The true potential of quality improvement for psychiatrists and mental healthcare

Summary

Nidumolu et al’s article in BJPsych Advances illustrates how psychiatrists might use the key concepts of quality improvement (QI) to analyse and improve mental healthcare systems. This commentary on the article points out the importance of recognising the type of problem for which QI is best suited and the role of softer, relational approaches alongside the technical tools of improvement. It also highlights that QI can bring broader benefits to a team and organisation, including improvements in staff engagement and well-being. In mental health services, psychiatrists can play a key role in enabling and role-modelling this approach to problem-solving, as their extensive experience of leading multidisciplinary teams and shared decision-making with patients can be a great asset in QI.

In this issue of BJPsych Advances, Nidumolu and colleagues put forward a primer to help psychiatrists apply quality improvement (QI) to a quality problem (Nidumolu 2025). Using a fictitious case study, they describe how one might apply a set of systematic steps and improvement tools to understand a quality issue, develop a theory of change and utilise plan–do–study–act (PDSA) cycles to test and adapt ‘change ideas’ (feasible solutions to the problem). The article is helpful in demonstrating how one might apply QI to any complex problem – but we should probably begin by defining the kind of problem that is best suited to this approach. Complex problems are ones that require multiple perspectives for a fuller understanding, where we have theories but do not know what will work in our given context until we test and learn, and where we are likely to require change in beliefs and behaviours alongside technical changes (Forbes 2023).

The potential of QI in psychiatry

The article does not put forward strongly enough, in my view, the potential of QI in psychiatry. Describing it as ‘one approach to improving healthcare that has gained popularity’ seems to suggest that QI is relatively new, and perhaps a transient fad. Learning from the past 30 years of applying QI in healthcare, and multiple decades of application in other sectors, tells us that embedding a systematic approach to improvement is critical for teams and organisations to adapt and thrive (Swensen 2013). This is as true in the field of mental healthcare as in any other. In fact, there may be even greater need for QI in the mental healthcare field, given that many of the quality issues experienced are ones where there is not a strong evidence base, and so an approach that encourages and utilises the experiences of both patients and clinicians to identify new, creative ideas to be tested offers the most effective way to improve care quality. From our own experience at East London NHS Foundation Trust, complex quality issues such as in-patient physical violence or in-patient observations have been tackled through QI, with a step change in quality that has taken us beyond the existing knowledge base in the field (Institute for Healthcare Improvement 2024).

There is a tendency within healthcare in general, and perhaps even more within the medical profession, to view QI as a required competency for trainees, and by extension, a project that requires completing. This mindset is some distance from seeing QI as part of an approach to managing a service – an integral component of a holistic management system that incorporates planning, control and assurance alongside improvement (Shah 2020). Psychiatrists, as leaders within the multidisciplinary team, play a key role in enabling and role modelling this approach to managing the service, and embedding QI as a core component of this – with the whole team, plus patients, involved in determining the biggest opportunity for improvement and then working on this together in a concerted effort for several months.

The relational aspect of QI

Nidumolu and colleagues helpfully describe the value of using improvement tools at different stages of the improvement process. And of course, there is an important technical component of QI – through the use of tools and data. However, the article does not emphasise sufficiently the critical relational aspect of QI. Alongside the use of tools at different stages of the improvement process, there is a requirement to engage stakeholders, build an effective team, flatten hierarchy, create psychological safety, and give voice and power to patients. Psychiatrists have a long history of working in multidisciplinary teams and of shared decision-making with patients. This gives psychiatrists, and mental health teams more broadly, strong experience, skills and assets to bring to the work of QI.

Broader benefits

Alongside the softer, relational skills needed for effective QI, there is also a broader set of benefits from QI that are not articulated in the article by Nidomolu and colleagues. Of course, one would expect a well-designed QI project with the right context and set-up to see improvement in the quantitative outcome measure. However, the broader effects of integrating QI into the way a service operates, and the way a psychiatrist leads the team, can go far beyond this – and perhaps are even more important. There is increasing evidence to demonstrate the correlation between application of QI and staff engagement (Braithwaite 2017). Perhaps this is unsurprising, given that QI implies the granting of autonomy to teams to be able to make change, empowering staff and patients to take control over the system they work in and to develop and test ideas in the pursuit of making care better. The democratising nature of QI, with all voices being heard and contributing, flattens hierarchy and creates stronger teams. The best QI work is done through co-production – with patients and staff partnering in the improvement effort, from start to finish, as equal partners (Kostal 2021). This brings additional benefits of building stronger, more trusting relationships, addressing power imbalances and incorporating co-production into other elements of service delivery. Recent QI work in this field has explicitly focused on staff engagement and well-being (Shah 2023), as well as the culture of care within mental health services (Royal College of Psychiatrists 2024), building on this important relationship.

The role of the psychiatrist and the orgnaisation

Of course, achieving this is not easy. Attempting to undertake QI as a whole team – with multidisciplinary input and patients as equal partners in the project team – is hard work. It requires time, perseverance and support. The role of the psychiatrist, as clinical leader, is key in modelling the importance of applying this structured approach to complex problem-solving and also staying true to the systematic and democratic, inclusive nature of the improvement process. But it also requires organisational support to be truly effective and sustainable. Healthcare systems that make QI a way of life, embedding it as core to the way that teams function, build a second operating system – with support wrapped around teams as they apply QI in a burst of activity and energy over a short space of time to solve a complex issue. This support includes improvement expertise, leadership attention and sponsorship, support to involve patients and carers, and a way to learn and apply the method and tools of QI (Boland 2020).