Doctors, managers and the battle for quality

Ask any negotiator how they achieve results and they will tell you to concentrate on what brings the two sides together rather than on what drives them apart. Since the introduction of general management into the NHS over 30 years ago, doctors and managers have not always been good at finding common ground. The criticisms are stereotypical and well-rehearsed.1,2 Managers say that doctors are only interested in clinical effectiveness and not in other aspects of quality, are unwilling to engage in wider discussions about resources and behave in elitist ways. Doctors say that managers are preoccupied with balancing budgets and hitting targets, never stay around long enough to see the consequences of their decisions and fail to understand professionalism. Both sides build separate identities around their own specialized bodies of knowledge. For most doctors and mangers there seems to be little connection between the basic medical sciences and the clinical method on one side, and business strategy and operational efficiency on the other. Despite these tribal tendencies, doctors and managers do share the common aim of improving patient care. In order to achieve this aim, there is a body of knowledge that both groups need to understand and put into practice. W Edwards Demming, the doyen of quality improvement, called this ‘profound knowledge’3 and identified four key components. First, an understanding of systems thinking which conceptualizes work as a series of inter-related processes and describes different ways of achieving change in systems of differing complexity. Second, a commitment to developing valid and reliable measures which can be used to evaluate these processes and the ability to interpret the results – in particular to differentiate between variability due to chance and variability resulting from real defects in care. Third, an understanding of epistemology, the strengths and weaknesses of different forms of evidence and a commitment to using the most appropriate form of evidence to address the problem in hand. Finally, a pragmatic understanding of the behavioural sciences and how they can be used to get the best out of individuals and teams. Health systems are becoming more complex and the expectations of those who use and fund the system are rising. This places an onus on doctors and managers to address well-recognized deficiencies by thinking and acting differently and not to simply do more of the same or to try harder. And yet neither group are adequately trained to address the systematic problems inherent in the ways that care is currently provided. It may not be an exaggeration to say that the people who work in the health service are only half trained. Most managers will know something about systems thinking and most doctors will have a basic knowledge of statistics and psychology. Both groups are well versed in their specialist areas of knowledge but not in the areas identified by Demming as fundamental to improving quality. The health service is way behind most commercial sector organizations which have actively embraced the science of improvement for over two decades. The result is an impasse – politicians and policy makers exhort the workforce to produce radical improvements but doctors and managers lack the knowledge and skills to respond. What needs to be done? If the problem is a lack of knowledge and skills, the solution must be first and foremost an educational one. There is good evidence that educational interventions to improve quality of care not only work4 but have an effect size orders of magnitude greater than alternative high-profile interventions such as financial incentives.5 What are the key characteristics of an educational programme which aims to build knowledge and skills in improvement? First, since both doctors and managers need to understand and apply the science of quality improvement, there is a unique opportunity for them to learn together. Little in the real world of improvement is absolute; most is a matter of judgement and trade-offs. Learning together provides an opportunity to test judgements which are often highly culturally bound, to be challenged, to have to defend, negotiate and compromise. The process may be uncomfortable and might benefit from expert facilitation. Second, the ethos and style of the programme should be different from the traditional didactic approach to education experienced by most managers and clinicians. Batalden describes this different mindset as learning by curiosity, invitation and experimentation, rather than learning by intention and control.6 The underlying principles are compatible with those of adult learning.7 Learners should be active participants rather than passive recipients, they should set and pursue goals that are important to them and are relevant to their day-to-day experiences. Learning should be about experimentation and role-modelling, and self-reflection and peer feedback are essential. Third, a curriculum is required which clearly defines the knowledge and skills that both doctors and managers need to know in order to practice and lead improvements. The components are well defined and include technical knowledge of quality measurement, improvement methods, data analysis and interpretation, change management and risk assessment. The focus should be on patients, communities and the public and on acquiring a good understanding of the historical, social and political context within which the health system operates. Fourth, the learning should be work-based as much as possible, so that theories and techniques learnt in the classroom can be tested out in real-life situations. Finally, managers and doctors who attend educational courses should pass on their learning to their peers. The challenge is to create a learning environment in which all who work in the health service are continuously improving their skills, challenging their own working practices and constantly looking for better ways to work.8 The challenges are great and the meeting of strong medical and managerial cultures may be uncomfortable. But as we celebrate the sixtieth birthday of the NHS, the potential gains for patients and the service of doctors and managers finding common ground in the science of quality improvement could be significant.