Monday, March 14, 2011

Progress of the Safety Movement

Some (relatively) disappointing news recently. An analysis of the Safer Patients Initiative was published in the BMJ (here and here). This was a large scale intervention comprising a large number of components of care. Unfortunately, there was no evidence of any difference in outcomes between control and intervention hospitals. What could the possible reasons be? There are a number of hypotheses,

  1. hospitals will get safer regardless of interventions, and do not need this type of large scale change, (unlikely)
  2. These interventions were too complex, encompassing 43 different interventions, (probable)
  3. Management and clinician buy in, expertise, knowledge and support were insufficient to show a difference, (highly likely)
  4. The interventions sought has insufficient evidence to underpin their use, (highly likely in some cases)
  5. Many hospitals, (both intervention and control) already had high levels of quality in some domains, hence the big effects were less likely to be seen, (likely)
So what lessons can be drawn? I think there are a number.

  1. Large scale change is difficult, messy, a long term commitment and often fails
  2. Leadership, at management and clinical level is critical
  3. Improvement and quality must be seen to be the only way to do business, not an optional extra
  4. There must be a better system of measurement; even today measuring mortality is contentious. The ideal measurement system should be one that measures patient outcomes from the perspective of the patient, and reimburses the system, not a provider for optimal outcomes. See Micheal Porters work from Harvard for more on this

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