TY - JOUR T1 - Quality improvement as a primary approach to change in healthcare: a precarious, self-limiting choice? JF - BMJ Quality & Safety JO - BMJ Qual Saf SP - 860 LP - 866 DO - 10.1136/bmjqs-2021-014447 VL - 31 IS - 12 AU - Keith E Mandel AU - Steven H Cady Y1 - 2022/12/01 UR - http://qualitysafety.bmj.com/content/31/12/860.abstract N2 - Total quality management activities have produced undeniable positive results. However, I predict that the way these activities are implemented will lead to the programs becoming self-limiting…seeds for the deterioration of total quality management lie in the very practices that today produce successful outcomes. (Chris Argyris, professor of organizational behavior, Harvard Business School)1 Argyris’s contention above begs the question: Is quality improvement as a primary approach to change in healthcare potentially self-limiting? Our viewpoint is yes, particularly when fundamental underpinnings and mental models are not continually surfaced and challenged.1 2 We propose two imbalances underlie why quality improvement as a primary approach to change in healthcare can become self-limiting: prioritising performance (improving organisational-level quality measures) over participants’ (improvement leaders, facilitators, team members) emotional experience, and privileging process-technical over sociobehavioural design elements.3 Contributing to these imbalances are performance-driven cultures (eg, ‘zero-harm’ goals4), pacesetting leadership styles,5 and environmental and organisational pressures for rapid, substantial improvement.To make clear, healthcare quality improvement approaches do address participants’ emotional experience as well as sociobehavioural design elements. Examples of the former include assessing participant emotions during design6 and implementation,7 addressing drivers of participant burn-out,8 using psychology of change principles,9 and attending to participants’ emotional energy.3 5 10 Examples of the latter include human-centred design thinking,6 mindful organising,11 appreciative inquiry,12 relational coordination,13 social movements theory,3 14 sociotechnical systems theory3 and video reflexive ethnography.15 However, we argue for optimising performance and participants’ emotional experience as an explicit, enduring aim of all healthcare quality improvement initiatives, and for change approaches (inclusive of quality improvement) that dually privilege process-technical and sociobehavioural design elements as the norm. Failure to address these imperatives has real consequences. Specifically, we contend that pushing ever-harder on process-technical strengths of … ER -