Two main themes run through the papers in this issue of JournalScan, both of which seem central to new strategies to improve quality and safety in health care:

• an emphasis on culture relationships within organisations between managers and professionals, clinicians and patients; and

• incentives—ways of rewarding behaviour to enhance quality.

Learning from organisational failure

▸ A paper in Health Affairs begins by saying that, if healthcare organisations are to become exemplar in quality and safety, they should mimic the airline industry where “every airplane crash is carefully catalogued and painstakingly analysed to learn lessons for the future”. If not, “important opportunities for improvement will be missed, and the chances are surely higher that similar failures will happen again”. It examines examples of major failures from six countries—US, UK, Australia, New Zealand, Canada and the Netherlands—to explore how healthcare systems and organisations deal with these failures.

Analysis shows that common themes run through many of the instances of major failure:

• Longstanding problems which have been present and known about for years before they are brought to light.

• Well known but not handled.

• Lack of management systems: the organisations where these failures occur usually lack fundamental management systems for quality review, incident reporting, and performance management, or those systems have been bypassed with ease. They frequently show little collaboration between managers and clinicians and a lack of coherent clinical leadership. They are often isolated and inward looking organisations unwilling to learn from elsewhere.

“Perhaps the most important barrier to disclosure is the endemic culture of secrecy and protectionism in health care facilities in every country. Knowledge about these problems and responsibility for acting to tackle them are often fragmented across many people, who all know something about the problem or failure but don’t necessarily know the full picture or have the authority or incentive to …