We welcome Singer and colleague’s contribution to developing the
concept of a safety culture.[1] Policy-makers, managers and clinicians
are slowly realising that patient safety will not be improved solely by
counting adverse events or by introducing technical innovations. History
tells us that when these initiatives are evaluated the results will
probably show a marginal impact on patient safety, and one...
We welcome Singer and colleague’s contribution to developing the
concept of a safety culture.[1] Policy-makers, managers and clinicians
are slowly realising that patient safety will not be improved solely by
counting adverse events or by introducing technical innovations. History
tells us that when these initiatives are evaluated the results will
probably show a marginal impact on patient safety, and one that is likely
to be poorly sustained. In order to maximise their impact we need to
understand the shared attitudes, beliefs, values and assumptions that
underlie how people perceive and act upon safety issues within their
organisations. This is what is commonly called the ‘safety culture’ of an
organisation.
The problem with the approach adopted in this paper is that it fails
to get to the heart of the hospital’s culture. What they have done is to
use a blunt survey instrument to assess the opinions of individual members
of staff to a series of statements about safety. The responses represent
the most superficial evaluation of the ‘climate’ of the organisations in
which they work. These opinions are likely to be influenced by a wide
range of factors that have little to do with the organisation’s culture.
Furthermore, the relationship between these opinions and the shared values
that underlie them is largely unknown.
If we really want to understand the safety culture of an organisation
we need to use more sophisticated approaches.[2] These should draw on a
wide range of methods – participant observation, in-depth and semi-
structured interviews and focus groups, alongside attitudinal surveys and
the use of new and established culture-measurement tools.[3]
Developmental or action research approaches might provide additional
insights into the complexity of the organisations. The aim should be not
only to understand and assess the concept of safety culture but also to
examine ways of improving it and integrating it with the broader field of
organisational culture. This presents a significant challenge to health
service researchers. Singer and colleagues have made a start but there is
a long way to go before we know how, or indeed whether it is possible, to
change the safety culture of our hospitals and primary care centres.
References
(1) Singer S et al. The culture of safety: results of an
organization-wide survey in 15 California hospitals. Quality and Safety in
Health Care, 2003. 12: p. 112-118.
(2) Mannion R, Davies H, Marshall M. Cultures for performance
in healthcare: evidence on the relationships between organisational
culture and organisational performance in the NHS. Centre for
Health Economics: York, 2003.
(3) Scott J et al. The quantitative measurement of organisational
culture in health care: A review of the available instruments. Health
Services Researcher, in press.
Buetow and Wellingham present a comprehensive overview of
accreditation of general practices in New Zealand, and elsewhere, in this
well-written article.[1] They make the very significant point about the
limitations of quality assurance as compared with the more important
performance outcome orientation of continuous quality improvement.
However I am puzzled that they make no reference to the...
Buetow and Wellingham present a comprehensive overview of
accreditation of general practices in New Zealand, and elsewhere, in this
well-written article.[1] They make the very significant point about the
limitations of quality assurance as compared with the more important
performance outcome orientation of continuous quality improvement.
However I am puzzled that they make no reference to the major
organisational changes which have occurred within general practice over
the last decade, now involving some 90% of GPs.[2-4] These have a strong
focus on continuous quality improvement. Nor do they make reference to
the major quality achievements in primary care through primary care
organisations,[3] now rapidly evolving into more broadly-based primary
health organisations. Accreditation is only part of this broader primary
health care strategy.[5]
Recent studies of these organisations have shown that visionary GP
leadership, driven to achieve the best possible quality outcomes for
patients, has been the critical factor in these achievements.[3] These have
included the better management of substantial resources associated with
service delivery, including improved pharmaceutical use and prescribing
behaviour.
Practice accreditation has a contribution to make to the quality
strategies of these organisations, which in turn will facilitate
accreditation amongst member practices. But accreditation is only one
part of a comprehensive package. Clinical leadership, within these new
organisational settings, will play a key part in promoting a broader
approach to quality improvement.
References
(1) Buetow S, Wellingham J. Accreditation of general practices:
challenges and lessons. Qual Saf Health Care 2003; 12:129-135.
(2) Malcolm L. Mays N. New Zealand’s independent practitioner
associations: a working model of clinical governance? BMJ 1999; 319:1340-1342.
(3) Malcolm L, Wright L, Barnett P, Hendry C. Clinical leadership and quality improvements in primary care organisations in New Zealand. Clinical Leaders Association of New Zealand, Auckland, 2002. http://www.clanz.org.nzhttp://www.moh.govt.nz/
(4) Malcolm L, Wright L, Barnett P, Hendry C. Building a successful partnership between management and clinical leadership: experience from New Zealand. BMJ 2003; 326:653-654.
Congratulations to the authors for this wonderful comprehensive survey
undertaken across 15 hospitals regarding safety cultures.
The results of an overall response rate of only 47.4%, was largely due to
the poor response for physicians (33%) . Efforts need to be taken to
increase the response rate for a more reliable study result.
The majority of participants in the survey responded in ways which
in...
Congratulations to the authors for this wonderful comprehensive survey
undertaken across 15 hospitals regarding safety cultures.
The results of an overall response rate of only 47.4%, was largely due to
the poor response for physicians (33%) . Efforts need to be taken to
increase the response rate for a more reliable study result.
The majority of participants in the survey responded in ways which
indicated a culture of safety. However it will be interesting to determine
the safety culture among hospitals which do not come under the ‘hospitals
participating in the California Patient Safety Consortium’ group.
It is noted that higher responses are attributable to shorter survey
questions. People generally do not get interested if they have to go
through a large format. Clinicians, as expected are more critical about
the patient care safety and thus scored more “problematic responses”.
Survey sample noted that a total of 6312 eligible individuals
participated. As a matter of fact, that figure is actually 6332
individuals (initial mailing list of 6909 names minus 347 duplicates
minus 227 undeliverable = 6332).
The high percentage of non respondents an overall figure of 53% could
possibly still lead to non response bias. A survey on the non responders
will be interesting.
Senior managers gave fewer problematic responses than frontline workers.
Generally speaking all senior managers will want to give a high opinion
regarding their own organization/institution. Also it could that the
patient care problems may not have been briefed to them.
Going by the High Reliability Organization’s (HRO) standards of a cut off
point of 10% problematic attitudes the results of an overall problematic
response of 13% is worrying.
Generally speaking, it can be assumed that we still need to improve and
to internalize the culture of safety in healthcare settings among all
levels of healthcare workers.
Culture of safety should be cultivated into all health care workers from
our undergraduate student days itself if it is to be internalized within
ourselves. The article on “Finding safety in medical Education” [1]- Importance of a ‘Safety Culture’ in Medical Education” emphasises that
“Improving health and health care begins with the focus on improving
medical education”.
Another point for consideration is “Bringing issues of quality and safety
out of the shadows can remove some of the sting associated with
improvement."[2] Who can doubt that the real agenda in the controversy
currently raging over mandatory reporting of medical errors is the fear of
being ashamed?
The results of this study also supports this as stated: problematic
responses were higher for questions that were phrased as hypothetical or
impersonal, and lower to questions that were personal or time delimited.
Having said all that, it would be good to adapt and conduct a similar survey
on the cultures of safety in our very own healthcare setup, compared to the established results of this article as a baseline measure.
References:
(1) Stevens D P. Finding safety in medical education. Qual Saf Health Care 2002; 11:109-110
(2) Davidoff F. Shame: the elephant in the room. Qual Saf Health Care 2002; 11:2-3.
Doctors Santiago, Debanne, and Neuhauser correctly point out the
frequent deficiencies in post-marketing surveillance of newly marketed
drugs.[1] Because of aggressive marketing to physicians and direct-to-
consumer advertising in the US, a new drug can now have very rapid
dissemination, exposing large populations in a short time. Passive
surveillance with ambiguous definitions of adverse effects may ofte...
Doctors Santiago, Debanne, and Neuhauser correctly point out the
frequent deficiencies in post-marketing surveillance of newly marketed
drugs.[1] Because of aggressive marketing to physicians and direct-to-
consumer advertising in the US, a new drug can now have very rapid
dissemination, exposing large populations in a short time. Passive
surveillance with ambiguous definitions of adverse effects may often
impair early identification of serious problems. I agree with the
recommendations of Santiago et al. for better and more consistent
guidelines for drug surveillance.
Santiago et al. also correctly note that drug trials with efficacy
end points rarely have sufficient statistical power to identify unusual
adverse drug effects. This may argue for wider use of observational study
designs, such as the case-control method used by Psaty et al, to help
identify important drug complications after marketing. As in the case of
the calcium channel blockers, such observatonal designs may also help to
estimate drug effects on important but infrequent end results of treatment
(e.g. myocardial infarction or death), when the primary efficacy trials
were focused on surrogate endpoints such as blood pressure.
Reference
(1) Santiago LM, Debanne SM, Neuhauser D. Tracking adverse events in randomize control trials the lack of agreement among regulatory instituti [electronic response to Deyo RA, Bruce Psaty and the risks of calcium channel blockers] qshc.com 2003 http://qhc.bmjjournals.com/cgi/eletters/11/3/294#25
In response to the recent article in QSHC by A Coulter,[1]
as a junior ophthalmic surgeon in training it worries me to see such views
expressed as it has seriously detrimental consequences on our training.
It seems that Ms Coulter is suggesting that only Consultants or
very senior, experienced surgeons should be operating on patients and
any "junior" member operating would put a patient at ser...
In response to the recent article in QSHC by A Coulter,[1]
as a junior ophthalmic surgeon in training it worries me to see such views
expressed as it has seriously detrimental consequences on our training.
It seems that Ms Coulter is suggesting that only Consultants or
very senior, experienced surgeons should be operating on patients and
any "junior" member operating would put a patient at serious risk of a
complication. How does she think that a surgeon gets to their so-called
"experienced" level? What is the definition of an experienced surgeon and
where does she propose we go to get this experience? Contrary to her
beliefs I must stress that the majority of trainees in this country are
very carefully supervised by senior surgeons until they are felt to be
safe enough to operate without supervision.
Also, it is not standard practice to withhold information on surgeon
grade and "deliberately" keep patients in the dark as stated in her
letter. A preoperative ward round is routinely done by most teams with
junior and senior members present and a consent form signed by the patient
which clearly states that there are no guarantees that the consultant will
be operating. It must be remembered that this is the National Health
Service and not the private sector. Besides, what would happen to waiting
list times if only Consultants were allowed to operate?
The worry at the moment is of the high surgical complication rates of
juniors [2] but if opportunities to operate are restricted further as is
foreseen, the worry in ten years' time will
be of the high surgical complication rates of consultants (due to the lack of training).
Junior doctors have the right to be trained in a safe environment for
both themselves and the patient. Without sounding too melodramatic, if
attitudes like this continue, the junior surgeon's training in this
country runs the risk of being completely destroyed. The irony is that
Hobson's choice is no longer the patient's fate but that of the junior
doctor.
Acknowledgement
I would like to thank Mr AJE Foss for his
support in writing this letter.
References
(1) Coulter A. Safe treatment or a shorter wait: Hobson's choice? Qual
Saf Health Care 2003;12:5-6.
(2) Ross,M-A, Avery AJ, Foss AJE. Views of older people on cataract
surgery options: an assessment of preferences by conjoint analysis. Qual
Saf Health Care 2003;12:13-17.
Regarding the article by L Locock,[1] we would like to share our healthcare redesign experiences with you.
In recognising that up to 19.4% of all adverse patient events are
attributable to medication mishap, Bayside Health Service (Melbourne,
Australia) has identified medication safety as a priority.[2-5] A
multidisciplinary Drug Management Committee was established to identify
systemic factors contr...
Regarding the article by L Locock,[1] we would like to share our healthcare redesign experiences with you.
In recognising that up to 19.4% of all adverse patient events are
attributable to medication mishap, Bayside Health Service (Melbourne,
Australia) has identified medication safety as a priority.[2-5] A
multidisciplinary Drug Management Committee was established to identify
systemic factors contributing to medication error and implement safety
strategies. Our experiences have demonstrated that the application of
total quality management (TQM)/ continuous quality improvement (CQI) and
re-engineering principles can effect significant medication process and
practice improvement.
Anticoagulants contribute up to 11.2% of all medication-related
adverse events.[2,3] Consultation with medical staff and patients identified
that the requirement to prescribe warfarin for 2000 hours administration
contributes to dosing complications, since the prescription is often
written after-hours by staff who may be unfamiliar with the patient. To
address this issue, warfarin administration time was altered to 1600
hours. This ensures that the treating practitioner doses his own patient
rather than deferring this responsibility to after-hours staff; nursing
staff are also prompted to contact the treating practitioner if warfarin
has not been prescribed by the time it is due for administration (1600
hours). The change was implemented hospital-wide over a brief period, and
embraced by both clinical staff and patients. This sustainable change has
resulted in reduced potential for bleeding complications and improved
workflows for medical, nursing and pathology staff.
Infusion rate errors are also commonly reported in the literature,
and contribute to approximately 30% of all medication incidents reported
at Bayside Health.[6] A review of intravenous administration guidelines for
13 high-risk medications (e.g. dopamine) identified considerable variation
that was likely to cause confusion and error. Infusion guidelines were
standardised for 12 of 13 high-risk medications (92%). In contrast to the
warfarin initiative, this change process necessitated lengthy consultation
and negotiation over a year.
Both TQM/CQI and re-engineering approaches have been subject to
criticism regarding impact and sustainability.[7] However, Bayside’s two
redesign initiatives demonstrate the effectiveness of strong executive
support and leadership, the need to create a sense of urgency and a common
vision, and to demonstrate early successes to engage staff.[8] The
importance of active clinician participation from the outset is critical
to the success of any change strategy; staff must believe that the
proposed practice change will contribute to improved workflows and patient
safety. Whilst it may be argued that healthcare quality improvement
necessitates major structural reform, our experiences indicate that simple
systems redesign is effective in achieving positive change.[9]
References
(1) L Locock Healthcare redesign: meaning, origins and application. Qual Saf Health Care 2003;12: 53-57.
(2) Leape LL, Brennan TA, Laird NM et al. The Nature of Adverse Events
in Hospitalized Patients: Results of the Harvard Medical Practice Study
II. NEJM 1991; 324 (6): 377-384.
(3) Wilson RM, Runciman WB, Gibberd RW et al. The Quality in
Australian Health Care Study. MJA 1995; 163: 458-471.
(4) Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a
safer health system. Committee on Quality of Health Care in America.
Institute of Medicine. Washington, DC: National Academy Press, 1999.
(6) Flynn F, Mohr L, Lawlor-Klean P. Right Programming of Pumps to
Prevent Errors in the Infusion Process. Joint Commission Journal on
Quality and Safety 2003; 29(1) 37-40.
(7) Locock L. Healthcare redesign: meaning, origins and application. Qual Saf Health Care 2003;12: 47-52.
(8) Kotter JP. Leading Change: Why Transformation Efforts Fail. Harvard Business Rev 1995, 59-67.
(9) Nolan TW. Understanding Medical Systems. Ann Intern Med 1999; 128:293-298.
We need to do a better job of keeping track of potential side effects when designing randomized clinical trials (RCTs). Consider a RCT for a new drug tested for the main, or first order effect, the reduction of hypertension. Power calculations are carried out so that meaningful differences between the drug users and the controls can be detected on this effect. Second order effects, mortality in this case, a...
We need to do a better job of keeping track of potential side effects when designing randomized clinical trials (RCTs). Consider a RCT for a new drug tested for the main, or first order effect, the reduction of hypertension. Power calculations are carried out so that meaningful differences between the drug users and the controls can be detected on this effect. Second order effects, mortality in this case, are those adverse events that are prospectively tracked, recorded, planned for in advance, and if sufficiently serious may bring the trial to a halt through review conducted by a Data Safety Monitoring Board. Too rarely are there systematic prospective efforts to collect information on other unpredicted effects of the drug being tested. These third order effects may be important, but are rare and unexpected and thus not necessarily sought out and consequently systematic data are not necessarily prospectively collected about them. This problem of falling to track such third order events is vividly shown in the recent article about Bruce Psaty and his recognition of the 3rd order side effects related to the use of calcium channel blockers [1].Although the United State of America Food and Drug Administration (FDA) and other Government agencies have systems in place for the post-marketing reporting of possible side effects, this surveillance is passive in nature and relies mainly on the judgment of practitioners to suggest whether or not a patient's complaint is related to the drug in question. This creates an inherited underreporting of side effects. It also assumes that everyone has the same access to health care or that by the time the complaint is reported there is enough time to avoid serious complications in other patients.
The USA National Institutes of Health (NIH) and the World Health Organization (WHO) are aware of these issues. NIH guidelines appear to be focused on multi-center clinical trials. The definition of adverse events less well characterized for single center trials. Furthermore, the definition of an adverse event, while in compliance with the FDA regulations, is somewhat broad or vague. For example, the federal regulation requires the reporting of adverse events that are "serious and unexpected". This term could be interpreted differently. Does the event in question need to be both serious and unanticipated by the investigator? What about unanticipated effects regardless of the seriousness? How serious? Are events that are costly to a patient in terms of productive time, money or psychological damage considered serious? See Table 1 for a summary of the NIH Institutes and their guidelines and their web sites.
This lack of uniformity and clarity is not particular to the United States. Some international institutions rely on the World Health Organization (WHO) to establish their adverse reporting mechanism standards. The WHO in their Guidelines for good clinical practice (GCP) for trials on pharmaceutical products, states that the investigator is "…responsible for notifying (with documentation) the relevant health authorities, the sponsor and, when applicable, the ethics committee immediately in the case of serious adverse events or reactions, as governed by national regulations…" This statement contains little guidance as to who is the relevant authority, what documentation to use and under what circumstances the established ethical committee should be involved. Furthermore, the statement "…as governed by national regulations", does not clearly assign responsibility for the reporting of adverse events, especially in situations when one nation is conducting medical trials in another country. Moreover the WHO falls short in suggesting any type of analyses for the examination of possible population wide repercussions[2].
Countries in Central and South America basically follow the guidance of the WHO through the Pan-American Health Organization (PAHO). In England and Australia, countries that have a comprehensive system of health care, information about adverse events, especially if observed after the trials and/or the medication is in the open market, is not easily accessible.
We think there should be more clarity and uniformity in these guidelines and all guidelines should be accessible through the Internet or some other form of common global communication to the scientific community. Furthermore, investigators and agencies alike should be aware of studies reporting adverse events. These reporting mechanisms should have direct relationship with post marketing surveillance efforts [3, 4].
Table 1 Procedures for Monitoring Adverse Events for USA NIH Institutes
Agency 1
Procedure
Web site
NIH
General guidelines for all Institutes and Centers (IC). Requires
establishment of Data Safety Monitoring Boards (DSMB) for multi-site
clinical trials. Gives each IC the ability to establish its own
procedures.
Follows general NIH guidelines. Additionally, defines "adverse
events" and gives categories for severity, attribution, action taken
and outcome of such events.
1: NIH: National Institutes of Health; NCI: National Cancer Institute; NEI: National Eye Institute; NHLBI: National Heart, Lung and Blood Institute; NHGRI: National Human Genome Research Institute; NIA: National Institute on Aging; NIAAA: National Institute on Alcohol Abuse and Alcoholism; NIAID: National Institute of Allergy and Infectious Diseases; NIAMS: National Institute of Arthritis and Musculoskeletal Diseases; NIBIB: National Institute of Biomedical Imaging and Bioengineering; NICHD: National Institute of Child Health and Human Development; NIDCD: National Institute on Deafness and Other Communication Disorders; NIDCR: National Institute of Dental and Craniofacial Research; NIDDK: National Institute of Diabetes and Digestive and Kidney Diseases; NIDA: National Institute on Drug Abuse; NIEHS: National Institute of Environmental Health Sciences; NIGMS: National Institute of General Medical Sciences; NIMH: National Institute of Mental Health; NINDS: National Institute of Neurological Diseases and Stroke; NINR: National Institute of Nursing Research.
References
(1) Deyo RA. Bruce Psaty and the risks of calcium channel blockers. Qual Saf Health Care 2002 11(3): 294-6.
(2) WHO. Guidelines for good clinical practice (GCP) for trials on pharmaceutical products. 1995. p. Annex 3.
(3) Begg C et al. Improving the quality of reporting of randomized controlled trials. The CONSORT statement. .JAMA 1996. 276(8):637-9.
(4) Tramer MR et al. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use. Pain 2000. 85(1-2):169-82.
Watkins and colleagues[1] add to the growing literature on the many
and varied influences on general practitioner prescribing behaviour and
costs.[2,3] They argue, from the results of their analyses, that the
dispensing status of the general practitioner is a statistically
significant predictor associated with high prescribing costs, though it is
unclear from their report exactly how many dispensing pract...
Watkins and colleagues[1] add to the growing literature on the many
and varied influences on general practitioner prescribing behaviour and
costs.[2,3] They argue, from the results of their analyses, that the
dispensing status of the general practitioner is a statistically
significant predictor associated with high prescribing costs, though it is
unclear from their report exactly how many dispensing practices are
involved and the numbers in each prescribing cost category. One difficulty
with the attribute of dispensing status is that practices are classed as
such if they dispense for just a small proportion of their registered
population or if they dispense to all the registered population, and we do
not know to what extent this variable influences prescribing costs.
The authors point out that dispensing doctors, because of the need to
operate their dispensary as a business, are likely to have better
knowledge of drug costs than their non-dispensing colleagues. In addition,
they are more likely to restrict repeat prescribing quantities to 28 days’
worth, as opposed to the two or three months’ worth that non-dispensing
practices commonly issued at the time of the study. In theory this greater
overall control over repeat prescribing should exert downward pressure on
costs by controlling medicine wastage arising from patient demand for
unnecessary repeat medication. Work carried out in Cornwall and Isles of
Scilly supports the notion that the prescribing costs of dispensing
practices are similar to, if not slightly less than, those of non-
dispensing practices.[4] In addition, aggregate data from the
Prescription Pricing Authority show, for Cornish practices, that the cost
per person of prescriptions arising from dispensing practices is
consistently lower than that of prescriptions originating from non-
dispensing practices, and this has been the case for many years.
References
(1) Watkins C, Harvey I, Carthy P, Moore L, Robinson E, Brawn R.
Attitudes and behaviour of general practitioners and their prescribing
costs: a national cross sectional study. Qual Saf Health Care 2003;12:29-34.
(2) Jacoby A, Smith M, Eccles M. A qualitative study to explore influences
on general practitioners’ decisions to prescribe new drugs. Br J Gen Prac
2003;53:120-125.
(3) Jaye C, Tilyard M. A qualitative comparative investigation of
variation on general practitioners’ prescribing patterns. Br J Gen Prac
2002;52:381-386.
(4) Wilcock M. Dispensing doctors and non-dispensing doctors - a
comparison of their prescribing costs. Int J Pharm Prac 2001;9:197-202.
Milne and Hill suggest the 'Getting Research into Practice' programme
may have contributed to the decline in surgery for glue ear that we have
reported. We cannot, however provide any evidence to support this
suggestion. The rate of decline in surgery throughout England was similar
to that observed in 13 former health districts in the Oxford/Anglia
region. The ratio of change in rates after 1992 over the...
Milne and Hill suggest the 'Getting Research into Practice' programme
may have contributed to the decline in surgery for glue ear that we have
reported. We cannot, however provide any evidence to support this
suggestion. The rate of decline in surgery throughout England was similar
to that observed in 13 former health districts in the Oxford/Anglia
region. The ratio of change in rates after 1992 over the change in rates
beforehand was 0.88 (95%CI 0.86 to 0.90) in the 13 districts and 0.88
(95%CI 0.84 to 0.92) in England. When we consider Berkshire alone (West
and East Berkshire districts combined) where GRiP was initially
implemented, the ratio was 0.87 (95%CI 0.84 to 0.90).
I would like to thank Dr Checkland for her thoughtful
comments on our paper about evaluating quality
programmes. I have some sympathy with her views
and for the intriguing proposal about research in this
area which she makes.
I would agree that insufficient attention has been given
to how features of organisations described in
organisational theory influences how quality
programmes are carried throu...
I would like to thank Dr Checkland for her thoughtful
comments on our paper about evaluating quality
programmes. I have some sympathy with her views
and for the intriguing proposal about research in this
area which she makes.
I would agree that insufficient attention has been given
to how features of organisations described in
organisational theory influences how quality
programmes are carried through. Certainly the concept
of organisational culture can be inadequate: it is often
used as a lazy explanation and as an excuse for
thinking about exactly what affects quality programmes
and how. Our paper also emphasized how power and
internal politics affect how a programme is
implemented, and the point in the letter about conflict
over goals in organisations is well made. The same is
true about criteria for success: different actors have
different criteria.
I think the key point is the question about whether
“essential conditions” can be derived for all
organisations to ensure successful implementation,
given the complex nature of health care organisations.
Dr Checkland thinks not, and that no “proscriptive
quality programme” will succeed in more than one site.
And certainly, both observation and TQM advice
suggest that each programme must be designed and
regularly replanned to suit the organisation and its
situation.
The research we described included empirical studies
which examined associations between factors and
improved quality in each organisation and draw
together these findings in an aggregate model. Such
models suggest factors which are common when all
the findings are pooled. The model does not predict
which will be the most important in a particular
organisation in particular circumstances. The
influences only appear in the aggregate, and suggest
that some of these influences might be operating in an
individual case.
Such aggregate models can be misleading if they are
taken to suggest these influences apply in all
situations. However, models derived in this way do give
leaders a good basis for examining which factors might
be important in their situation. The model does not
prescribe, but gives useful guidelines for diagnosis
and a local strategy. They also give useful research
frameworks for case studies to discover which
influences were acting in a particular situation. Case
studies of different processes and methods for
designing local strategies and systems can discover
which are most effective for this purpose.
Dr Checkland’s proposal is for a particular type of case
study. The proposal is to dispense with “standard”
interventions and instead to define outcomes.
Organisations would be helped through action
research to “work to understand their own internal
dynamics, and in reaching that understanding, go on to
make any changes necessary to reach the desirable
outcomes”. This is an intriguing proposal and one I
would support – as an experiment. It should also be
evaluated like any other development intervention. Soft
systems methodology has its principles like TQM, and,
like TQM, a prescriptive approach can be taken but this
is one which can contradict the principles. I also note
that theories would be used to help the actors
understand their own dynamics: the same comments
could be made about the validity of theories in relation
to the organisation in question.
The letter illustrates one of two perspectives: the
“context-dependency” perspective which holds that
each organisation and situation is unique. The “quality
programme” which is implemented is like no other.
Even if there is agreement amongst different parties
that this programme is “a success”, the factors and
conditions which accounted for this cannot be
generalised to other organisations and programmes.
Another perspective is that quality programmes are
interventions to organisations which have elements in
common which distinguishes them from other
development interventions, and which can be
assessed for their effectiveness. Further, that
generalisations can be made across organisations
about factors which are needed for an effective
programme.
The approach we took in our paper is a third which lies
between these two caricatures: quality programmes
are different in the details of their implementation but
they follow similar principles. Particular types of
programmes can be identified and are sufficiently
similar to be classified as the same type of
organisational intervention. A key issue is whether
there are certain elements of a programme which are
essential to success in most situation.
Organisations are different, with different histories,
cultures and internal power struggles. But comparable
organisations can be found in comparable
envrionments. If they introduce similar quality
programmes, then some knowledge can be generated
about whether the programmes produce certain results
and the conditions which appear to be associated with
this. This knowledge can be useful to other
organisations and to policy makers, and can be added
to with other studies of other programmes and other
organisations. Patterns may or may not emerge, but at
this stage too little research has been undertaken to
tell.
In general, I am in agreement with much of the letter,
including the action research approach described,
which I have also advocated (Øvretveit 2002).[2] However
I would not agree with ceasing to plan quality
programmes and to fund evaluations of them just
because certain theories suggest that any standard
type of intervention must fail, or that generalisations
cannot be made. This should encourage enquiry, not
close it down.
References
(1) Øvretveit, J and Gustafsson, D Evaluation of
quality improvement programmes. Qual Saf Health Care 2002;11:270-275.
Øvretveit, J. Action Evaluation of Health
Programmes and Change: A handbook for a user
focused approach 2002. Oxford: Radcliffe Medical Press.
Dear Editor
We welcome Singer and colleague’s contribution to developing the concept of a safety culture.[1] Policy-makers, managers and clinicians are slowly realising that patient safety will not be improved solely by counting adverse events or by introducing technical innovations. History tells us that when these initiatives are evaluated the results will probably show a marginal impact on patient safety, and one...
Dear Editor
Buetow and Wellingham present a comprehensive overview of accreditation of general practices in New Zealand, and elsewhere, in this well-written article.[1] They make the very significant point about the limitations of quality assurance as compared with the more important performance outcome orientation of continuous quality improvement.
However I am puzzled that they make no reference to the...
Dear Editor
Congratulations to the authors for this wonderful comprehensive survey undertaken across 15 hospitals regarding safety cultures. The results of an overall response rate of only 47.4%, was largely due to the poor response for physicians (33%) . Efforts need to be taken to increase the response rate for a more reliable study result. The majority of participants in the survey responded in ways which in...
Dear Editor
Doctors Santiago, Debanne, and Neuhauser correctly point out the frequent deficiencies in post-marketing surveillance of newly marketed drugs.[1] Because of aggressive marketing to physicians and direct-to- consumer advertising in the US, a new drug can now have very rapid dissemination, exposing large populations in a short time. Passive surveillance with ambiguous definitions of adverse effects may ofte...
Dear Editor
In response to the recent article in QSHC by A Coulter,[1] as a junior ophthalmic surgeon in training it worries me to see such views expressed as it has seriously detrimental consequences on our training.
It seems that Ms Coulter is suggesting that only Consultants or very senior, experienced surgeons should be operating on patients and any "junior" member operating would put a patient at ser...
Dear Editor
Regarding the article by L Locock,[1] we would like to share our healthcare redesign experiences with you. In recognising that up to 19.4% of all adverse patient events are attributable to medication mishap, Bayside Health Service (Melbourne, Australia) has identified medication safety as a priority.[2-5] A multidisciplinary Drug Management Committee was established to identify systemic factors contr...
Dear Editor
We need to do a better job of keeping track of potential side effects when designing randomized clinical trials (RCTs). Consider a RCT for a new drug tested for the main, or first order effect, the reduction of hypertension. Power calculations are carried out so that meaningful differences between the drug users and the controls can be detected on this effect. Second order effects, mortality in this case, a...
Dear Editor
Watkins and colleagues[1] add to the growing literature on the many and varied influences on general practitioner prescribing behaviour and costs.[2,3] They argue, from the results of their analyses, that the dispensing status of the general practitioner is a statistically significant predictor associated with high prescribing costs, though it is unclear from their report exactly how many dispensing pract...
Dear Editor
Milne and Hill suggest the 'Getting Research into Practice' programme may have contributed to the decline in surgery for glue ear that we have reported. We cannot, however provide any evidence to support this suggestion. The rate of decline in surgery throughout England was similar to that observed in 13 former health districts in the Oxford/Anglia region. The ratio of change in rates after 1992 over the...
Dear Editor
I would like to thank Dr Checkland for her thoughtful comments on our paper about evaluating quality programmes. I have some sympathy with her views and for the intriguing proposal about research in this area which she makes. I would agree that insufficient attention has been given to how features of organisations described in organisational theory influences how quality programmes are carried throu...
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