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Quality Improvement Programmes: Plagued by the Paradox of Choice

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Improving health and social care services is challenging. Deciding what needs to change, who needs to change it, and how to accomplish that change is a complex process that requires input across diverse teams of staff and patients. Underlying the outwardly messy nature of quality improvement programmes should be a systematic approach. This approach will allow teams to efficiently define the problems they need to fix and then co-produce solutions with the greatest potential for improvement.

The Paradox of Choice

When faced with too many options we have a difficult time selecting any option.

While sometimes quality improvement teams are paused because they have no ideas for improvement, we suspect this problem is rare. More often, quality improvement teams are plagued by what Professor Barry Swartz called the “paradox of choice”: when faced with too many options we have a difficult time selecting any option. This problem is familiar to all of us.

For instance, when at a new café I pause at the vast array of deliciously described menu options, as I am uncertain which option will maximise my dining experience.

To overcome the paradox, one can use default strategies to satisfy their needs. For example, if I decide not to eat meat, I only need to focus on the much smaller array of vegetarian options to fill my grumbling tummy. But this default strategy is harder for quality improvement teams to justify. After all, the goal of quality improvement programs is not to maintain satisfactory care, but rather to maximise the potential for optimal health and social care.

The goal of quality improvement programs is not to maintain satisfactory care, but to maximize the potential for optimal health and social care.

The problem with suboptimal medication prescribing

Let us focus on the problem of suboptimal medication prescribing. As recognised in the NHS Long Term Plan and amongst diverse groups of stakeholders, suboptimal prescribing is an increasing healthcare problem across primary, secondary, and community care and causes substantial financial burden. But when you explore opportunities for improvement and start to ask what medications, who needs to change, and how should we get them to change, disagreements quickly surface.

Quality improvement programmes often have more ideas than time and resources allow for them to develop the correct implementation process, and even a good idea will fail if it is poorly implemented.

Which idea is taken forward for implementation?

Determining which idea can be taken forward for implementation is dependent on various criteria. Some of those criteria may be relevant to the individual characteristics of quality improvers, while others may be specific to the nature of improvement ideas, implementation process or something very particular that the quality improvers value as important.

We should have a tool that enables quality improvement teams to evaluate ideas faster.

While we cannot know what ideas will surface in the coming years, we can choose the most salient preferential criteria that underlie what ideas are most likely taken forward. Professor Ivo Vlaev from the Behavioural Science Group at Warwick Business School is currently leading a project that will compile these criteria, and then use them to evaluate ideas to improve medication prescribing over the next year.

By the end of this process, we should have a tool that enables quality improvement teams to evaluate ideas faster. And by determining what idea to take forward faster, quality improvement programs can devote the more crucial time needed to develop an implementation plan that suits their organisation’s unique contextual needs.

Get Involved

To develop this project further, we would love to hear stories about challenges you face when deciding what quality improvement ideas to take forward. We would like to hear about the essential criteria you use when considering whether to take an idea forward.

You can share your ideas with me via the Q community website or by sending me an email.

We look forward to engaging with you while we move forward with our project. Together, we can develop a decision aid tool which will be very helpful to the improvers and improvement researchers like us.


  1. Saval, I think that you have highlighted an issue that is very important. Staff time in the NHS is too valuable to be following just improvement 'ideas'. Your research may find a solution to this 'paradox of choice'. A more 'systems' approach to implementing QI may also be a solution. Variation in work processes negate the value of data collected in QI projects giving false interpretation from the analysis of that data. If work processes were better understood, through a process of process management, then a better quality of process based data could be use in QI projects providing better ideas for improvement.

    Better understanding of clinical processes and non-clinical processes is required and also the difference between 'improvement' and 'service re-design'. Maybe your research will consider these differences.

    1. Thank you Tom for your feedback. Yes, completely agree that we need to differentiate between 'improvement' and 'service re-design thing. We will consider such a thing when we plan to move our research into the next phase. The input like yours will definitely help us refining our main survey. Thank you once again.

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