Room for Improvement: Local Action.

Global Quality and Ground Realities:

A Look at Healthcare Global Quality Systemically-Global, Inter-national, Trans-cultural.

Change efforts fail often due to one of two reasons. When they are implemented with passion but without systems or with systems without passion– Tom Peters

Theories of Healthcare improvement in developing countries is based on the work of western scholars and thus has a dependent and marginalized relationship to research of healthcare quality in developed countries. Local and global are two concepts but have one goal.One of the greatest advantages of creating  quality locally is that, it would address local needs and thus ensure mental decolonization by western ideas of modernity that are based on technology.

The Problem of Quality in Developing Countries:

The problem of quality is, that it is not considered a problem in developing countries. The moral panic following the publications of IOM reports did create awareness among developing countries but remained merely a curiosity. What is the cause of this negligence of quality?  A common view is that 0nly resources are a solution and improvement requires resources. The viewpoint betrays the mistaken assumption that quality is possible only at increased cost. The true moral test of quality is that, money must follow quality, not quality follows money. Currently, participation in the improvement economy, actually has competitive dis-advantages: both for individuals and organization. In developing countries, both the demand and supply of improvement is problematic. Western scholars are perhaps unaware of this crisis. Redress of such a basic abrasion, requires systemic innovation not incremental improvement.

A lagging healthcare policy is the root cause for the missing quality paradigm in healthcare progress in developing countries. The absence of quality consciousness in the determinants of health policy is the reason for developmental malformation of missing institutions and regulatory incentives for quality in healthcare. Adhocracy and the absence of a conceptual framework capable of scrutinizing the ethical dilemmas between quantitatively measured access and the accounting of quality in healthcare. What is equity worth without quality? Sadly, in developing countries ‘structural thresholds’ have driven out outcome expectations, denying the systemic properties of processes as instruments of progress. Thus ,poor quality and inertia are institutionalized and sadly institutions are locus of power: Systems have historically been seen as a mode of control not change.

For almost half a century developing countries have not explicitly focused on quality. This is not merely a reflection of the lack of institutions or knowledge but deeper issue of socialization: a common sense of purpose. The lack of clarity on the aim of improvement or ‘knowing why’ is the weakest link. Quality to thrive in developing countries is dependent on capabilities for improvement: any approach to start or sustain improvement  must capture the moral imagination of the workforce.

Value framework for improvement:


The agenda for change has two parts:

A. Institutionalization of Quality.                                      B. Socialization of Quality.

Institutionalization includes : Marketplace , Organizations ,Human capital, Knowledge capital, community capital.

The latter includes:

A. Professionalization of Quality.                 B. Personalization of Quality.

What does professionalization entail?

A. Expertise.                      B. Experience.

What is common to both professionalization and personalization is accountability: one to the public and the other to conscience.

What does Personalization entail?

A. Internal structure of personal quality: micro motivations for improvement. How to make systems personally useful. Making improvement popular:  Designing popularity. How to navigate the chain of effects?

B. Sense of purpose or potential: strategy, competition, professional development, knowledge management, willingness to be judged, future orientation, analysis and synthesis: Taking things apart and putting them together.

Who should get involved in quality improvement and how will we define success .If you are already doing well in your practice you will benefit most by the knowledge and skills .If you are not doing well but would like do well, like the more resource advantaged, then quality improvement can help you  catch up and compete. If you are doing well and someone else is taking away you practice then it will help you recover . If you are a beginning practice and wish to know how  best to do it, then you will benefit by design . But non of this is the agenda of socialization of quality. Quality is about social status , survival and  progress of medicine as a profession. While anthropologists like Gould question question the 100 year cycle of breakthroughs, Brent James at the Intermountain Health Care, has consistently pointed to the epochal nature of quality.

The beginning of the 20th century , often referred to  by american political scientists as the Progressive era, has also seen most of the ‘fundamental’ breakthroughs in the epistemology of clinical practice: in basic sciences,organization of practice, medical education.  These ‘knowledge based breakthroughs’ laid the foundation for the tremendous advances in ‘technology’ that has led to the blooming of the modern version of practice.

Now, at the beginning of the 21st century , it is ‘quality based improvement’ leading to breakthroughs in clinical practice : in the design,systems and communities, that will serve as the fulcrum, for continued  progress. Practice cannot be viewed merely as an extension of research, but has multiple drivers such as decision[EBP], design[QI], empathy [care] and creativity[innovation]. If the last century belonged to Osler, Codman and Donabedian, this century belongs to Berwick, Bataden and James, three physicians who have not only had a ‘historic sense of quality’, but have had the privilege of sharing the dais with Deming.

Personalization of quality does not occur in a vacuum, it requires ‘Room for Improvement’: Actual and Actualizing spaces.

Any improvement space can be distinguished as two separate kinds, based on the what motivates the improvement. a] Actual spaces B] Actualizing spaces. Actual spaces are driven by economic incentives such cost reduction, contracts, competition, accreditation, prospective payment, pay for performance etc. The underlying logic is cost – benefit analysis or economics. In the case of actualizing spaces, improvement is born out of the urge to do the best or belief in achieving ones true potential. It is driven by the harm – benefit analysis or ethics. Both these spaces coexist as natural and harmless. In itself one is not better than the other. However, if one brings the analysis of developed and developing countries then there arises a polarization, with developing countries having only actualizing spaces. My thesis is that there is injustice here. While actual spaces can be actualizing spaces, the converse is not true. In actualizing spaces the risk is borne entirely by the innovating organization or innovating individual. No single organization or individual can bear the total risk of the improvement paradigm. While they both share equal opportunities for improvement. The capabilities are different! The natures of freedoms are different: people in actual spaces have positive freedom, while those in actualizing spaces have negative freedom. The difference is that of the difference between a person fasting and one that is starving. Both have compromised nutritional status but the former retains freedom. There is a need for different metaphor for healthcare quality in developing countries, rather than ‘Catching up with the west’. A notion of quality as a public good is an ideal candidate for local and global improvement. Global quality as a common wealth of quality. Quality is a Knowledge embedded good. Professional of Quality : need to acquire practical identities as individual experts and as part of plural agencies more supportive than healthcare organizations and their leadership who are limited by ‘managerial inference’. The profession of quality must, like medicine or nursing, be directly accountable to the public. A line of thinking expressed by Berwick , in his call to get politically organized.

  1. Arbitrary career paths, Career opportunism, Improvement Tourism
  2. Unsolicited opinions – examined Practice hypothesis. Good questions. Gates: develop practice analysis skills ; introspection , questioning skills , big picturing skills, Accountability for learning .Accountability for action . Taking things apart
  3. Solutions approach: includes cost cutting. Responsiveness. Present.

Any solution to improve healthcare in developing countries must evolve into trust in knowledge and systems. Only then , will global interaction lead to local action.

Keywords: Global Quality, Institutionalization, Socialization, Professionalization, Personalization of Quality, Actual Space , Actualizing Space, Substantive Freedom, Quality as a Public Good.

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