The theory behind change and quality improvement is well outlined by Dr John Øvretveit ¹ who, in a report supported by the Health Foundation ², identifies two types of approach: extrinsic, and intrinsic. The extrinsic approaches include centralised government initiatives, economic drivers and professional requirements, while the intrinsic approaches incorporate a range of models and methods that can be put in place by individual organisations. These are known as organisational or industrial approaches because they were originally developed within an organisational or industrial context.
The Health Foundation believes that a combination of extrinsic and intrinsic approaches is needed to ensure sustained improvement. External reward and incentive systems, such as the CQUIN (Commissioning Quality and Innovation) ³ framework (NHS Institute for Innovation and Improvement), are important, but individual organisations can usefully complement these by adopting internal approaches, which involve developing and setting their own goals, with full staff engagement.
Once the goals are set, quality improvement approaches offer organisations a systematic way of implementing change and monitoring progress. Actually initiating change so that services improve can be difficult. There are many reasons for this. One of the important figures, who have worked, both in the USA and worldwide, in analysing the reasons for this, is Don Berwick ⁴, who founded the Institute for Health Improvement (IHI ⁵), in Boston. He has highlighted the failure of audit to make the important impact that we had hoped for. He and others have suggested a different approach termed Total Quality Management (TQM) (among other names, including Six Sigma ⁶) which integrates quality, efficiency and leadership. They have fallen back on work done in industry, particularly by the father of this science, W Edwards Deming ⁷ ⁸, to improve quality, which is based on organisational change.