Transcript Presentation title - Healthcare Quality Improvement

Why is improvement so hard?
HQIP Annual Conference 2010
Martin Marshall
Clinical Director and Director of R&D
“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.
Clostridium difficile, death certificate mentions, England, 2001 - 2006
7000
6301
6000
5000
4000
3648
3000
2146
1720
2000
1149
1325
1000
0
2001
2002
2003
2004
2005
2006
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
100
Age adjusted 5-year relative survival - all malignancies, males diagnosed
2000-02
90
80
70
60.3
relative survival (%)
60
55.4
54.6
53.2
53.0
49.8
50
47.9
47.1
44.8
42.0
40.2
40
30
20
10
0
Sweden
Austria Switzerland Belgium
Norway
Italy
Wales NetherlandsEngland
Northern Ireland
Scotland
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
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
Quality
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?
Ways of
improving
patient care
Governmental
Regulation
Performance management
Legislation
Economic
Professional
Incentives/sanctions
Patient choice
Competition
Commissioning
Education and training
Clinical audit
Peer review/ collaboration
Guidelines
‘Industrial’/
organisational
Org. development
TQM/CQI, BPR, PDSA, Lean, 6
sigma
Factors relating to
the intervention
Why is
improvement so
hard?
Factors relating
to the
environment
Factors relating
to the people
involved
Factors relating to
the intervention
Research examining the
Research examining the
overall
Why
is
characteristics of successful
effectiveness of interventions
improvement so interventions
hard?
• Most can be effective but overall effect
size small
• Variable impact depending on context
• Often
takes long time to achieve
Factors
relating
change
to the
e.g. QQuiP evidence reviews
environment
• Active approaches better than passive
ones
• Multifaceted interventions more
Factors
relating
effective
than single
ones
• Interventions more effective if
to
the people
• relative advantage
• compatible
involved
• simple
• testable
• observable/measurable
• involving
e.g. Grimshaw, Grol, Greenhalgh
The policy environment
•
The organisational environment
Factors relating to
•
Different policy approaches
to
the intervention
achieving change need to be integrated
and based on evidence
• The unintended consequences of
different levers need to be predicted
and managed
Why is
improvement so
hard?
Factors relating
to the
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
Factors relating
to the people
e.g. Kotter, Baker, Bate, Davies, Shortell, Fullop
involved
Psychological approaches
Sociological approaches
•
Factors relating to•
Improvement can be seen as social
the intervention
activity rather than technical
Change is more likely to be effective
when individual characteristics are taken
into account
achievement
• attitudes to new ideas e.g. innovators,
early adopters, early and late majority,
• Clinicians may behave more like
laggards
‘workers’ than as professionals
• stage of journey towards change e.g. pre• Professional identity explains many
contemplation, contemplation,
behaviours e.g. defining and
preparation, action, maintenance,
Why is
legitimising risk, heroic behaviours,
completion
improvement so e.g. Rogers, Prochaska and Velicer, Grol
rituals
• There are often inadequatehard?
structures of
authority and accountability in clinical
teams
Factors relating
to e.g.
theRoberts, McDonald, Dixon Woods,
Checkland, Greenhalgh
environment
Factors relating
to the people
involved
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
Thanks for listening
[email protected]
www.health.org.uk