The Sequence of Improvement: A Structured Step-by-Step Approach to Quality Improvement in Healthcare.

Quality improvement in healthcare needs methods that balance rigor with usability, and the sequence of improvement offers a practical way for teams to work through complex issues. It moves from defining a problem to understanding it, shaping strategy, testing ideas, and embedding change, drawing on improvement science, Deming, systems thinking, and complexity theory while remaining accessible for everyday practice. More than 900 projects and thousands of staff have used it, creating a strong peer-reviewed evidence base. Applications include reducing pressure ulcers across an organization and improving the timeliness of serious-incident investigations, with progress monitored through statistical process control. Results were measurable: complaints completed on time rose from 30% to 54%, and pressure ulcers fell by 30%. Its impact depends on capable teams and supportive infrastructure. Future development could deepen systems analysis, strengthen quasi-experimental evaluation, use leverage-point and relational coordination theories, and integrate implementation science.