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Why don't clinicians engage with quality improvement?

The active involvement of staff is widely accepted as an essential requirement for quality improvement in any organizational setting. However, quality improvement initiatives have typically been faltering, often failing to engage health care professionals, with the responses of many ranging from apathy to outright resistance. In particular, doctors, whose status and role make them pivotal to organizational change, have largely remained on the fringes of such initiatives. Managers and politicians struggle to understand the reasons why the majority of health professionals do not engage fully with quality improvement initiatives despite those professionals’ oft-stated commitment to high quality patient care. When questioned, clinicians typically assert that more time and more resources would enable them to take part in quality improvement. However, a recent review of the literature on health professionals’ views on clinician involvement in quality improvement shows that the reasons for noninvolvement go much further and much deeper than these stock responses suggest. Health professionals are typically not involved because of a range of factors. These include: limited knowledge and understanding of current concepts and methods of quality improvement; differing definitions between health professions about what constitutes high quality care; and the widespread belief that high quality care is already being provided, at least locally. Other factors include conflicting views about who is responsible for quality improvement and specific concerns about potentially deleterious impacts arising from the measurement of health care quality. Many health professionals are concerned that quality initiatives will be at best ineffective and a waste of scarce personal and organizational resources, and at worst actually detrimental to patient care. The reasons for non-involvement are, therefore, multiple and complex. Because of this, securing the active engagement of health professionals with quality improvement will not simply be a matter of providing all health professionals with more time and more resources, although these might help. The complex underlying reasons will also need to be addressed, and this will not be easy. As the key factors listed above suggest, active involvement in quality improvement challenges strongly held beliefs and requires substantial ‘unlearning’. Firstly, active involvement challenges the fundamental belief that health professionals are already providing high quality care. Secondly, it requires openness to a range of data that have not traditionally shaped health professionals’ practice. Thirdly, the personal and professional costs of doing things differently may in fact be quite high. Key components of professional identity for many health professionals are belief in the value of the work done by that profession and belief that simply ‘being a professional’ is the strongest guarantee of high quality care. Many empirical studies demonstrate the strength of these beliefs in service contexts. Studies show, for example, the high level of evidence that is required to shake the conviction that local services are satisfactory or even excellent; the reliance on dubious indicators of quality (e.g. an absence of patient complaints); the co-existence of conflicting beliefs (e.g. that services are excellent locally but that services are deteriorating overall); and the strong resistance towards any moves to alter substantially the system of professional self-regulation. Securing active engagement may first require some loosening of this professional selfconfidence. Active involvement with quality improvement initiatives also requires health professionals to engage with and act upon a wider range of data than they are used to. Health professionals may resist using such data because they believe (sometimes with justification) that the data are not accurate, scientifically robust or valid in relation to the care provided, or because they are concerned that the data may be misused. Health professionals may also need to develop a receptivity to types of data that are unfamiliar, such as qualitative data or statistical process control information. There may also be data that are disturbing in the clarity of their underlying message, i.e. that there is a substantial problem with the local service. Unfamiliar methodologies and unwelcome messages can be significant barriers to real engagement. Active involvement in quality improvement initiatives may be perceived to have high costs for clinicians, individually and as professions. It requires them to listen to and respond to a range of ‘voices’ that they may not usually acknowledge; and it may also require them to work in new and challenging ways. For example, many quality improvement initiatives require, implicitly or explicitly, that health professionals pay greater attention to patient experience and patient engagement in ways that are at odds with their prior training, socialisation and customary practice. Another, perhaps unwelcome, ‘voice’ is that of the government, whose reform programme is opposed by many health professionals for a range of philosophical,