Myth: We can improve quality one doctor at a time

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Myth busted March 2007

The solo doctor who embodies every process needed to ensure highest-quality care is now nearly a myth. All physicians depend on systems, from the local ones in their private offices to the gargantuan ones of national health care. i

Quality problems are pervasive. But poor quality is not a result of a series of individual mistakes. ii

Individual doctors are often singled out as "bad apples" when healthcare safety is lacking. iii In the same way, when it comes to achieving a high-quality healthcare system, doctors are frequently regarded as the system's lone rangers, standing to improve quality of care one "first-rate" doctor at a time. i But the performance of the healthcare system depends on the actions of many players: just imagine a row boat with a team of rowers pulling on the oars; one is a doctor and is rowing at a completely different rhythm from the rest of the team. Progress will be slow, frustrating for all, and with a great deal of splashing and bruising.

The belief that quality of healthcare rests solely on the shoulders of doctors has led to strategies focused on improving the quality of care offered by individual physicians through approaches such as clinical practice guidelines. Clinical guidelines have long been regarded as key to improving quality of care; this idea is based on the notion that if we gather the evidence on appropriate healthcare for specific circumstances and tailor this evidence to the needs of individual practitioners, we can improve professional practice and health outcomes. iv Unquestionably, guideline development is worthwhile, but doctors face a number of barriers - including those that are beyond their control - that serve to undermine guideline implementation. v- vii For example, physician adherence to clinical guidelines often relies on systems-level improvements such as acquisition of new resources, facilities, and enhanced staff support. v, viii, ix One academic put it best when he said "There has been a preponderance of patient-level outcome studies within a biomedical paradigm which is incomplete without attention to the context within which patients receive their care." x

There's undeniably no "magic bullet" when it comes to improving clinical practice, xi and the same is true for improving quality in healthcare. xii, xiii A more promising strategy would bear in mind not only the evidence on effective practice, but the evidence on how to transform the healthcare system at large.

No Simple Prescription

While the popular focus is on solo doctors, we know "no person acting alone is as effective as a team to drive best practices and outcomes." xiv And looking beyond the clinical level, a broader team exists. It is at the macro level, where managers and policy makers drive system-wide quality improvement initiatives, including greater use of information technology, performance measurement and reporting, and integration of services.

Few would dispute the significance of interprofessional collaboration in promoting safe, efficient, and quality healthcare. xv, xvi Teams are less prone to making mistakes than individuals, especially when team members are well-aware of their and their team members' roles and responsibilities. xvii, xviii And a healthcare system that supports effective teamwork can improve the quality of care through enhanced patient safety and reduction of workload issues causing burnout among healthcare professionals. xix Systematic reviews of collaboration and teamwork also show effectiveness across a range of chronic conditions - from cancer to mental health to geriatric care - ultimately leading to shorter hospital stays, reduced costs, and increased patient satisfaction. xx- xxiii An additional benefit of teamwork is its ability to help with effective transfer of evidence to practice. viii

Taking a Systems Approach

Another important contribution from research is to consider processes (such as information and patient flow) xxiv and systems (suites of processes) for improving healthcare outcomes. xxv

The "theory of continuous quality improvement" (or CQI) counteracts the still-popular "theory of bad apples" i, iii and operates on the principle that, while healthcare providers aim to do their best, they are limited by faulty healthcare processes. i, xxv, xxvi With an emphasis on improving processes and systems for improving healthcare quality, CQI initiatives take the heat off individuals.

One example of CQI functioning at its best comes from the American Department of Veterans Affairs (VA), which initiated a "system-wide re-engineering" to improve its quality of care in the mid-1990s. xxvii Taking a systematic approach to measure, manage, and be held accountable for quality, the VA saw a drastic upgrade in its overall performance, with statistically significant improvements for all quality indicators collected from 1994-95 through to 2000. xxvii In addition to instituting routine quality indicators and performance measurements and introducing an electronic medical record system, the VA's success relied on performance contracts and making performance data public, which served to make managers accountable for meeting quality improvement goals. xxvii


Physicians aim to provide quality healthcare for their patients, but they cannot achieve high-quality healthcare alone or without support. If we are to improve healthcare quality, we must focus our attention at the systems level - the "big picture" - and involve multiple actors, from healthcare providers to managers and policy makers.


i. Berwick D. 1989. "Continuous improvement as an ideal in health care." New England Journal of Medicine; 320(1): 53-56.

ii. Rachlis M. 2004. Prescription for excellence. Toronto: HarperPerennialCanada.

iii. Canadian Health Services Research Foundation. 2004. Myth: We can eliminate errors in healthcare by getting rid of the "bad apples."

iv. Field MJ and Lohr KN. 1990. Clinical practice guidelines: Directions for a new program. Washington, D.C.: National Academy Press.

v. Cabana MD et al. 1999. "Why don't physicians follow clinical practice guidelines? A framework for improvement." Journal of the American Medical Association; 282(5): 1458-1465.

vi. Natsch S and van der Meer JWM. 2003."The role of clinical guidelines, policies and stewardship." Journal of Hospital Infection; 53: 172-176.

vii. Lomas J. 1993. Teaching old (and not so old) docs new tricks: Effective ways to implement research findings. McMaster University Centre for Health Economics and Policy Analysis Working Paper: 93-94.

viii. Grol R and Grimshaw J. 2003. "From best evidence to best practice: effective implementation of change in patients' care." Lancet; 362: 1225-1230.

ix. Di Blasi Z et al. 2001. "Influence of context effects on health outcomes: A systematic review." Lancet; 357(9258): 757-762.

x. Sheldon TA. 2001. "It ain't what you do but the way that you do it." Journal of Health Services Research and Policy; 6(1): 3-5.

xi. Oxman AD et al. 1995. "No magic bullets: A systematic review of 102 trials of interventions to improve professional practice." Canadian Medical Association Journal; 153(10): 1423-1431.

xii. Institute of Medicine. 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academies Press.

xiii. Woolf SH. 2004. "Patient safety is not enough: Targeting quality improvements to optimize the health of the population." Annals of Internal Medicine; 140: 33-36.

xiv. Montague T. 2006. "Patient-provider partnerships in healthcare: Enhancing knowledge translation and improving outcomes." Healthcare Papers; 7(2): 56-61.

xv. Baker DP et al. In press. "Team training in health care: A review of team training programs and a look toward the future." Advances in Patient Safety: From Research to Implementation.

xvi. Baker DP et al. 2003. Medical teamwork and patient safety: The evidence-based relation.

xvii. Smith-Jentsch KA et al. 1996."Training team performance-related assertiveness." Personnel Psychology; 49: 909-936.

xviii. Salas E and Cannon-Bowers JA. 2000. "The science of training: A decade of progress." Annual Review of Psychology; 52: 471-499.

xix. Canadian Health Services Research Foundation. 2006. Teamwork in healthcare: Promoting effective teamwork in healthcare in Canada.

xx. Bower P and Sibbald B. 2000. On-site mental health workers in primary care: Effects on professional practice. Cochrane Database of Systematic Reviews.

xxi. Hearn J and Higginson IJ. 1998. "Do specialist palliative care teams improve outcomes for cancer patients? A systematic literature review." Palliative Medicine; 12: 317-332.

xxii. Rubenstein LZ et al. 1991. "Impacts of geriatric evaluation and management programs on defined outcomes: Overview of the evidence." Journal of the American Geriatrics Society; 39: S8-S16.

xxiii. Sulch D and Kalra L. 2000. "Integrated care pathways in stroke management." Age and Aging; 29: 349-352.

xxiv. Ovretveit J. 1994. "Pathways to quality: A framework for cost-effective team quality improvement and multiprofessional audit." Journal of Interprofessional Care; 8 (3): 329-333.

xxv. James BC. 1993. "Implementing practice guidelines through clinical quality improvement." Frontiers of Health Services Management; 10(1): 3-37.

xxvi. Berwick D. 1996. "A primer on leading the improvement of systems." British Medical Journal; 312(7031): 619-622.

xxvii. Jha AK et al. 2003. "Effect of the transformation of the Veterans Affairs Health Care System on the Quality of Care." New England Journal of Medicine; 348(22): 2218-2227.


Mythbusters are prepared by staff at the Canadian Health Services Research Foundation and published only after review by experts on the topic. The Foundation is an independent, not-for-profit corporation. Interests and views expressed by those who distribute this document may not reflect those of the Foundation.