Recent eLetters

Displaying 1-10 letters out of 79 published

  1. An answer to the dilemma whether emergency department length of stay improves quality of care?

    Dear Editor,

    I commend Vermeulen et al for addressing a fundamental question: Is ED length of stay (ED LOS), a globally used key performance indicator, actually associated with improvement in quality of care[1]?

    Vermeulen et al set out to compare whether patients presenting with one of three acute conditions (high acuity asthma, upper arm/forearm/shoulder fracture and acute myocardial infarct) at hospitals with reduced ED LOS following the introduction of the Ontario Emergency Room Wait time strategy were also likely to experience improvements in other measures of quality of care; i.e. is evidence based treatment more likely given and if so, is it done in a timely fashion [1]?

    Interestingly, the study did not reveal an association between reduced ED LOS and improvement of other quality indicators, surprisingly not even for measures involving timely delivery of care [1]. Nevertheless, they did find that shift-level crowding is inversely associated with quality indicators related to timeliness of care: timeliness of reperfusion in AMI, splinting and analgesia in adult patients with fractures and steroid, bronchodilator within 60 minutes of presentation with acute asthma[1]. This supports prior studies reporting a correlation between ED crowding and increased short-term or in patient mortality [2, 3] and failure to administer timely care [4]. In my view, this study confirms that both quality initiatives and assessment of quality of care ought to be multidimensional and not focussed on one quality indicator. The association with shift-level crowding emphasises that we must concentrate on mapping trends in ED crowding over time to allow for appropriate ED staffing and institute systems that aid efficiency while assuring safety during those times. This may prove to be a more effective system to improve overall quality of care that encompasses safety, efficiency, timeliness and patient centredness [5] rather than focussing on reducing ED LOS in isolation, which appears to be a poor measure of quality of care[1]. Furthermore, reducing ED LOS equals time pressure, a known major contributing factor to error in human performance, which is likely to predominantly affect the diagnosis and treatment in complex patients due to performance degradation[6]. Finally, though it seems obvious that reduced ED LOS improves patient satisfaction, if it is associated with abrupt staff and contributes to human error[6], this is unlikely to be the case. I applaud Vermeulen et al for highlighting the critical issue with using one-dimensional measures to assess quality of healthcare.

    Word count: 394.


    1. Vermeulen, M.J., et al., Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis. BMJ Qual Saf, 2015. 2. Guttmann, A., M.J. Schull, and M.J. Vermeulen, Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ, 2011. 342. 3. Sun, B., R. Hsia, and R. Weiss, Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med, 2013. 61: p. 605-611. 4. Pines, J., J. Hollander, and A. Localio, The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med, 2006. 13: p. 873-878. 5. Pronovost, P., et al., How can clinicians measure safety and quality in acute care? Lancet, 2004. 363: p. 1061-1067. 6. Suzuki, T., T.L. Von Thaden, and W. Geibel Influence of time pressure on aircraft maintenance errors. 2008.

    Conflict of Interest:

    None declared

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  2. The Quadruple Aim: Care of the Patient Requires Care of the Providers

    The paper by Sikka, Morath and Leape is spot on (1). The authors call for adding a fourth aim to the Triple Aim: improving the experience of those providing care--physicians, nurses and others. This builds on our previous work "From Triple to Quadruple Aim: Care of the Patient Requires Care of the Providers" in which we make a similar recommendation (2).

    We also agree with the importance of creating conditions where healthcare workers can thrive, and find meaning and joy in their work (3,4, 5).

    Widespread physician and other health professional dissatisfaction can be taken as an early warning sign of dysfunction within the healthcare system. At present many front line clinicians experience a toxic environment, with near-constant multi-tasking, heavy documentation burdens, frequently shifting performance measures, high cognitive workloads and what is often perceived to be oppressive regulatory micromanagement.

    Remedying the widespread burnout among physicians and other health professionals will require empathy, sympathy and compassion for those on the front lines of care, and directing efforts to the intrinsic motivation and professionalism of the workforce.

    For healthcare organizations we recommend regularly measuring and improving workforce well-being, making this a vital measure on an institution's data dashboard. For policy makers we recommend evidenced- based regulation, coupled with studies demonstrating the time-costs of compliance. For technology vendors we recommend the humility to understand clinicians' workflow and incorporate human factors, efficiency and the ability of clinicians to maintain relationship with patients into design. For payers we recommend payment models that align with the values and goals of the healthcare system, and the documentation for which are minimized and manageable. For all stakeholders, before a new expectation is established, we recommend asking: What will busy clinicians forego to manage this new requirement?

    Well-being of the healthcare workforce is a shared responsibility. As part of that shared responsibility, we have contributed to a set of on- line, free, interactive practice transformation resources designed to help physicians and their practices increase efficiency, improve the quality of care, strengthen relationships and thereby increase joy in the practice of medicine. (6)


    1. Sikka R, Morath JM, Leape L. The quadruple aim: care, health, cost and meaning in work. BMJ Qual Saf. Published on line 004160.full.pdf+html 2. Bodenheimer T, Sinsky CA. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014;12:573-576. 3. Sinsky CA, Willard R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high- functioning primary care practices. Ann Fam Med 2013;11:272-278 4. Lucien Leap Institute. The National Patient Safety Foundation. Through the eyes of the workforce: creating joy, meaning, and safer health care. 2013 5. Wallace, Jean E et al. Physician wellness: a missing quality indicator. The Lancet , Volume 374 , Issue 9702 , 1714 - 1721 6.

    Conflict of Interest:

    None declared

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  3. Making sense of the story - the true value of incident reporting

    I was interested to read the thoughtful article by Imogen Mitchell and colleagues, echoing longstanding criticisms by Kaveh Shojania, Charles Vincent and others on the low value of high volume incident reporting. There is little learning from categorical data, repeated many times, around falls or minor medication errors. However, there was a time at the National Patient Safety Agency, where we experimented with a multidisciplinary meeting to make sense of reports, screened by skilled clinical reviewers. We concentrated on the freetext - the `story' of the incident. These weekly meetings became a dynamic and illuminating discussion of problem and solutions, with fiercely contested accounts from differing perspectives (surgeon, theatre nurse, GP, human factors or design experts). This space for reflective learning (Lamont 2011)reached places that desk-based data analysis couldn't go. The key was in the quality of the clinical reviewers, the range of clincal and safety expertise at the weekly meetings and a national function with ability to act on the risks, once articulated in this forum. It would be a shame to lose this potential for learning from a few carefully selected incidents, with the right analytic and sense-making skills and resources, in justified criticism of the limited safety gains to date from large incident reporting systems.

    Tara Lamont Deputy Director NIHR Dissemination Centre

    Lamont Tara. "Re-cognising" risks: from space shuttles to chest drains BMJ 2011; 343 :d4393

    Conflict of Interest:

    I worked at the National Patient Safety Agency 2004-2011.

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  4. Incident Reporting - Let's Decentralise

    The Editor, BMJ Quality and Safety,

    Mitchell, Schuster, Smith et al (1) present the results of semi-structured interviews with 11 international patient safety experts, 15 years after publication of the US Institute of Medicine's landmark report 'To Err Is Human'.(2) One of the Institute's recommendations was the introduction of healthcare incident reporting.

    Qualitative analysis of the interviews by Mitchell et al identified 5 problems - sheer volume of reports received and inadequate report processing, lack of involvement by medical practitioners, insufficient response and feedback to reports, inadequate funding and organizational backing, and failure to use electronic records. The article stated that the interviewees noted little progress in utilizing adverse event information to positively influence patient outcome - a sobering finding.

    In drawing on the opinion and experience of these national and international experts, maybe we are missing critical elements essential for utilization of incident reports. Their perspective and experience of incident reporting may have diluted or lost the value of this activity at the local healthcare facility. Taking anaesthesia as my example, reporting of adverse events and 'near misses' functions most robustly in the local department setting, where regular morbidity and mortality meetings allow free discussion of events in a 'no blame' culture. Knowledge of working conditions, staffing levels, rosters and surgical capabilities allows useful input regarding system factors involved in the incident, human factor analysis, and provision of feedback to people and the institution, in a timely fashion. Discussion of adverse events is a learning experience for everyone involved. The costs incurred by a department in the process of incident submission, analysis, discussion and feedback is minimal, as it is part of the contracted and expected duties of anaesthetic consultants and trainees. Trainees have evidence of reporting leading directly to tangible action, as closing the loop with feedback occurs soon after the incident. Anaesthesia incident reporting has become embedded in the functioning of my specialty at a departmental level, because it has addressed the identified problems - thus doctors do report, the data collected is processed, and feedback is provided in a timely fashion, the heads of department support and facilitate morbidity and mortality reporting, and minimal costs are incurred. Electronic record usage is utilised in some departments and will enhance audit and review when more readily available. Trainees are shown that safety and quality, with incident reporting, are integral parts of everyday practice, not an added extra, or afterthought.

    It is important that statewide and national reporting systems [Australian examples are Victorian Consultative Council on Anaesthetic Mortality and Morbidity (3), web-based reporting systems such as webAIRS (4)] are established, to identify patterns of failures or worrying trends in care, and recommend changes in practice. However, the considerable time-lag between adverse event occurrence, and their de-identified analysis and recommendations may reduce the impact of findings. The 5 problems identified by the interviewees are seen with these larger investigative bodies.

    Incident reporting is an essential part of health safety culture and climate (5), but to reap the benefits of the essential analysis and feedback components, I advocate decentralizing the process to craft groups and hospital departments. The manageable volume of reports, increased medical involvement, and feedback loops possible with smaller units would enhance learning and quality improvement.

    There is much to learn from incident reporting - we must not be buried under the pile of reports. We need to act locally, in our departments, our wards, our units, to promote and demand the collection of good data. We must provide the analysis and facilitate discussion of reports, and have safer and better quality care result from the feedback given.


    1. Mitchell I, Schuster A, Smith K et al. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human'. BMJ Quality and Safety Published Online First: 12th August 2015 doi:10.1136/bmjqs-2015-004405 Accessed 22nd August 2015

    2. Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC. National Academy Press 2000.


    4. webAIRS: [Internet]: Accessed 7th September 2015

    5. Benn J, Koutantji M, Wallace L et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care 2009;18(1):11-21

    Conflict of Interest:

    None declared

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  5. Length of stay as a marker of quality?

    Dear Editor,

    Vermeulen et al [1] provides further insight into the effect of emergency department (ED) crowding and length of stay (LOS) on several quality indicators. This piece of work not only adds to the body of literature which suggests ED crowding delays timeliness of interventions, but importantly highlights that government initiatives targeting LOS alone are not enough to enhance other aspects of true, quality care delivery.

    Donabedian [2] originally explored the various dimensions of quality, using a measurement framework recognising structural, procedural and outcome indicators. These have since been refined by various authors but are widely recognised to include efficacy, access, efficiency, safety, equitability, appropriateness and acceptability - the full spectrum of which must be considered when assessing the quality of care in emergency departments and hospitals.

    Like the Ontario ER Wait Time Strategy, Australia has adopted a National Emergency Access Target (NEAT) as a way of addressing crowding, patient flow and access to emergency care. Overcrowding and prolonged LOS in ED for admitted patients is certainly associated with poorer outcomes, and the introduction of a 4-hour rule can reduce hospital mortality [3].

    As is well demonstrated by Vermeulen et al, LOS targets measure when you arrive and when you leave ED - nothing in between. While seen as a quality access target, it in no way measures what actually happens within this time gap. Extended wait times for medical assessment and intervention have been associated with higher mortality rates and hospital admissions [4], but this only looks at one part of the patient's overall emergency experience. So although it is acknowledged that access is important, having LOS targets may also create unintended, negative consequences. ED doctors have less time to spend with complex patients, potentially resulting in diagnostic error and avoidable admissions. The results of this study show a lack of improvement in most quality indicators measured, suggesting that perhaps purely targeting LOS can in fact compromise effectiveness. The push to get patients through the system faster has also resulted in sick patients being transferred to ill-equipped medical assessment units - this I have experienced first-hand.

    Quality of care is of upmost importance but is complex and difficult to measure. Performance indicators such as NEAT are easily monitored but are, at best, only surrogate markers of quality. As Vermeulen highlights, strategies aimed at reducing ED LOS do not necessarily result in improvements to the other dimensions of excellent care provision. Whilst no detrimental effects to safety are demonstrated in this research, other measures such as adverse events, medication errors or changes in hospital admission rates were not captured to support this conclusion.

    LOS targets may have been an appropriate first step to tackle the issue of crowding, but there is now a need to look deeper into the quality of care being delivered in our ED's. Interestingly, the UK has lowered its performance threshold on the 4 hour rule, now placing emphasis on a number of other quality indicators [5]. Quality of patient care must be prioritised while ensuring access is maintained. This requires more sophisticated measurements of the quality of emergency medical care.

    Tess Baker

    References: 1. Vermeulen MJ, Guttmann A, Stukel TA, Kachra A, Sivilotti M, Rowe BH et al. Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-difference analysis. BMJ Qual Saf 2015;0:1-10

    2. Donabedian A. The quality of care. How can it be assessed? JAMA 1988; 260(12):1743-1748

    3. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. MJA 2006, 184;208- 212

    4. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011;342:D2983

    5. Department of Health. Accident and emergency provisional quality indicators [internet] UK: Department of Health; August 2010 [cited 2015 Sept 7]. Available from emergency-provisional-quality-indicators

    Conflict of Interest:

    None declared

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  6. Curricula redesign requires assessments of value

    This study focused on the lack of standardization for human factors content in postgraduate training curricula. The authors emphasized the importance of non-technical skills (NTS) such as leadership, decision making, team working and resource management during training, highlighting that a significant proportion of errors are based on failures of NTS as opposed to just knowledge and technical errors. The curricula of medical, surgical and critical care specialties (CCS) were analyzed for non- technical skills, situational awareness and human factors as well as additional terms under the headings task management, team working, and decision making. The authors concluded that non-technical skill terms occurred infrequently on the whole with the main occurrences in critical care specialties. These specialties were in addition the only ones that specified requirements for formal training in NTS. Overall non critical care specialties lacked specific detail on learning objectives and assessment strategies.

    As of 2013 exiting UK medical students are now expected to demonstrate situational based attributes of a foundation doctor allied to professionalism, coping with pressure, communication, patient focus and team working as part of the situational judgement test (1). After its introduction, a total of 7770 applicants were asked to provide their reactions to the SJT. Only 52.5 % concluded that the content seemed relevant to what they thought the role of a foundation doctor should be (vs 57.1 % in 2014 and 56.5 % in 2015) (2, 3, 4). 38.6 % agreed or strongly agreed that the content of the SJT appeared to be fair to the foundation programme (vs 40.4 % in 2014 and 40.6 % in 2015), with 25.4 % applicants agreeing or strongly agreeing that the results of the SJT could help selectors to differentiate between weaker and stronger applicants (vs 26.1 % in 2014 and 26.3 % in 2015) (2, 3, 4). At present, there is a lack of longitudinal research studies evaluating the extent to which SJTs effectively predict performance throughout the medical education pathway, from medical school admissions through to independent clinical practice, and beyond (5). This is relevant given evidence that SJTs have different predictive validity at different stages during medical education, training and practice (5).

    The study authors highlighted that NTS training impacts patient safety in a wide range of clinical domains, but NTS based learning objectives feature rarely outside CCS. They argue that curricula in general are designed with assumed NTS acquisition in a non-formalized fashion and call for NTS to feature explicitly in all curricula and to be assessed accordingly. I wholeheartedly agree. It is important to note that despite initial measures to assess situational judgement robust evidence for its actual value is lacking. We need to be certain therefore that testing is adequate with measures that are appropriate in order to ensure long term valuable outcomes.

    Dr Neel Sharma

    1. UKFPO. Situational Judgement Test 2015; Available from:

    2. Patterson, F. Analysis of the Situational Judgement Test for Selection to the Foundation Programme 2013. 2013; Available from: Report-May-2013-updated-for-publication.pdf.

    3. Patterson, F. Analysis of the Situational Judgement Test for Selection to the Foundation Programme 2014. 2014; Available from: Report-June-2014.pdf.

    4. Patterson, F. Analysis of the Situational Judgement Test for Selection to the Foundation Programme 2015. 2015; Available from: Report.pdf.

    5. Patterson F et al. Situational judgement tests in medical education and training: Research, theory and practice: AMEE Guide No. 100. Medical Teacher 2015 1-15.

    Conflict of Interest:

    None declared

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  7. Let's address everyday emotional harms.

    One example of our almost universal, daily inflicting of emotional harm on patients is our mis-labeling of the patient's presenting problem as the 'Chief Complaint'.

    Years ago, an ICU patient said plaintively, "I'm not a complainer." after a bedside presentation is which that is just what he was called.

    Let's call it the 'Presenting Problem'--in our talk and in our notes. It might contribute to a climate in which extreme cases become more rare.

    And perhaps we could eliminate these into the bargain: "The patient has failed multiple therapies." (when it is the therapies that failed) "The patient is a poor historian." (when the physician is meant to be the historian) "The patient admits/denies. . . "

    Conflict of Interest:

    None declared

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  8. Moving Beyond Tokenism: a public health response on Researcher in Residence models

    Marshall et al's (2014) paper was highlighted as an exemplar of stakeholder participation by a speaker at a recent public health research conference, held in Newcastle. Participants gave useful feedback about many of the core issues raised, which we reflect here.

    Marshal et al's (2014) 'Researcher in Residence' models are suggested as a means of co-engaging academics and practitioners in the promotion of evidence-informed service improvement. But participants at our event raised questions about public involvement as key stakeholders from earlier on in the research process. In the experience of our presenters and participants, research that starts from questions derived from both academics and participants (i.e. that is co-produced) is more likely to address patient needs than questions driven by academics, funders or institutions.

    Important (though hardly novel) questions remain. Are academics open enough to co-produced research ideas? Is there sufficient willingness to see questions differently, to work differently, and to enable tacit knowledge and patient and public experience to be valued as a legitimate contribution to the research process? Public stakeholders at our event expressed hunger to know how to engage with academia, but felt the opportunities to do so were unclear. There is much to learn from Patient and Public Involvement (PPI) in research.

    As others have observed, effective patient and public involvement (PPI) requires difficult conversations about vested interests (Greenhalgh et al 2014) and power and status among stakeholders (Centre for Social Justice 2012). Discussions about paying research participants can present thorny issues for some, among wider concerns around how public views are sought/used/valued/acknowledged. PPI raises philosophical questions around 'independent research' and what this means, as well as similarly tricky issues around what expertise and experience 'counts' (for researchers and the public) and how to address institutional barriers and facilitators to its use.

    Public health, classically defined as 'organised community effort' to prevent disease, prolong life and promote health (Winslow 1920 cited in Lang and Raynor BMJ 2012), presents a unique set of challenges. The relocation of public health responsibilities to local government raises questions about the different cultures of research and evidence use, the place of public involvement and democratic accountability, and how to use opportunities to address the social determinants of health. The exemplars used by Marshall et al (2014) are all drawn from clinical settings, and models of PPI may need adapting for use in public health.

    Our event showcased pockets of good practice and highlighted different methods to involve patients and the public, including in public health (see Some of these have been published elsewhere (Centre for Social Justice 2012, Lewis and Russell 2014). Taken together with feedback from those with experience of PPI, we can discern some underlying principles to guide meaningful PPI in research (which may also support research use in practice). Though not comprehensive, these include the need to; clarify motives; reach out to marginalised groups; use existing networks; take account of context; be reflexive and adaptive; value different forms of knowledge and expertise; be committed to the possibilities of facilitating change.

    Neither in public health nor clinical settings have we 'cracked it' in terms of PPI. Our conference opened a black box of similarities and contrasts between PPI in public health and clinical settings - requiring different approaches. Learning opportunities can flow in both directions, recognising the complexity inherent in PPI in population health interventions (Best et al 2009).

    The researcher in residence model introduced by Marshall et al (2014) is one approach to co-production. However, we argue that early involvement in setting research agendas is more likely to meet the needs of the public. There are critical blocks to effective engagement, for example silo thinking, the "paradigm shift" (Hunter 2009) required in academia, and specific skills amongst researchers. New ways of doing research must have co-production at their core - they must be collaborative and engage stakeholders from the start of the research process, when questions are being formulated, through to dissemination.

    References Best, A., Terpstra, J.L., Moor, G. Riley, B., Norman, C.D., Glasgow, R.E. (2009) Building knowledge integration systems for evidence-informed decisions Journal of Health Organization and Management, Vol. 23, issue 6, pp 627 - 641.

    Centre for Social Justice and Community Action, Durham University and the National Co-ordinating Centre for Public Engagement (2012) Community- based participatory research. A guide to ethical principles and practice, available from

    Hunter, D. J. (2009) Leading for Health and Wellbeing: the need for a new paradigm Journal of Public Health, Volume 31, No. 2, pp 202-204

    Lang, T and Raynor, G (2012) Ecological public health: the 21st century's big idea? British Medical Journal 345: e5466. 21 August.

    Lewis and Russell (2011) Being embedded: A way forward for ethnographic research Ethnography 2011 12: 398. DOI: 10.1177/1466138110393786

    Lomas, J (2007) the in-between world of knowledge brokering British Medical Journal, 334, (7585): 129.

    Conflict of Interest:

    All authors were members of the organising committee for Beyond tokenism: PPI with impact Enriching patient and public involvement in public health research, October 16th 2014. The event was sponsored by the Newcastle Institute of Social Renewal, Newcastle University Faculty of Medical Science, Fuse Centre for Translational Research in Public Health and Involve North East.

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  9. Ryan's Rule - consumer / family escalation.

    Dear Editor,

    We read with interest your Editorial re the role of families in preventing avoidable harm in children (1).

    Many public hospitals in Queensland Health in Australia have now implemented Ryan's Rule. When Ryan's parents were worried he was getting worse they didn't feel their concerns were acted upon in time. It was subsequently established that Ryan died from likely preventable causes. Ryan's Rule was developed to provide patients of any age, families and carers with another way to get help. Families and carers are educated by staff and with the prominent display in the wards of Ryan's Rule posters containing the following advice re escalation.

    There are three steps for families and carers to raise their concerns:

    [1] talk to a nurse or doctor about your concerns. If you are not satisfied with the response->

    [2] Talk to the nurse in charge of the shift. If you are not satisfied with the response ->

    [3] Phone 13 Health (13 43 25 84) or ask a nurse to call on your behalf. Request a Ryan's Rule Clinical Review and provide information about hospital name, patient's name. ward, bed number, your conduct number. A Ryan's Rule nurse or doctor will review the patient and assist.

    We await with interest the results of the prospective audit of this statewide process.

    Yours sincerely,

    Dr Mai-Ing Koh MBBS (JCU), Resident, Namboru Hospital

    Assoc Prof Tieh Hee Hai Guan Koh BA MA (Oxon) MBBChir(Cantab) MD (Cantab) FRCPCJ Director Neonatology The Townsville Hospital Queensland 4814 AUSTRALIA

    1) Roland, D. But I told you she was ill! The role of families in preventing avoidable harm in children BMJ Qual. Saf. 2015 24:186-187

    2) Ryan's Rule (accessed 11.3.15)

    Conflict of Interest:

    None declared

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  10. Response to letter regarding 'working smarter, not harder'

    We thank Dr. Iedema for highlighting that a gap exists in providers having the skillset to 'work smarter.' We agree that novel approaches to healthcare improvement are required that move beyond gadget-based solutions and that require a new set of skills of providers and provider organizations. The suggestion of video taping one's performance to review how the system (and its participants) currently operates and reflect on how to (re-) design their workflows is intriguing. It exemplifies the concept of 'exnovation' or 'innovation from within', meaning innovation arises from within established practice, and from within practitioners.

    However, our article did not aim to imply that it is providers who are responsible for, or required to gain the skills to work smarter. Our message is directed to all those seeking and driving healthcare system improvement. Although we agree that providers may benefit from the skillsets that Dr. Iedema proposed, we believe that those seeking change also need additional skillsets and perspectives. We can no longer presume that healthcare providers have the space to add new tasks, workflows, procedures etc. We have, as a system, to work on simplifying the current work environment, finding non-value added tasks and work with healthcare providers to design ways of achieving improved outcomes that don't add net new workload or complexity. Now some may argue that added work at one part of the system may have larger benefits downstream. This may be true but those charged with carrying the weight of the new tasks have to do so in a sustainable and reliable way. Otherwise subsequent change initiatives will disrupt this balance and its downstream benefits.

    Our message was also aimed at those adding new regulation, policies, performance measures and incentives or disincentives. Adding pressure on top of an environment that doesn't have the space nor the knowledge and skill to create it only adds to workplace burden, resistance and non- sustained improvement. We believe that there needs to be a system-wide look at the capabilities and investments required to create a 'working smarter' healthcare system. Providers will play their role but they need a commitment that a 'work harder' strategy is no longer acceptable.

    Conflict of Interest:

    None declared

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