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Improving quality improvement in communicable and non-communicable disease « Back to Blogs

There is a great deal of room for improvement in the delivery of healthcare. According to an analysis by Makary and Daniel, if medical error was a disease, it would be the third leading cause of death – following heart disease and cancer. (1) This is just one analysis – there are many others and they all point to the high prevalence of error in healthcare.

Over the past twenty years, the healthcare community has attempted to tackle the high prevalence of medical error in a variety of ways. One response has been conducting quality improvement projects. Quality improvement methodologies constitute a variety of activities – including audit, process improvement, plan-do-study-act cycles, care bundles, and checklists. (2, 3) These methodologies have been implemented in a range of healthcare settings and integrated into curricula and continuous professional development programmes for healthcare professionals.

However, the evidence base for the effectiveness of quality improvement programmes is weak. (4) This has led the quality improvement movement to look critically at itself and reconsider what it could do to ensure that quality improvement programmes have the impact that they should have.

There are a number of activities that all those involved in quality improvement could do better:

  1. Measurement is fundamental to quality improvement: so teams could ensure that they use measures that are valid and reliable and that they use measurement techniques correctly.
  2. The plan-do-study-act (PDSA) cycle is a core part of quality improvement – yet it is not always carried out correctly or in the way that it is reported. If PDSA is fundamental to quality improvement, then it is worth getting right.
  3. The purpose of quality improvement should be to improve care for patients. Yet patients are not always involved in quality improvement. When patients are involved, it is often at a tactical or delivery level – rather than at a strategic level – where they can actively influence the strategic design of quality improvement initiatives. It would be better to ensure that patients and/or carers are part of the leadership team and taking part in strategic decisions such as where to concentrate improvement efforts.
  4. Quality improvement and continuous professional development that can enable quality improvement are too often focussed on individual professionals rather than teams. Interdisciplinary teams deliver improved care – so there should be a much greater emphasis on enabling them to improve together.

Quality improvement has the potential to impact the delivery of care across all settings and in all countries – including communicable and non-communicable diseases. When implemented correctly, it can result in the better delivery of care that all health systems need.


1. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139.

2. Walsh K, Gompertz PH, Rudd AG. Stroke care: how do we measure quality? Postgraduate Medical Journal 2002;78:322-326.

3. Martin GP, Dixon-Woods M. After Mid Staffordshire: from acknowledgement, through learning, to improvement. BMJ Qual Saf. 2014 Sep; 23(9):706-8.

4. Dixon-Woods M, Martin GP. Does quality improvement improve quality? Future Hosp J 2016;3:191-4.

Competing interests

KW works for BMJ which produces journals and conferences on quality improvement

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