“You can’t solve a problem by using the thinking that got your there” Albert Einstein
10 percent of patients admitted to hospital experience iatrogenic harm More than half of this harm could have been prevented if staff had followed established good practice Vincent et al., BMJ, 2001
On average, 45% of patients fail to receive recommended care McGlynn et al., NEJM, 2003
Between 2001 and 2006 there was a 450% increase in death rates in England from C. Diff. Source: HPA, Scottish Parliament, NHS Wales, CDSC Northern Ireland, 2007
The overall 5 year survival for all malignancies is 20% higher in Sweden than in the UK Source: EUROCARE-4, 2007
Nearly 60% of patients are not told about the potential side-effects of their prescribed medications Source: Commonwealth Fund, 2005
How are other sectors doing? Safety Quality In the aviation business there is one death per 10 million flights In the health sector there is 1 iatrogenic death per 300 hospital admissions Motorola tolerates 3.4 defects per million manufacturing processes In the health sector the ‘defect’ rate is 900,000/million processes for the management of alcohol dependence
How have policy makers, clinicians and managers responded to the quality challenges that we face?
Professional Education and training Clinical audit Peer review/ collaboration Guidelines Governmental Regulation Performance management Legislation Economic Incentives/sanctions Patient choice Competition Commissioning ‘Industrial’/ organisational Org. development TQM/CQI, BPR, PDSA, Lean, 6 sigma Ways of improving patient care
Why is improvement so hard? Factors relating to the intervention Factors relating to the environment Factors relating to the people involved
Why is improvement so hard? Factors relating to the intervention Factors relating to the environment Factors relating to the people involved Research examining the overall effectiveness of interventions Most can be effective but overall effect size small Variable impact depending on context Often takes long time to achieve change e.g. QQuiP evidence reviews Research examining the characteristics of successful interventions Active approaches better than passive ones Multifaceted interventions more effective than single ones Interventions more effective if relative advantage compatible simple testable observable/measurable involving e.g. Grimshaw, Grol, Greenhalgh
Why is improvement so hard? Factors relating to the intervention Factors relating to the environment Factors relating to the people involved The policy environment Different policy approaches to achieving change need to be integrated and based on evidence The unintended consequences of different levers need to be predicted and managed The organisational environment Change management programmes often fail High performing organisations have strong leadership, clear vision, commitment to build capacity, well integrated services, excellent IT, focus on users and on measurement, engaged clinical staff through active explicit processes, strong sense of accountability, aligned incentives, sensitivity to local context/culture Characteristics of failing organisations tend to be mirror image of above e.g. Kotter, Baker, Bate, Davies, Shortell, Fullop
Why is improvement so hard? Factors relating to the intervention Factors relating to the environment Factors relating to the people involved Psychological approaches Change is more likely to be effective when individual characteristics are taken into account attitudes to new ideas e.g. innovators, early adopters, early and late majority, laggards stage of journey towards change e.g. pre- contemplation, contemplation, preparation, action, maintenance, completion e.g. Rogers, Prochaska and Velicer, Grol Sociological approaches Improvement can be seen as social activity rather than technical achievement Clinicians may behave more like ‘workers’ than as professionals Professional identity explains many behaviours e.g. defining and legitimising risk, heroic behaviours, rituals There are often inadequate structures of authority and accountability in clinical teams e.g. Roberts, McDonald, Dixon Woods, Checkland, Greenhalgh
Why is improvement so hard? Isn’t it remarkable that we are doing as well as we are?!!
So, why is improvement so difficult? We don’t know as much about large scale and sustained improvement as we should ACTION: We need to build the evidence base underpinning improvement in the health sector What we do know, we rarely put into practice ACTION: We need to be more systematic about how we design and implement policy and practical approaches to improvement We are giving insufficient attention to the human side of improvement ACTION: We need to adopt more sophisticated approaches to influencing and motivating people We have naïve expectations of what we can achieve ACTION: A generous dose of realism and tenacity is required