The current issue of Quality and Safety in Healthcare contains an incisive editorial by Kaveh Shojania and Eric Thomas about why the QI field has not been able to demonstrate widespread improvements in patient safety as a result of their efforts.  To show such an improvement, they write, would require three achievements:

• "Identification of interventions that reduce common types of adverse events.
• Dissemination of (some of ) these effective interventions into routine practice.
• Development of a tool to measure improvements in patient safety problems.

Unfortunately, none has occurred. We have few effective patient safety interventions. Those that may be effective have not been widely adopted (or not adopted in an effective form). And, the gold standard instrument for measuring patient safety problems is probably too blunt to detect changes over time."

Sobering. What we have from health care is a bunch of small scale change efforts that look really promising. "Hey, look what we did here!" "Hey, look at this change over here!"But at least in the  broad area of adverse events in health, they don't add up to what we wish it did.

At the very least, it shows how slow progress is. It also shows how we need simultaneous progress on several fronts.

1. QI work needs to partner with dissemination work. It is not enough to have a great strategy to improve care, but we have to be able to scale it up and measure change over time. Are the people who know these skill sets the same people? Not likely.

2. It also shows how we are going to have to replicate and apply science to the gains that QI work brings to a specific setting. Applying science usually means partnering with academic researchers, who are in short supply in the social services.

3. For the social services, it also means we need to be able to determine, a priori, the big scale indicators in our fields that we think can be changed by applying QI to the our social service fields. If we can't change the big ones -- safety, permanence, recidivism, poverty reduction -- through our efforts, then the QI work will not be funded and sustained over time.

Eventually, we need to think big. But in the meantime, we need to simply get started. We need to educate people in the social services about what QI is, get some great folks skilled up in QI, and start building successful QI interventions.

This is a long haul, baby. A long haul.

Kaveh Shojania, M.D.