On the basis of the alarming reports and the evolution of a vision for high-quality health care systems, the movement for quality improvement in health care has grown stronger. The goal is to do the right thing for every
Better patient (population) outco™0
Everyone professional development
' Better system performance
Figure 1 The aims of improvement need to be linked and to involve everyone. Source: Adapted from Ref. 9.
patient, every time. Theories, concepts, models, methods, and tools have been developed and adapted to suit health care needs. Many good examples to learn from have emerged, along with advice on how to use these methods and tools in everyday clinical practice (4,11-13). Much of the knowledge is generic and can be adjusted and adapted to many different care situations. If we, as caregivers in adolescent rheumatology, want to fulfill our goal of offering the best possible care and support for the young people and families we serve, every day to every patient, we need to embrace the idea that we have two jobs when we come to work every day: to do our job and to improve it (Table 1) (9). Quality is inherent in every moment in everyone's actions in health care and can not be delegated to a special office or to "quality people." However, in order to fulfill both our jobs we need not only
Table 1 Questions for Reflecting About Your Current Rheumatology Practice
Discuss the proposed aims of high-quality care and how they apply to your workplace:
How does your workplace live up to "no needless care" delivery standard? Are procedures as pain free as they could be? How can you know? Are there waits for appointments with a pediatrician? For intra-articular steroid injections? How can you know?
Does the teenager always know where to turn or is there a sense of helplessness? How can you know?
Is the care safe and reliable? For example; are eye examinations timely according to guidelines? Are blood counts timely for patients on cytotoxic drugs according to recommendations? How can you know?
Is access equal when needed? Are services and outcomes equal for patients from different social backgrounds? How can you know? If, after you have reviewed these questions, you discover you do not know enough about the performance and outcomes of patients or our system of care delivery, what might you do to improve the current state? How might you "find" the answers to these questions?
to keep up with the evidence-based subject matter but we also need a new set of knowledge and skills, "the knowledge of improvement," which is usually not included in the basic training of health care professionals (Fig. 2) (14). The professional knowledge, here defined as knowledge of subject, discipline and values including ethical considerations needs to be combined with the second block of knowledge to create maximum value for our patients. This second block was described by Deming (15) as the knowledge of improvement and includes knowledge of system, variation, psychology, and theory of change. These knowledge domains will be further explored below and later put into improvement in the context where care is provided, or the "clinical microsystem" addressed in this book—the adolescent rheumatology clinic.
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