Is New Zealand according too much importance to continuous quality improvement in healthcare? In this 2004 paper in the Journal of the NZ Medical Association (Vol 117 No. 1198), Stephen Buetow and Gregor Coster comment on a New Zealand Ministry of Health publication of a systems approach to help guide and plan quality improvements in the health and disability sector. The writers argued that the Ministry should align itself less exclusively with the 'the small steps of continuous quality improvement' and 'maintaining the gains'. Instead, they wrote, "it should encourage the adoption of a variety and combination of quality improvement strategies that include continuous quality improvement between the discontinuities that can occasion a need to re-engineer core processes for revolutionary, quantum gains in quality and safety." Here's a summary of the paper: The Ministry's publication Improving quality (IQ): A Systems Approach for the New Zealand Health and Disability Sector describes a systems approach to help guide and plan improvements in the sector; and suggests a means of supporting and coordinating quality improvement activities underpinned by a shared vision of people 'receiving people-centred, safe and high-quality services that continually improve and that are culturally competent.' IQ defines quality improvement as including continuous quality improvement and quality assurance; and signifies 'a commitment to supporting continuous quality improvement.' The writers commended this focus on quality improvement but also questioned the emphasis on continuous quality improvement, alongside the relative neglect of other approaches to quality improvement. Three sets of difficulties bedevil continuous quality improvement in heathcare, Buetow and Coster claimed: (1) there is little scientific evidence that continuous quality improvement improves the quality of healthcare among large numbers of professionals or organisation-wide. The effectiveness of initiatives for continuous quality improvement appears to be highly variable, possibly reflecting their diversity and changing nature, and differences in organisational context. (2) Disparities between the rhetoric and reality of continuous quality improvement. For example, continuous quality improvement seeks to drive out fear - while promoting external quality assessments, such as practice accreditation, that can stress workers and threaten their job security. Among other examples are a tendency for unequal benefits to workers, a requirement for leadership, and the dominance of managerial perspectives and agendas that contradict the ideals of bottom-up participation, teamwork, and overall commitment. The focus of continuous quality improvement on slow, incremental change to existing individual processes tends to discourage learning and innovation. Continuous quality improvement requires investment in long-term change, but health services in the public sector are typically undercapitalised and tend to focus on the management of short-term crises. (3) Systematic tools of continuous quality improvement were popularised in, and for, fairly slow moving industries, such as the automotive industry. These tools are largely unsuited to the modern-day environmental conditions of accelerating technological change: uncertainty, high complexity, and patient 'bargaining.' The writers support, nevertheless, the use of continuous quality improvement, considering that the three sets of difficulties are offset by progressive features of continuous quality improvement, including the degree to which worker involvement is valued and the ability of continuous quality improvement to help us understand and improve quality rather than merely add to the proliferation of studies documenting unintended variations and quality deficits. The need to grapple with the contradictions stated above should not deter the use of continuous quality improvement - rather, this need invites the use of continuous quality improvement as one of multiple, concurrent approaches. This is because continuous improvement is not enough and other approaches cannot substitute for continuous quality improvement. They can instead support the implementation of continuous quality improvement as, for example, a series of small-scale projects. From this perspective, continuous quality improvement is merely a tool - not the only one, and not necessarily the most important one - to help healthcare organisations, teams, and individuals improve quality in healthcare. The writers went on to suggest how insights from process re-engineering can complement the commitment of the Ministry of Health to continuous quality improvement and quality assurance. Compared with continuous quality improvement, and its focus on incremental improvements in performance, the top-down approach of process re-engineering emphasises greater and more rapid change over a shorter time period. It involves fundamental, not superficial, rethinking; exploits information technology capability in the revolutionary redesign of macro-level organisational processes; and can be adapted locally to incorporate factors that are critical to successful change management in the public sector. Integral to the approach of process re-engineering is the concept of discontinuous thinking, by which is meant a total change in thinking. Process re-engineering enables organisations to introduce discontinuous improvement into their work culture. This overcomes the problem that change in small, incremental steps may be inappropriate when an urgent need arises to quickly fix systems that severely compromise patient safety. For example, the Cartwright Inquiry and major inquiries into hospital services in Christchurch and Gisborne suggest such a need, notwithstanding that radical change can yield incremental improvements and vice versa. Process re-engineering also surmounts the problem that if what is already done operates predictably at an unacceptable level and adds no value to a service, improving it incrementally is likely to be a false gain and a cost to the system. This situation can occur where technology is obsolete, such that the entire process requires changing through systematic process improvement. Such a requirement is not out of place in the public sector, where policy and direction can change suddenly and dramatically. In contrast, where special cause variation is present, its origin should be examined and managed; for example, in accordance with continuous quality improvement. This is necessary to eliminate negative special causes of the variation, and make positive special causes (such as an improvement effort) part of the normal process. Continuous quality improvement can also overcome limitations of process re-engineering. These include the stress and costs of radical change, and a top-down, business focus on operational processes, which can weaken the focus on patients. With exceptions, these writers concluded, " ... continuous quality improvement and process re-engineering have seldom been integrated. However, recognition is increasing that these quality movements can complement and enhance one another. Each focuses on patients and processes, including training and teamwork, to produce measurable results. Each helps to address the other's deficiencies. To keep pace in a fast-changing, complex and unpredictable world, the Ministry of Health should thus align itself less exclusively with the small steps of continuous quality improvement and maintaining the gains. "Thornley and her colleagues suggest that, apart from incremental changes in practice, 'more radical change is required' - meaning a need 'to revolutionise our thinking about quality' by focusing more on quality improvement than quality assurance. While tending to agree - we have indicated in this paper a further need to delineate and discuss the nature of the quality improvement strategy required for such 'radical change.' This is because, as a means of quality improvement, continuous quality improvement is itself evolutionary rather than revolutionary. Furthermore, in our opinion, the Ministry of Health accords too much importance to continuous quality improvement. " "Just as in areas such as guideline implementation, we see a need for the Ministry to encourage the adoption of a variety and combination of quality improvement strategies—including the approaches of continuous quality improvement and process re-engineering. "Which of these approaches is most appropriate depends on the individual circumstances. However, coordinated within a systems-based framework such as clinical governance, continuous quality improvement can (and should we believe) be used continuously between the discontinuities that can occasion a need to re-engineer core processes for revolutionary, quantum gains in quality and safety."