Why quality language is killing quality - and how the IHI governance framework can help...QNews2 2019

If I never read a sentence again like that it will be too soon.  But I know I will. Over and over. These words, and the many others like it lurking in strategic plans and annual reports and quality frameworks, have played a starring role in slowing progress with improving the quality of care in health and human services.

At this point many of you will be thinking that I need a holiday.  What on earth could be so wrong with this perfectly fine looking sentence?  This, or something like it, may even feature in your own documents.

The problem is, when you deconstruct it, it doesn't make much sense.  And words that don't make sense have little power to inspire the common understanding and action required to create consistently high quality care.

Health and human services have been in a dance with the language of quality from the beginning. Ever since 'quality assurance' became a thing, we've shuffled between language that described what we were trying to do and what we were trying to achieve without ever really coming to grips with what we were trying to say.  I know! - I was guilty of it for many years.  For one thing, most of us didn't have enough knowledge to use the right language - it seemed any old words would do and everyone put their own interpretation on them and we bumbled along. That lack of deep understanding, coupled with a constant stream of jargon associated with new improvement fads, meant that we were butchering the language of quality like a tourist with a week of night school local dialect under their belt.

Which is why the sentence above, if we were to utter it in 'qualityland' where everyone spoke fluent quality, would attract serious eye rolling, sighing and a few laughs from the locals.

Technically, 'person-centred' and 'safe' are dimensions of quality care, so adding 'quality' as a component of quality care makes no sense.   It's a bit like describing the components of a car engine as 'cylinders, radiator and engine.'  Apart from keeping us stuck in senseless jargon, these types of sentences also allow people to claim 'quality' care when it doesn't exist, because it's something that doesn't need to be further defined, or can't be defined. It just 'is'.  So people can point to mediocrity and call it 'quality' - and who's to argue? And these kinds of quality statements do nothing to help the staff  who are charged with  providing the care to fully understand exactly what it looks like and means to them, so they are unlikely to make it happen.  My other beef with the sentence is the 'ensure': very little ensures anything in a complex system; once again, sounds great, but creates a complacency that if we say it, somehow it's already done.

One day I realised that by persisting with this language, I was not only confusing other people, I was confusing myself.  So I started to have a good look at the language of quality, eventually settling on something I could work with, even if no-one else could.  You can see this in my books and videos.

It's not too late...

We all know how powerful language is in developing shared understanding, influencing opinions and shaping behaviours.  Language is evolving all around us: sometimes it seems to be change for the sake of it, and sometimes we can see the benefit to the way we frame and think about things, such as not assuming that a medical doctor we don't know in a story is a 'he' for example. It seems like such a little thing to say 'she - or he' - but it immediately reminds us that the days of assuming all doctors are men are gone - mostly -  and that the power that goes with being a doctor is no longer vested only in men.

In the same way, we can  - and must - evolve the language of quality in health and human services. Around about one score and five years ago, from my reckoning, the word 'safety' entered the 'quality' lexicon and immediately became the alpha term.  It didn't matter how many frameworks and papers were published describing quality care as the sum of a number of dimensions; the shock of finding out that we provided unsafe care sent 'safety' directly to the top of the dimensions charts for so long that many of the other dimensions faded away. I've said many times that this is perfectly understandable, considering that prior to that safety hadn't been widely discussed, reported on or addressed as a specific issue - what happened in the hospital stayed in the hospital. So 'safety' definitely needed to assert its place and receive the attention it deserved. 

But as so often happens in human services, the pendulum swung too far - and with it the language. People started referring to 'safety' when they really meant more. And over time, safety became quality, and a whole generation of healthcare professionals and managers grew up thinking that managing risk, reporting incidents and meeting standards was essentially all there was to 'quality'.  Access and efficiency were taken care of via funding requirements and, later, 'consumer focus' entered the fray.  Effectiveness, appropriateness and integration got lost in all but a few organisations.