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Equipped: overcoming barriers to change to improve quality of care (theories of change)
  1. Peter Lachman1,
  2. Jane Runnacles2,
  3. Jan Dudley3
  4. On behalf of RCPCH Clinical Standards Committee
  1. 1Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
  2. 2Department of Paediatrics, Royal Free Hospital, London, UK
  3. 3Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
  1. Correspondence to Dr Jan Dudley, Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK; jan.dudley{at}

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Quality improvement is about the patient; the child who comes to us to be cared for. It is our obligation to meet the needs of the child in a reliable way, to get care right the first time every time. Yet we often fail to achieve this. The key is to develop systems of care that will more than meet the rising expectations of the population. This article explores the complexity of change in healthcare, based on Deming's theories of change1 with practical ideas for introducing improvements in quality of care.


In his review of safety in NHS England post Mid Staffordshire, Berwick2 recommended that “Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives”. This places a requirement on all of us to take the lead in quality initiatives. To achieve this duty, we require an understanding of the science of improvement and of theories of change.

Despite the impressive clinical gains in the past years, the problems of waits, delayed diagnosis, harm and lack of equity remain. Healthcare professionals do not always provide evidence-based care for a variety of reasons, including lack of awareness, or scepticism of the validity of the data, beliefs derived from our own experiences and a perception of the individuality of patients. In addition, healthcare has become unaffordable in terms of waste and cost. Although we may be aware of what needs to change and how to go about it, introducing change can be extremely challenging. It may be difficult to convince doctors or organisations to do things differently. Clinical standards reflect the distillation of best evidence into guidelines that then are applied in the clinical environment. The National Institute for Health and Care Excellence …

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  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.