We note Dr Checkland’s comments on our paper on scepticism with
interest.[1] In response, we do not believe that the paper argues that it is
not legitimate for staff to be sceptical; indeed, we acknowledge the fact
that scepticism can be useful in highlighting gaps and flaws in
improvement initiatives. Nevertheless, the study – based on interviews
that centred on listening to the opinions of others...
We note Dr Checkland’s comments on our paper on scepticism with
interest.[1] In response, we do not believe that the paper argues that it is
not legitimate for staff to be sceptical; indeed, we acknowledge the fact
that scepticism can be useful in highlighting gaps and flaws in
improvement initiatives. Nevertheless, the study – based on interviews
that centred on listening to the opinions of others – did identify the
negative impact that scepticism and resistance are having on the pace of
change in the NHS.
With regard to the use of terms such as modernisation and
improvement, we think that this is a semantic argument that ignores the
underlying spirit and intent of planned reform. It is surely legitimate to
make certain assumptions about meaning in this context. Changes designed
to make health care better for patients deserve to be described as
improvements until subsequent research evidence demonstrates otherwise.
The drive to involve frontline staff in leading service improvement
encompasses the notion that change that proves not to be beneficial in
practice can be reversed. If we implement only that which has been
scientifically proven to be effective, the pace of change will be very
slow.
Reference
1. Checkland KH. Sceptics or realists [electonic response to Gollop et al. Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors’ and managers’ views] qshc.com 2004http://qhc.bmjjournals.com/cgi/eletters/13/2/108#80
The article by Gollop et al.[1] raises an interesting question:
does labelling a programme of change an "improvement" programme mean that
such a programme will automatically deliver improvements?
I am disturbed
by the implication that simply because something is "a key component of
the government's strategy to modernise the NHS and make it more
accessible to patients" it is therefor...
The article by Gollop et al.[1] raises an interesting question:
does labelling a programme of change an "improvement" programme mean that
such a programme will automatically deliver improvements?
I am disturbed
by the implication that simply because something is "a key component of
the government's strategy to modernise the NHS and make it more
accessible to patients" it is therefore not legitimate for staff to be
sceptical. In fact, the inclusion of such a sentence in the article
provokes me to yet greater scepticism: what exactly does "modernise" mean
in this context, and when did it become synonymous with "improve?" This
Orwellian use of language and the presumption that it is not legitimate
for intelligent observers to be sceptical about unproven innovation are
two of the reasons that many of us are so disillusioned with life in the
NHS. Having worked in the NHS for nearly twenty years, I have experienced
many waves of change: some have brought improvements, some have been
disastrous; some I have embraced and some I have resisted. I reserve the
right to remain sceptical and questioning, and I hope that the
Modernisation Agency will, as it matures as an institution, lose some of
its evangelical fervour and learn to listen to the opinions of others.
Changing its name might be a start!
References
1. R Gollop, E Whitby, D Buchanan, and D Ketley. Influencing sceptical staff to become
supporters of service improvement: a qualitative study of doctors' and managers' views, QSHC 2004; 13:108-114.
Firth-Cozens article explores the effect of trust and the ways in
which it can be developed in health care organizations to enhance patient
safety.[1] Leadership attributes of ability, benevolence and integrity
most certainly contribute to the establishment of trust in a leader
however, these attributes alone are not enough to overcome the barriers to
open disclosure of errors.
Firth-Cozens article explores the effect of trust and the ways in
which it can be developed in health care organizations to enhance patient
safety.[1] Leadership attributes of ability, benevolence and integrity
most certainly contribute to the establishment of trust in a leader
however, these attributes alone are not enough to overcome the barriers to
open disclosure of errors.
Organizational trust must first be earned by its leaders through
demonstrated commitment to a ‘no blame’ policy with respect to adverse
event investigations. The author acknowledges ‘the importance of
considering the multi-causal and sociotechnical nature of most
accidents’[1] however, I believe this aspect of the article requires more
explicit discussion as it is fundamental to the development of
organizational trust.
Quick judgments and routine assignment of blame obscure a more
complex truth, a series of events and departures from safe practice, each
influenced by the working environment and the wider organizational
context.[2] If analysis of adverse events focused less on individual error
and more on organizational or system factors, an environment of trust may
begin to prosper and strategies to enhance patient safety would become
visible. No amount of leadership ability, benevolence or integrity will
lead to organizational trust if fear of blame exists. A consistent and
transparent process for a root cause analysis of adverse events is
essential for health care leaders to demonstrate in order to achieve any
degree of organizational trust and subsequent open disclosure.
As Firth-Cozens states in a previous publication, ‘the main driver of
higher organizational trust is going to have to come from the actions and
attitudes of leaders and managers at every level’.[3] Actions undoubtedly
speak louder than words when it comes to investigation and assignment of
blame in the analysis of adverse events. A culture change is required and
it must begin with the leadership of each health care organization.
Leaders who consistently demonstrate and acknowledge the role of system
failures as the root cause of adverse events, will have greater success in
establishing the trust that health care organizations so desperately
require. Maybe then we will begin to impact on the quality and safety of
the health care which we deliver.
References
1. Firth-Cozens J. Organisational trust: the keystone to patient
safety. Qual Saf Health Care 2004;13:56-61
2. Vincent C, Taylor-Adams S, Jane Chapman E, Hewett D, Prior S,
Strange P, Tizzard A. How to investigate and analyze clinical incidents:
Clinical Risk Unit and Association of Litigation and Risk Management
protocol 2000;320:777-781
3. Firth-Cozens J. Learning from error. In: Harrison J, Innes R, Van
Zwanenberg T, eds. Regaining trust in health care. Albingdon: Radcliffe
Medical Press, 2003.
At the Linnaeus Collaboration meeting in Canberra, Australia last week
(sponsored by the Australian Primary Health Care Research Institute and
the US Agency for Healthcare Research and Quality), primary care
researchers from Australia, Canada, England, Germany, New Zealand, and the
United States met to consider further research aimed at improving patient
safety in primary health care. We discussed the...
At the Linnaeus Collaboration meeting in Canberra, Australia last week
(sponsored by the Australian Primary Health Care Research Institute and
the US Agency for Healthcare Research and Quality), primary care
researchers from Australia, Canada, England, Germany, New Zealand, and the
United States met to consider further research aimed at improving patient
safety in primary health care. We discussed the issues raised in the
editorial by RM Wilson because we also think that improvements in medical
record-keeping are crucial to improving patient safety. From our
discussion, the following was clear:
1. Paper medical records are not a viable phenomenon for the 21st
century and beyond. This is a particularly challenging notion for the
countries in North America and Australia, where there has not yet been a
wholesale clinical and political commitment to electronic medical records.
2.. The medical record of the 21st century may well be patient held
and maintained. As researchers we found this idea worrying because medical
records are a rich and valuable research resource - we worry that they may
become so well disintegrated that they may no longer be available for
research.
But to answer Wilson's questions:
1. We agreed that the key functions of the medical record are to keep a
record of all encounters between patients and the formal health system.
This record may then be used: (1) to maintain patient safety by ensuring
that health information about a patient exists and is accessible to those
who need it - at any time and in any place, (2) to identify early signs of
catastrophic events (e.g. bioterrorism) through sentinel monitoring, (3)
to measure costs and benefits of healthcare in the real-world setting, and
therefore (4) in light of the above, to be a continuous healthcare quality
improvement tool.
2. What constitutes a "minimum" dataset for a patient record has
already been considered (e.g. [1]). To best fulfil all its functions,
medical records should hold full information about each healthcare
encounter, including setting and encounter method (face-to-face, phone,
email, video, etc), dates, both patient and provider views of reason for
encounters, and details of care provided (including information about
medications, investigations, referrals, immunisations, and other
preventive measures). There is disagreement between countries on the
extent of patient information that is necessary in a patient's medical
record. For instance, in New Zealand the government is concerned that
patients' ethnicity and residence location (for calculating deprivation
and measuring inequalities) are recorded - neither piece of information
having particular significance for gps' clinical decisions. No other
country represented at the meeting had to provide these particular items,
but in the US and Germany health insurance information is absolutely
required. There will obviously be international variation in "key"
elements.
3. How do we implement such requirements? Marshall and Smith write
persuasively in this issue of financial incentives [2]. While we agree
that financial incentives are necessary for systemwide adoption of medical
records standards, we also think political will, a rationale that is
credible to healthcare providers, and cultural change in practice are
crucial.
References
1. Tilyard MW, Munro N, Walker SA, Dovey SM. Creating a general practice
national minimum data set: present possibility or future plan? NZ Med J
1998; 111: 317-20.
2. Marshall M, Smith P. Rewarding results: using financial incentives
to improve quality. Qual Saf Health Care 2003; 12(6): 397-8.
We fully agree with Hasenfeld and Shekelle that many published guidelines
fall short of the internationally consented quality criteria for their
production and use, although the principles for the development of sound
evidence–based guidelines are well established. In response several
national and international initiatives have been working on programmes for
the promotion of quality in guideline developm...
We fully agree with Hasenfeld and Shekelle that many published guidelines
fall short of the internationally consented quality criteria for their
production and use, although the principles for the development of sound
evidence–based guidelines are well established. In response several
national and international initiatives have been working on programmes for
the promotion of quality in guideline development.[1-3]
In order to promote sustainable international partnerships in the field of
guideline development, use and research activities, a network of non-for-
profit organisations dealing with development, implementation and
evaluation of EBGs was founded in November 2002, called Guidelines
International Network (G-I-N). To date 46 institutions from 24 European,
American, Asian and Oceanian countries including WHO have become members
of the network.
In November 2003, G-I-N's released the first international Electronic
Guideline Library (http://www.g-i-n.net) giving access to nearly 1400 guidelines
and related resources with special focus on the methodological quality of
clinical practice guidelines.
This initiative is meant as a contribution to the improvement of
guidelines' quality and to dissemination of best available practice
guidelines worldwide.
References
1) Burgers JS, Grol R, Klazinga NS, Mäkelä M, Zaat J, for the AGREE
Collaboration. Towards evidence-based clinical practice: an international
survey of 18 clinical guideline programs. Int J Qual Health Care 2003; 15:
31-45.
2) Council of Europe. Developing a methodology for drawing up guidelines
on best medical practice. Recommendation Rec(2001)13 and explanatory
memorandum. Strasbourg, Council of Europe Publishing 2002.
3) The AGREE Collaboration. Development and validation of an international
appraisal instrument for assessing the quality of clinical practice
guidelines: the AGREE project. Qual Saf Health Care 2003;12:18–23
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.
Dear Editor
We note Dr Checkland’s comments on our paper on scepticism with interest.[1] In response, we do not believe that the paper argues that it is not legitimate for staff to be sceptical; indeed, we acknowledge the fact that scepticism can be useful in highlighting gaps and flaws in improvement initiatives. Nevertheless, the study – based on interviews that centred on listening to the opinions of others...
Dear Editor
The article by Gollop et al.[1] raises an interesting question: does labelling a programme of change an "improvement" programme mean that such a programme will automatically deliver improvements?
I am disturbed by the implication that simply because something is "a key component of the government's strategy to modernise the NHS and make it more accessible to patients" it is therefor...
Dear Editor
Firth-Cozens article explores the effect of trust and the ways in which it can be developed in health care organizations to enhance patient safety.[1] Leadership attributes of ability, benevolence and integrity most certainly contribute to the establishment of trust in a leader however, these attributes alone are not enough to overcome the barriers to open disclosure of errors.
Organizational...
Dear Editor
At the Linnaeus Collaboration meeting in Canberra, Australia last week (sponsored by the Australian Primary Health Care Research Institute and the US Agency for Healthcare Research and Quality), primary care researchers from Australia, Canada, England, Germany, New Zealand, and the United States met to consider further research aimed at improving patient safety in primary health care. We discussed the...
Dear Editor
We fully agree with Hasenfeld and Shekelle that many published guidelines fall short of the internationally consented quality criteria for their production and use, although the principles for the development of sound evidence–based guidelines are well established. In response several national and international initiatives have been working on programmes for the promotion of quality in guideline developm...
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...
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