Scrutiny of processes critical to sustainable healthcare improvement



In their editorial addressing the measurement of quality improvement in obstetrics, Draycott et al.1 emphasise the need to shift the focus away from process towards clinical outcomes. The frequent preoccupation of managers with process measurements having no obvious correlation with patient outcomes is a source of annoyance for frontline clinicians. Often felt to be imposed ‘top-down’, process targets can feel distant from the realities of clinical practice. However, although we agree with the authors that a focus on outcome measures of quality is essential, the value of attempts to improve process should not be ignored.

In Wales, a new concept called ‘Intelligent Targets’ is being piloted to map both processes and outcomes more clearly.2 These are focused on meeting the patients’ needs and are agreed following consultation with the professional groups responsible for achieving them in practice. This requires measuring performance, but importantly, it will be measurement aimed at improving the service and not blaming individuals for any shortcomings discovered. Intelligent Targets must meet key criteria, specifically the advantages should be obvious to the professionals and be compatible with their values and working style; be simple and testable; and the professionals should be able to change them if this becomes necessary.3

For example, clinicians learned what compromised the quality of stroke care from a review of patients’ notes in Welsh hospitals.2 They next decided what interventions must be made within agreed time-scales to improve clinical outcomes. One group of Intelligent Targets focused on achieving diagnosis and emergency treatment within 3 hours. Therefore, diagnoses must be made using a recognised decision-making tool, the diagnosis must be confirmed by a senior clinician, and aspirin should be given. Other targets focused on early mobilisation within the first 3 days and specialist goal-orientated care by day 7. To help staff to cope with changes in practice, a methodology called the ‘Model for Improvement’ was introduced. This involves defining clear aims, appropriate measures of process, and piloting change via PDSA (Plan–Do–Study–Act) learning cycles, described in detail by Gozzard and Willson.2

The process of acquiring new knowledge via traditional research methods can be lengthy, as can its translation to the bedside. A change in attitude is likely to be necessary if this new approach is to succeed. We suggest that the 21st century medical graduate must be educated in how the health service works, and be trained in how to analyse and then improve the delivery of care, and not be prepared solely for the individual medical encounter.

Involving students and juniors with the enthusiasm and ideas to improve healthcare will help. Clinical champions of quality care are, and will continue to be, important as role models. We must establish continuing healthcare improvement as the norm for future trainees.


  1. *The authors of the original article were invited to respond to this letter, but declined to do so.