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 Quality
improvement is an empirical, goal-oriented method of improving
the performance of a system. Although systems sometimes
improve serendipitously, experience shows that things tend
to stay the same or get worse without deliberate efforts
at improvement. The goal of quality improvement in health
care is to improve delivery of scientifically based care
in order to prevent or cure a disease or ameliorate the
effects of a disease.
Effective
system improvement requires identifying and understanding
aspects of a system that are primarily responsible for its
performance so that changes can be efficiently focused and
replicated. Such changes are more likely to be effective
if they are evidence-based and implementation is guided
by empirical knowledge of the system rather than ideology
or unexamined hunches.
Complex
social systems, however, present researchers with qualitatively
different subjects than is typical in medical science. Traditional
research tools such as tightly controlled experiments, double-blind
trials, and standardized interventions are appropriate and
effective for investigating the molecular basis of metabolism,
for instance, but are often difficult to use in the examination
of large, diffuse social systems such as hospitals and hospital
systems. It is not always obvious how to conduct research
that would lead to system improvements, such as making regional
hospital systems work well with local long term care providers,
or providing for patient pain relief regardless of time
of day, or day of the week.
An
approach to this dilemma that has been embraced by many
thoughtful scholars and leaders in health care is a system
of quality improvement dubbed "pragmatic science" (Berwick
and Nolan, 1998). "Pragmatic science" means learning
about a system and its operation by using all available
evidence, including evidence generated by the participants
in an investigation through an iterative process that repeatedly
makes changes and measures their effects over time. This
approach to quality improvement is more fluid, more dynamic,
less controlled, and less precise than "traditional" research
methodology, but it remains fundamentally empirical and
is often the only cost-effective and time-effective option
open to busy practitioners.
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