How to improve healthcare improvement: an essay by Mary Dixon-Woods

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Dixon-Woods Mary. How to improve healthcare improvement—an essay by Mary Dixon-Woods BMJ 2019; 367 :l5514

  • 01 October 2019



In the NHS, as in health systems worldwide, patients are exposed to risks of avoidable harm and unwarranted variations in quality. But too often, problems in the quality and safety of healthcare are merely described, even “admired,” rather than fixed; the effort invested in collecting information (which is essential) is not matched by effort in making improvement.


More resources are clearly necessary to tackle many of these problems. There is no dispute about the preconditions for high quality, safe care: funding, staff, training, buildings, equipment, and other infrastructure. But quality health services depend not just on structures but on processes. Optimising the use of available resources requires continuous improvement of healthcare processes and systems.


QI has been advocated in healthcare for over 30 years, and we have policies emphasising the need for QI and mandating QI practice for many healthcare professionals (including junior doctors). Yet the question, “Does quality improvement actually improve quality?” remains surprisingly difficult to answer. The evidence for the benefits of QI is mixed and generally of poor quality. It is important to resolve this unsatisfactory situation. That will require doing more to bring together the practice and the study of improvement, using research to improve improvement, and thinking beyond effectiveness when considering the study and practice of improvement.

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