical and adaptive issues. The science must be robust yet it must address values, beliefs, and attributes of the group involved in the work.

There is clearly a science to QI. Strategies to implement interventions or changes require sound evidence, or at the very least consensus among opinion leaders, supporting their effectiveness,3 and a methodology to apply the QI work such as translating evidence into practice.4 While careful attention to the technical and methodological work is important, equally important is the engagement of health professionals and others affected by the QI project. There is local context and culture to contend with, and also psychological, social and political dynamics of staff and managers, and the organisation's history and resources. One thing is certain, health professionals want to help …

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  • Competing interests Dr Pronovost reports the following potential competing interests: grant or contract support from the Agency for Healthcare Research and Quality, the National Patient Safety Agency (UK), the Robert Wood Johnson Foundation, and The Commonwealth Fund for research related to measuring and improving patient safety; honoraria from various hospitals and health systems and the Leigh speakers Bureau to speak on quality and safety; consultancy with the Association for Professionals in Infection Control and Epidemiology, Inc.; and book royalties for authoring Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

  • Provenance and peer review Not commissioned; externally peer reviewed.