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Process implementation: the black box of quality

Last year, quality in acute hospitals was in the news with the release of the Duckett report (Targeting zero: Supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care). This year, residential aged care is making headlines for similar reasons, following the publication of an article in the Medical Journal of Australia that reveals an increased incidence of preventable harm – including deaths – amongst Australian aged care residents over the period 2001–12.

Sadly, I am no longer surprised by these reports. Quality and safety regimes have struggled to deliver the assurance of quality that was promised, largely because the middle part of the quality equation – i.e. how processes are actually implemented – is a black box that is rarely explored.

In theory, the combination of accreditation (to benchmark systems and protocols) and indicator monitoring (to benchmark outcomes) was supposed to guarantee quality. Instead, this "bookend" approach to quality has engendered a compliance focus amongst managers and staff alike that is antithetical to the concept of quality.

Quality should be integral to everything we do. Instead, quality is now something you “do” periodically, either to prepare for accreditation or to collect and analyse data for reporting against mandated indicators. Staff see the activities as burdensome and unrelated to their “real” jobs. Quality-related projects are treated as “special” and, once they are completed, things soon drift back to “normal” practice.

Unfortunately, once organisations start to see quality as a compliance issue, it becomes much easier to look for ways to trim the quality budget, because the measure of success is whether the compliance requirements have been met. “If we can still tick the boxes but spend 20% less on quality activities in the process, then we owe it to our shareholders to make that saving,” is how the logic goes.

The reverse argument is used as well. “Why should we apply any more resources to quality than we currently do, when we’re already meeting our requirements?”

Why? Because the inescapable conclusion from the Duckett report and the MJA article is that in the health and aged care sectors “meeting requirements” demonstrates a commitment to compliance, but is not necessarily a guarantee of quality.

It now seems clear that accreditation and indicator monitoring are necessary but not sufficient components of a holistic quality regime. The neglected piece is process auditing, i.e. structured review of routine practice. Without a mechanism for reviewing how processes are actually implemented by staff, quality assurance is based on the – demonstrably incorrect – assumption that systems and protocols will always be implemented as intended. Moreover, without a mechanism for determining what staff do now, there is no basis for addressing THE key question of quality improvement, namely: “How can we do this better?”

What we are witnessing is what happens when we allow process implementation to be a black box that we never look into. The reason we have put off looking inside the box is because looking takes time, and time staff spend in structured review of their routine practices is time they’re not spending doing those routine practices.

At some point, we’ll realise that not only is structured process review NOT a waste of time and money, it is the only way to really engage staff in meaningful quality improvement activities. It’s also the best way to identify issues before they become actual problems and the best way to embed the concept of quality in everything we do.

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