Making healthcare safer, effective, patient centred, timely, efficient, and equitable is an enduring aim of health services and care providers and quality improvement (QI) programs and care standards are commonly used approaches seeking to improve care outcomes in the health system including in palliative care. An Australian QI program for specialist palliative care services, Palliative Care Outcomes Collaboration (PCOC) is led by the University Wollongong while new National Safety and Quality Health Service (NSQHS) Standards and Aged Care Quality Standards are being implemented in 2019.
However, there have been calls for studies to assess the value and effectiveness of QI approaches.  Several issues have been identified in QI approaches including variable fidelity in the application of QI methods, reliance on time-limited, small-scale projects, lack of rigorous evaluation of improvement, and limited sharing of successes and failures. 
Commenting on unsatisfactory US and UK experiences, Djulbegovic 2018 proposes a unifying framework for improving health care quality to achieve much needed improvements.  As well as suggesting the need for better integration of quality initiatives, greater use of evidence to underpin QI initiatives was called for. Evidence based approaches including the ‘Choosing Wisely’ initiative were highlighted by Djulbegovic 2018 as successful examples. The commentary on QI by Glasziou 2011 was also highlighted and is mirrored in the proposed framework. 
QI was described by Glasziou as ‘doing things right’ or ensuring that the right things are being done.  Further pointing out that QI complements evidence-based medicine (EBM) which is about ‘doing the right thing’ or ensuring that actions are based on the best available evidence. Together the two activities lead us to ‘doing the right things right’.  Ultimately this is the aim of any QI initiative, to improve health outcomes for patients, improve health system performance and to improve practice of health professionals.  Glasziou also noted that the forerunner of the widely applied PDSA (Plan, Do, Study, Act) framework for QI originally included a review of the evidence for proposed changes as a first step. The connection to evidence in current PDSA models has largely been lost. 
A vigorous rebuttal to Djulbegovic’s article suggested that many quality problems are not solved by looking at the evidence but rather by addressing system and process failures, human error, or influences such as socioeconomic factors.  The authors argue that ‘the "right thing to do" often has little to do with "high quality" evidence or its application’. In a very detailed counter to this Djulbegovic 2019 agreed that different types of evidence are likely to be needed at the what and how stages but note that QI initiatives are fundamentally local activities and sometimes that evidence will be based on trial and error.  Data collection is a fundamental part of QI.
No doubt the debate will continue, as it should, and it might help us to understand how QI might be better harnessed to the advantage of patients and health professionals alike. As noted by Djulbegovic, ‘not all evidence is equal’ so evaluation and appraisal are essential. Change based on low grade evidence or for the sake of change is wasteful of limited resources. In fact, the GRADE working group argues that QI initiatives should be restricted to situations with strong GRADE recommendations. 
So, what are the lessons for Australia? Firstly, robust evaluation of all programs including QI initiatives is essential. Achieving targets does not always translate into improved quality of care or patient experience. Better integration of EBM with its focus on what is appropriate and QI with its focus on how to implement what is appropriate may well prove to be the missing link to achieving quality care. This will require collaboration and skill development. Appreciating the local context of care might also prove important when defining policy. These considerations have led CareSearch to look at how it can contribute to the enhancement of QI effectiveness in palliative care. We are about to announce inclusion of QI reports from PCOC and other Australian initiatives in the Grey Literature database. A recent scoping review of QI repositories concluded that the role of QI repositories is likely to expand.  Inclusion of QI reports will enable access to and sharing of Australian palliative care QI activities. We will also provide guidance on appraising the quality of QI reports, and on distinguishing research and QI. This will help build awareness and understanding of QI processes.
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Professor Jennifer Tieman, Director, CareSearch, College of Nursing and Health Sciences, Flinders University
Dr Katrina Erny-Albrecht, Senior Research Fellow, CareSearch, College of Nursing and Health Sciences, Flinders University