Quality improvement via systems thinking

In order to improve health-care outcomes in our increasingly complex environment, clinicians must confront greater understanding to influence a wider framework. This progression can be achieved by meeting such constraints within the growing science of quality improvement.

Many orthodontists perceive providing high quality care not only as our professional responsibility but our raison d’etre — our reason for being! Our focus is first and foremost on the patient in front of our eyes and, occasionally, on similar populations of malocclusions, concentrating on clinical effectiveness, safety and frequently on wider proportions of treatment quality; this includes impartiality and fairness, patient-appreciation and patient-responsiveness, as well as access and synchronization with others.

As a profession, we are encouraged to advocate and espouse a standards-based approach and regard discrete phases of education as the mechanism by which these standards are delivered. We are trained as erudite scientists and, therefore, educated to regard a randomized, controlled trial as the gold standard of evidence; progress is then achieved by trial findings, outcomes and assessments.

In the business arena, the science of quality improvement is well established. As orthodontists, we strive for delivering high standards of care and recognize that we have two jobs regarding clinical effectiveness: improving how we perform and performing to our utmost ability. This requires commitment to (a) influence patients and populations, by accepting responsibility for other dimensions of quality; (b) standards, by influencing the systems within which care is provided, (c) bio-science, by consigning ourselves to continuous learning and to the creation of learning organizations, and (d) behavioral science, by understanding and accepting the strengths and weaknesses of different forms of evidence that apply to appropriate problems.

Quality improvement illustrates a variety of recognized scientific disciplines, the core feature of which is systems thinking. This requires acknowledgement of variation and recognition of behavioral sciences in order to glean a broader appreciation for what constitutes profound knowledge.

Systems thinking can occur at the (a) practice level with our patients, and (b) national level with our leadership. Orthodontists are well versed in basic sciences and clinical application. By possessing the skills required to transform profound knowledge into practice, we bring together the expertise in a way that allows optimization of the working environment for the benefit of the clinician and patient. This evolution is called praxis. We must employ these skills and expertise to influence change in the local, state and national level.

Education, of course, is the answer to a lack of knowledge and the key to success for improving multi-level quality improvement. There are many approaches for developing initiatives of quality improvement, such as those presented in previous editorials (learning to look, systems thinking and scenario planning). We must have the desire to contribute at the level required to produce prolonged, system-wide improvements in quality. Education, incentives, leadership and revalidation are key ingredients for quality improvement to be omni-potent at all levels.

Quality improvement education differs from traditional dental education in terms of philosophy, culture, ethos, content and style. These are adult learning principles, highlighting active learning, experimentation, self-reflection and feedback. Existing educational programs must share and evaluate quality improvement in order to create effective evidence-based educational programs. Audits, outcome assessments and professional re-accreditation are important components for expanding and advancing the science of quality improvement; it is an explicit and integrated expression of best orthodontic practice.

Many general dentists, orthodontists and other specialists are only partially trained for future challenges, especially as our professional roles evolve within the system and our delivery of health care becomes more complex. In order to promote the science of quality improvement, systems thinking and appreciation for the praxis of theoretical explication and practical optimization are required to be applied. Academe, the profession and clinicians must rise to this challenge.

This editorial was inspired by an original essay: Hockey, P.M., & Marshal, M.N. (2009). Doctors and quality improvement. Journal of the Royal Society of Medicine, 102, 173–176.