Quality is goodness

In the spirit of stealing shamelessly, I am going to plunder Anna Roths latest post from her blog. She summarises a talk by Dr. Don Berwick. Highlights include:

"Quality is Goodness"

"What do we need to do? This is the 2.6 trillion dollar question isn't it? Here is a list to help guide us.

1. Put patients first

2. Protect the disadvantaged 

3. Start at scale –move fast – go "all in"

4. Return the money

5. Act locally"

"The Ethics of Improvement

1. Professionals have a duty to help improve the systems in which they work.
2. Leaders have a duty to make 1. Logistical, feasible and supported.
3. No excuses for inaction on 1 and 2 are acceptable.
4. The duty to improve encompasses safety, efficiency, patient-centeredness, timeliness, effectiveness, and equity requires continual reduction of waste. The IOM six dimensions quality of are dimensions of goodness
5. Those who educate professionals have the duty to prepare them for improvement work."

Wow, in 25 plus years of training, working, and teaching, no-one has ever said to me there is an ethical duty to educate professionals for improvement. Self evident but an indication of why we are finding healthcare improvement to be so challenging. 

Anna is always worth reading. Follow her blog and twitter. 

Economics of improving quality

There is a constant tension in healthcare between the economic/ financial imperatives and the clinical demands. Not unreasonably, based on healthcare inflation around the world over the last 40 years, there is a belief that more (which for many people, clinicians and patients) healthcare is better healthcare. Those of us interested in quality believe that this is not always the case. However the quality people I believe have been remiss in not addressing the evidence base for what they do, or the economic benefits of improving quality. Followers of Deming believe unequivocally that improving quality drives down cost. Brent James firmly believes that improving quality in Intermountain has not only improved care but dramatically driven down costs. Hence the importance of this paper just published and free to access.

The authors aim was to systematically review comparative economic analyses of patient safety improvements in the acute care setting and they explored 15 patient safety conditions and six associated improvement strategies. They concluded that pharmacist-led medication reconciliation, the Keystone ICU intervention for central line-associated bloodstream infections, chlorhexidine for vascular catheter site care, and standard surgical sponge counts were economically attractive strategies for improving patient safety.

Great stuff, a lot more needed.

Mirror, Mirror on the wall, who is the best of us all?

Conventional wisdom suggest that bigger and more sophisticated hospitals offer the best care. However, my anecdotal experience suggest that this may not always be the case. There are some emerging data which also put the lie to this hypothesis. Just published is The Joint Commissions annual survey of hospital quality in the US.
The measures used to assess quality might be criticized as “process“ measures, i.e. Are we delivering the care that we are supposed to deliver? but these are basic widely agreed measures. The most stunning finding was that many of the big name hospitals, even those that have tried to make their name as institutions that prioritize quality and safe care do not feature. Or maybe not so surprising; in a culture in which individuals prize their autonomy, it will be easier for smaller hospitals to ensure they are consistent in applying processes.

Does improving quality save money?

The instinctive answer is, "yes, of course." If only it were that easy. I am more and more coming around to the view that to change a complex system like healthcare will require radical restructuring, which will only happen in the Western World when we realise we can no longer afford to deliver our current service. It wont be easy, it wont be pleasant.
Levette has sent me a paper which suggests that improved quality and lower costs may not go hand in hand. Bottom line;

"The evidence suggests that there are ways of saving money at the same time as improving quality. But doing so on a large scale requires changes in how services are financed, and increasing the capability of ordinary services to make changes. Approaches that look effective in theory rarely seem to have the same impact when implemented in practice and on a large scale. In this respect, the challenges of achieving real finan- cial savings by improving quality and reducing waste are no different from any other attempt to change a complex system."

Some Thought on Value in Healthcare

Value is a dirty word in healthcare, conjuring up visions of ruthless bean counters, scrabbling for pennies while patients suffer. How different though is the reality? Regardless of location, healthcare costs are rapidly climbing, disease burdens, therapies, diagnostics and expectations are rising faster. Like it or not, hard choices must be made, if not by clinicians, then by the payer, ultimately the taxpayer. How does one align this imperative with the need to ensure quality of care is optimized?
A recent paper by former colleagues of mine brought home the reality of this dilemma. Cruz et al sought to improve compliance with goal directed therapy for children with sepsis. They demonstrated a marked reduction in time to first fluid and antibiotic administration, consistent with guideline recommendations. However, part of the solution was to deploy extra nursing, pharmacy, medical and EMT staff. While this may well have been a beneficial use of this scarce resource, it is unclear if the value increased.
Value can be defined as health outcomes (quality) divided by the cost of achieving those outcomes. So while quality almost certainly increased, it is likely that the cost of achieving this level of quality also increased. The question that must be asked, could better or more health outcomes be achieved for the same expenditure. Unfortunately our measurement systems are as yet unable to answer this question. For a more detailed discussion around this topic, please see Michael Porters website.

Reporting Poor Performance by Doctors

A very concerning piece, but not that surprising to those in practice. A study of >1000 UK doctors found that almost 30% would not report concerns about a colleagues poor performance. The main reason for this was concerns about retribution. It brings to mind a conference I attended 2 years ago in which a keynote speech was by three well known, (non-nmedical) whistleblowers. They made the point that whistleblowers are often motivated by anger or revenge, and that if they were faced with the situation again, they would not reveal their misgivings. This was very sobering; one assumes that whistleblowers (an awful term) are motivated by altruism.

Risky Business

One of the most exciting, stimulating, thought provoking events in the calendar. The idea is to promote a different way of seeing healthcare, by invoking parallels from other industries, occupations, walks of life. It is in equal measures exhilarating, thought provoking, sad, and optimistic. The varied speakers show how one can overcome adversity, achieve excellence, and succeed in the most challenging conditions. On the other hand, some speakers can almost bring one to tears with their descriptions of adversity and hardship; the daughter of a Tory MP killed in the Brighton bomb speaking on stage with the former IRA member who planted the bomb; the cardiac intensivist describing the trauma of litigation following the death of a child, the Canadian physician who demonstrates the weakness of our thinking patterns which lead us to cause mistakes. Well worth checking out. Risky Business. Registration is free. The highlights for me were the first day, devoted to paediatrics, not available to view. The evidence shown from Cincinnati Childrens demonstrating the effectiveness of their drive to zero harm was outstanding.

First Post

Welcome. The purpose of this blog is to share the latest happenings, events, news in the area of patient safety to an Irish audience. There are many healthcare workers interested in and committed to improving safety and quality in Irish healthcare, but they are faced with numerous problems in trying to develop their expertise and interest, including a disempowering management structure, lack of awareness of others in the system with similar interests and an absence of training in the area of the Science of Improvement.

I hope to post on a regular basis, and include news, links, ideas etc in order to stimulate discussion about patient safety.