If there is one thing we do not want to do as care professionals involved in improvement, it is to make a mistake that will cause anyone harm. At the same time, improvement is inherently about accepting that there are going to be setbacks and failures.

In fact, I have no examples of quality improvement work where everything went well and turned out perfectly. In my experience, that is not how quality improvement unfolds. By its nature, improvement involves looking very honestly at things that are not working well, or as well as they could.

So I wanted to consider occasions where our efforts to improve the quality of care for our patients can sometimes lead us away rather than toward improvement. I will look at how to work through these experiences to deepen our understanding of how to define improvement in a way that makes a meaningful difference to all of us: staff, patients and carers.

When improvement in one area leads to unwanted consequences in another

Last year, I had the opportunity to coach a colleague who was involved in a project to streamline the process of patient discharge in the emergency department of her organisation. The vision for the team was to create a kind of departure lounge for patients to wait while their paperwork and any necessary medications were arranged.

The team had set themselves a target of discharging patients from ambulatory care to the discharge lounge by midday. After putting new protocols in place and training the team, the process was implemented and patients began to be discharged efficiently by the deadline.

But by focusing on only one element of the process, some unwanted consequences arose. The disruption in the pattern of patient flow generated unexpected workload for other departments who were now receiving these patients.

We needed to reconsider this approach from a practical level. How could we make the discharge process more efficient without creating new problems elsewhere in the system?

We began by applying what I call the three lenses of QI.

Applying the three lenses of QI

The first lens I use is that of patients and carers. In this example, we stepped back to look more carefully at the pressures in the wider health and social care system, and we could see that the change in the pattern of patient flow was creating problems. We decided to set a more modest, refined objective to prioritise the patient’s continuity of care, rather than focusing on a deadline for discharge.

The second lens was the perspective of our staff. We needed to ensure that changing the process for discharges was achievable and sustainable for staff, so that we did not simply move patients down the corridor without a plan for their onward care. So instead of having a fixed deadline for discharge in the emergency department, we set a flexible target that allowed collaborative team working between departments and adjusted to each team’s capacity.

The third lens – and which I think is sometimes missed in QI – is whether the proposed improvement is aligned with the organisation’s interests. This is essential if the improvement is to be sustainable beyond its initial success and become part of the work culture. This involved thinking creatively and practically about how to handle the complexity of discharging patients.

We decided to change our approach and put more detailed information about the patient’s care needs in their care record – such as their condition and expected ability to self-care. By capturing and sharing that insight, we were able to realise a unique benefit from the patient’s interaction with the emergency department that would benefit all those involved in the patient’s care.  Giving patients this knowledge and understanding about their health needs empowers them to better plan their ongoing care.

I began by saying that I had no examples of improvement where everything went well and turned out perfectly. More often, what I find in QI is that the main pitfall is about having too narrow a perspective from the start, and not having sufficient understanding about what it is that we want to improve.

The key word in that sentence is ‘we’.

For me, QI is a way to involve myself more deeply as an individual professional to understand what ‘we’ really means. This a powerful, inclusive word. It embraces patients, carers, staff and the organisations in which we provide care. We are all involved in improvement and this is the most key element of QI that we need to continue to communicate.