IT’S THE QUALITY STUPID

Journal of Psychiatry Reform vol 12 #12, September 1, 2025

Author

Alan Eppel, MB, FRCPC

iD: https://orcid.org/0000-0002-4880-4097.

Senior Editor

Professor Emeritus McMaster University, Hamilton Ontario

I was first introduced to the “Quality Assurance” paradigm while working as a staff psychiatrist at the Homewood Sanatorium in Guelph, Ontario, in 1980. The Homewood (later renamed the Homewood Health Centre) was ahead of other hospitals I had worked at. It had an organized approach to maintaining quality, which included regular chart audits.

At the first meeting of the audit committee, I was surprised to find that one of my clinical charts had been audited by a member of the committee. The auditor had identified a number of areas that warranted some comment or suggestion. I was defensive and argued strongly against each of these suggestions and recommendations. I widened my attack by expressing that quality assurance was a “waste of time” and interfered with the central work of medicine, providing care and treatment to patients. Within two years, I had had an epiphany. Quality assurance was not a burdensome add-on activity but was in fact the whole enchilada! I was reminded of the saying “It’s the economy, stupid”. This phrase was coined by political strategist, James Carville, during Bill Clinton’s successful presidential campaign in 1992. Just as one domain may be predominant in politics, so too in medicine. Quality of care is the main objective of what we do as physicians.

In 1980, the paradigm was “Quality Assurance”. This consisted of an evaluation of the structural components of health care delivery: the credentials of the staff, the requirements of the medical record, the physical adequacy of wards and hospital facilities. Within a decade, this paradigm had been replaced by the paradigm of “Continuous Quality Improvement”, or CQI, imported to the US by leaders in industry who had studied the superiority of automobile production in Japan. The CQI process was then applied to healthcare system led by Don Berwick and others [1, 2].

CQI is a philosophy, a mindset. The goal is to continuously be improving what we do. To improve care we need to know how we are doing. This involves measurement of current practices and the outcomes of clinical care. Quality of care can be summarized as: the right intervention, at the right time, in the right place, and in the right manner [3].

The right intervention: The right intervention means the therapeutic process that is delivered should be the most effective based on the current scientific knowledge and evidence.

The right time and the right place: This means that services should be accessible both in terms of geographic location and timeliness. Services should be available 24 hours a day and close to where patients live. The right place includes general physicians’ offices, in the home, outpatient clinics, acute hospitals, long stay hospitals, day hospitals, and outreach teams. For example, a busy hospital emergency room is not the right place to assess older patients with dementia and patients that are agitated and aggressive.

The right manner: The right manner refers to the quality of the interpersonal interaction between patient and physician. This should include a respectful and empathic attitude and advanced communication skills. When patients are unhappy with medical care they describe lack of accessibility, long wait times, no response when they press the call bell when in hospital, lack of emergency care other than at hospital emergency rooms or “call 911”. The interpersonal manner often lacks empathy, respect, and time to listen to patient concerns.

Every defect is a treasure

There is a saying in CQI that “every defect is a treasure” because it leads to the identification of an “opportunity to improve”. Every member of the team can identify an opportunity to improve a therapeutic or organizational process because that is the core of what we do. Berwick has described key principles in striving for improvement and change, as described below [4]:

• Real improvement comes from changing systems, not changing within systems;
• To make improvements we must be clear about what we are trying to accomplish, how we will know that a change has led to improvement, and what change we can make that will result in an improvement;
• The more specific the aim, the more likely the improvement;
• Concentrate on meeting the needs of patients rather than the needs of organizations;
• Measurement helps to know whether innovations should be kept, changed, or rejected; to understand causes; and to clarify aims;
• Effective leaders challenge the status quo both by insisting that the current system cannot remain and by offering clear ideas about superior alternatives;
• Educating people and providing incentives are familiar but not very effective ways of achieving improvement; and
• Most work systems leave too little time for reflection on work.

Conclusion: Looking back looking forward

In the years since 1980, I have learned a lot more about good quality and poor quality in health care. The words of W. Edwards Deming, another pioneer of CQI, have remained inspirational [5]. Quality improvement is not a superordinate technical management process. It is not sufficient for leaders or quality improvement departments to post mission statements on the walls. Rather we must all identify our own mission statements and use the methods of CQI to continuously improve what we do.

References

1.Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989 Jan 5;320(1):53-6. doi: 10.1056/NEJM198901053200110. PMID: 2909878.

2.Mitchell J. Curing health care. New strategies for quality improvement. Qual Health Care. 1992 Dec;1(4):272–3. PMCID: PMC1055044.

3.Eppel AB. Achieving quality of care. CMAJ. 1992 Nov 1;147(9):1305-6. PMID: 1483226; PMCID: PMC1336418.

4.Berwick DM. A primer on leading the improvement of systems. BMJ.1996 Mar 9;312(7031):619-22.

5.Best M, Neuhauser D. W Edwards Deming: father of quality management, patient and composer. BMJ Quality & Safety 2005;14:310-312.