Improvement Is Not Yet Change: Making Effective Practice the Norm.

Quality improvement processes seek to establish effective practices as everyday habits. In other words, they aim to make evidence-based practices the norm. There are several barriers to consider. First, there is a tendency to conflate measured change with embedded practice. For example, hand hygiene initiatives benefit from a Hawthorne effect. People may change their behavior when they know they are being observed. And some observation tactics and settings are more noticeable than others. Second, measurements are often made at the project's peak of attention rather than during routine practice after the intervention. Factors that may distinguish initial engagement from sustained integration include attenuation over time, variation between implementation sites, and variation by observation conditions. Effective quality improvement projects will anticipate and measure these factors, report the conditions under which data were collected, and continue evaluation beyond the active project phase. Sustained change also depends on organizational conditions that support routine practice. Improvement is not change until it no longer depends on being watched.