The full title of this book from Richard J. Banchs, M.D., and Michael R. Pop, S.S.M.B., M.B.A., says it all: The Quality Improvement Challenge: A Practical Guide for Clinicians. The authors have done an admirable job of creating a readable work that describes the challenges of quality improvement in healthcare, outlines common techniques for change management, and presents useful and pragmatic case studies for review. As a long-time veteran of the quality improvement landscape myself, I found the observations and attitude of the authors to ring true throughout the book. They are clearly veterans themselves, and the guidance they provide will be invaluable to any physician new to quality improvement. This is the kind of useful reference manual that should sit on the bookshelf of any department library or private practice site chief and should be consulted whenever a new project is developed and assigned.
The authors begin by emphasizing the importance of physician engagement and physician leadership in quality improvement, a sentiment which I heartily endorse. One need look no further than the perennially recognized top hospital systems in America to see the importance of this principle: The majority of top facilities are led by physicians, often with unified control over both hospital function and clinical personnel. In discussing the challenges of quality improvement, the authors make the telling point that “Healthcare does great work with brilliant employees working with mediocre processes.”
One hazard of the quality improvement literature is descent into jargon, with trendy brand-name terminology slathered over the same common-sense principles that have worked in healthcare for decades. A routine failure of quality improvement novices is to mistake the wrapper for the candy bar, by force-fitting canned methodology into inappropriate situations; this approach inspires cynicism among frontline stakeholders, with development of passive resistance, active work-arounds, and inevitable failure of change efforts. In this manual, however, the authors resist the temptation toward jargon; the only brand-name approach cited is Lean Six-Sigma, which has gotten enough traction over the years to become reasonably generic. And even there, most of the actual recommendations for driving change in practice are presented in plain English.
The majority of the book is a step-by-step guide for tackling clinical problems, and these chapters will be meat and potatoes for any clinician charged with a quality improvement project. The sequence of steps is appropriate, and the deep dives into individual steps are presented in a simple and easily understood fashion, with copious examples—obviously drawn from real experience—of the ways in which quality improvement projects can fail.
My criticisms of the book are few and do not detract from its overall utility. I would have liked to see more philosophical framing early in the work, especially around the cost of change. As clinicians we are confronted with innovations every day, ranging from new medications that can be easily substituted into our workflow (e.g., sugammadex) to new technologies that produce massive and fundamental change (e.g., robotic surgery). Experienced clinicians are constantly—and usually unconsciously—balancing the desire for improvement against the predictable, but unknowable, unintended consequences of change. Early robotic surgery created a rise in ocular injuries; adaptation of video laryngoscopy increased the risk for pharyngeal trauma; other examples abound. Physician resistance to change is often a defense mechanism intended to protect patients from new complications; mindfulness of this reality can facilitate efforts to drive positive change.
I would have also liked to see a chapter on the challenge produced by the wide variabilities seen in healthcare, both in patient physiology and in clinician personality. Although everyone writing about quality improvement would like healthcare to be as smooth and consistent an industry as commercial aviation or nuclear power generation, the reality is that our systems are challenged every day by patients (and personalities) that are many standard deviations from the norm. To be successful, quality improvement projects must make provisions for wide clinical variability, and project leaders must have techniques in hand for dealing with obstructive personalities. More advice in these areas would have been helpful.
In total, however, The Quality Improvement Challenge will be a useful reference for any clinician trying to drive change in their healthcare system. Residents and new leaders will benefit from learning the basic techniques of quality improvement. Experienced clinicians will have a well-organized source for advice on specific projects. And even those with only a casual interest in the topic will learn from the pragmatic insight into the healthcare industry and the challenges of achieving better patient outcomes.