In the UK about 5000 people die each year from hospital acquired infections. That equates to 65 000 people since this journal was launched in 1992. This is an intolerable toll, which at least in part is linked to failure of healthcare professionals to clean their hands. Evidence that hand hygiene is effective in reducing infection is compelling and is available in the medical literature.¹ So, why cannot hospitals institute and insist on the sorts of changes that make hand washing become part of actual practice?

Arguably, all improvements in clinical care require an organisational change. Failure to understand clinical practice in organisational terms can slow the introduction of new treatments as well as stall efforts to improve the quality and safety of care. For example, there was about a 10 year delay between publication of convincing research showing that thrombolysis, given appropriately, improves survival following a myocardial infarction and for this evidence based treatment to become part of routine practice.² The knowledge of what worked was out there—but practice did not change. What was needed was a significant change in the organisation of emergency medical care. It seems that healthcare professionals and others are either unable to see the problems—and solutions—in organisational terms or, if they do, lack the skills to make the changes that will lead to improvement. And so, for years patients who suffered heart attacks were not offered life prolonging thrombolysis and today’s patients continue to be exposed to unnecessary risk of contracting hospital acquired infections.

Other sectors, such as the airline and oil industries, have had considerable success in the pursuit of improved safety and better quality of service, and this experience may provide some lessons that can be transferred across to health care. However, unlike these other industries, many within health care, particularly clinicians, have an ambiguous relationship with their employing organisations—usually hospitals. I wager that all hospitals have a policy somewhere that states every one should clean their hands between seeing patients. Many healthcare workers do not do this simple thing: there is a chasm between organisational intention and the action of individuals. An organisational rule goes unheeded. People continue to die from hospital acquired infection. It is difficult to imagine people in the airline or oil industries not doing something that was so important for safety. But those organisations would surely have made the rule explicit; have provided training and made sure that the appropriate cleansing agent was always available in places where it was needed.

Descriptions of when things go horribly wrong usually include failures of the system of care, often with an element of care being given outside the usual process or system. Rarely are they stories of failure of intention to care for an individual. The story of Wayne Jowett,³ a 16 year old recovering from leukaemia who had forgotten to attend for consolidation chemotherapy illustrates this point. He arrived later than scheduled and, in order to help and to respond to his individual situation, the doctors who saw him (who were not his usual doctors and were not familiar with the organisational processes) arranged to administer his chemotherapy. A kind act but, in the end, one that led through a series of organisational errors to a clinical error and to Wayne’s death. It is a story of the consequence of people who responded to an individual without understanding the dangers of working outside the system.

Learning to “buck” the system is a frequent early learning experience for many doctors. For example, hospitals in the UK do not allow pre-registration house officers (interns) either to prescribe or to administer cytotoxic chemotherapy. Although this “organisational rule” has been in force for several years, we sometimes find that it has been broken. This usually happens at night, when a nurse discovers that a patient has not been given chemotherapy; the person who should give it is no longer on duty and the “covering” doctor is called. Although this very inexperienced doctor and the nurse may both be aware that the doctor should not give the chemotherapy, neither perceives any real danger as the action needed is simply to attach an infusion bag to an already sited drip; both are concerned that the patient should get the treatment and so the treatment is given. An organisational rule is broken. Nothing happens, no one knows. A culture that ignores the system of delivery of care is enforced and the system becomes a little more dangerous.

Yet the literature on organisational improvement and customer focused service emphasises empowering individual workers to take responsibility and respond to the individual needs of their customers. So, how do you square this particular conflict? It must be by ensuring that empowerment also means training people to be able to do these tasks properly and understand the reasons for organisational rules and processes. Thus, nurses and pre-registration house officers don’t assume that they are forbidden to give cytotoxic drugs because they are not capable but because they haven’t been trained.

Healthcare professionals are trained very well to care for individuals but receive very little, if any, training in how to care for the system of healthcare delivery. Training about caring for and treating individuals is crucial. But it needs to be combined with learning about and respect for the system of care. Otherwise, focusing on individual needs and blind to the demands of the system of care, clinicians embark on actions that could jeopardise their patients’ well being.

Clinical education needs to catch up with this changing world. Clinical autonomy, valued by clinicians, cannot be allowed to expose patients to risks that result from not respecting organisational guidelines. The education of clinicians needs to be extended to include an understanding of the impact of organisational behaviours on clinical care. Berwick et al⁴ suggested eight skills for quality improvement (see box) and, more recently, the US Accreditation Council for Graduate Medical Education has proposed a competency based model designed to encourage residents to learn about improvement principles. The six competencies are: patient care; medical knowledge; practice based learning and improvement; interpersonal and communication skills; professionalism and system based practice.⁵ Clinicians coming through such programmes should be better equipped to offer safer care in today’s healthcare environment and, if hospitals provide the appropriate support and environment, will be able to put this training into practice. Most of those currently practising will not have had this training. These skills should be included within the revalidation and appraisal processes.

In the past, ignoring organisational rules and norms did not pose much danger to patients. As Cyril Chantler wrote: “Medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous”.⁶ Hospitals as organisations need to work with clinicians to make sure that organisational guidelines are respected and adhered to. Insisting on hand hygiene would be a good start. To achieve this will require significant cultural change—and it demands clinical leadership and organisational commitment and support. But it might just be the break that is needed to encourage development of a culture in which organisational guidelines are observed. Hospitals, too, could take responsibility for ensuring that newly qualified doctors, who are very knowledgeable about drugs and therapeutics, learn how to prescribe safely—perhaps under the auspices of a “Director of Prescribing”⁷ It is never comfortable insisting that “rules” should be kept. Clinical practice is one area where they are not there to be broken.

This journal has reflected the development of quality and safety improvement for 13 years. Undoubtedly, much more is now known and understood about the extent of problems and some of the underlying causes. Important documents, including the two reports from the US Institute of Medicine, have influenced thinking and shaped the debate about the quality and safety of care worldwide. In the UK we have seen the implementation of clinical governance; the development of National Service Frameworks for a range of conditions and client groups; and the setting up of agencies such as the National Patient Safety Agency and the National Institute of Clinical Excellence. All this seems worlds away from the UK Medical Audit Programme, implemented in 1990 just before the launch of this journal, yet it is not clear just how much patients have benefited from all of this activity. Nevertheless, the increasing concern about the quality and safety of care and a developing research agenda⁸ should be grounds for cautious optimism.

The editorial team of QSHC is about to change. I hope that the new team will get the opportunity to report groundbreaking changes that show that knowledge about “what to do” has at last been translated into significant actions that truly make a difference for patients. In the meantime I thank the many authors, reviewers, and the editorial team who together enabled QSHC to reflect the burgeoning debate on quality and safety improvement over the past 13 years.