In the Scandinavian countries we have a lot of discussions related to
how to publish quality improvement work, and process oriented writing
courses are ongoing. Therefore, this article comes on time. I really
agree with the authors that a quality improvement report has to follow
the IMRaD-model, and the Table 1 "Draft proposed guidelines for stronger
improvement evidence" and Table 2 are really helpfu...
In the Scandinavian countries we have a lot of discussions related to
how to publish quality improvement work, and process oriented writing
courses are ongoing. Therefore, this article comes on time. I really
agree with the authors that a quality improvement report has to follow
the IMRaD-model, and the Table 1 "Draft proposed guidelines for stronger
improvement evidence" and Table 2 are really helpful and understandable,
and will help me as a teacher and adviser of these courses. Thanks!!
The no-child-left-behind program grades schools on the basis of test-
scores on their pupils. Waters, Lefevre, and Budetti have arguably
developed a far more valid and relevant measure of school-performance by
assessing malpractice-experience, as a function of medical school.
It seems anomalous, even negligent, that the authors would develop
data on which medical schools produce graduates wh...
The no-child-left-behind program grades schools on the basis of test-
scores on their pupils. Waters, Lefevre, and Budetti have arguably
developed a far more valid and relevant measure of school-performance by
assessing malpractice-experience, as a function of medical school.
It seems anomalous, even negligent, that the authors would develop
data on which medical schools produce graduates who experience little
litigation, more litigation and most litigation, but omit publication of
those specific data, according to named medical schools. Such publication
would doubtless be incendiary, among medical schools in the third tier and
maybe even in the second but wouldn't the authors best serve the public
interest by releasing such data, the better to inform prospective medical
students, in advance, of the risks to which they may expose themselves and
their future patients, if any, by accepting admission to certain medical
schools? Shouldn't there be a National Medical School Data Bank,
available to prospective medical students to enable them to choose medical
schools rationally?
If not, what justification is there for the National Practitioner
Data Bank, which keeps track of the dirt on physicians? A physician, if
"bad", may hurt a few patients. A medical school, if "bad", may produce
hundreds of "bad doctors" who may hurt thousands of patients.
The paper by Spiegelhalter is a valuable contribution to the
literature on presenting and displaying performance related outcome
measures.[1] It provides further methodological guidance on identifying
service providers whose performance falls outside control limits using
funnel plot methodology. When reporting on performance it is important to
have procedures in place which should be followed when...
The paper by Spiegelhalter is a valuable contribution to the
literature on presenting and displaying performance related outcome
measures.[1] It provides further methodological guidance on identifying
service providers whose performance falls outside control limits using
funnel plot methodology. When reporting on performance it is important to
have procedures in place which should be followed when outliers are
identified. These issues have been considered by the Paediatric Intensive
Care Audit Network (PICANet) who use the funnel plot methodology for
reporting risk-adjusted mortality from all paediatric intensive care units
(PICU) in England and Wales. Prior to producing these funnel plots for the
latest National Report, we issued a policy statement drawn up in
consultation with both our Clinical Advisory and Steering Groups.[2] In
summary, the PICANet policy (published in full at http://www.picanet.org.uk)
recognises that a PICU whose risk-adjusted mortality lies outside of the
control limits will be identified as having returned data that is markedly
different to the other PICUs. It is important to note that a PICU lying
outside the control limits is not sufficient evidence to suggest that it
has either markedly higher or lower mortality than other PICUs, merely
that the data they have returned is different to that of other PICUs. To
resolve why this data is different, PICANet will work with the units to
provide a satisfactory explanation, following the plan below
i) Review the data to investigate whether there are data driven
reasons for a PICU lying outside of the control limits (it is known that
risk-adjustment tools can be unreliable when a PICU has a particularly
high proportion of patients at either end of the bounds of the tool.)
ii) Review the quality of data supplied by the PICU. The quality of
the data is the PICUs’ responsibility. PICANet will provide feedback from
PICU data validation visits and central validation procedures. PICUs will
be expected to check the quality of individual data items.
iii) Plot the data quality indicators over time to identify whether
the anomaly can be traced to a certain data collection period.
iv) Plot the mortality ratio over time to identify whether the
anomaly can be traced to a certain data collection period.
v) Plot the observed mortality over time to identify whether the
anomaly can be traced to a certain data collection period.
vi) Plot the expected mortality over time to identify whether the
anomaly can be traced to a certain data collection period.
vii) Investigate the primary diagnoses for admissions to the PICU.
If the PICU has a very different diagnostic casemix when compared with
other PICUs this may suggest further refinements to the risk-adjustment
method are required.
viii) Produce a brief summary report of the above for the lead
clinician and Chief Executive at the PICU concerned together with an
invitation to meet in person to review the data with the PICANet team.
We believe having such a policy in place, clearly outlining our
interpretation and proposed actions before publication of such funnel
plots is vital to the chances of such information being accepted by staff
at the participating units and thus more likely to result in positive
actions being taken.
Yours sincerely,
Dr Gareth Parry, co-director of PICANet and reader in Health Services Research, University of Sheffield.
Dr Elizabeth Draper, co-director of PICANet and senior research
fellow. Department of Epidemiology and Public Health, University of Leicester
Prof. Patricia McKinney, co-director of PICANet and professor of
paediatric epidemiology. Paediatric Epidemiology Group, University of Leeds
References
1. Spiegelhalter DJ. Handling over-dispersion of performance
indicators. Qual Saf Health Care 2005; 14: 347-351.
2. Paediatric Intensive Care Audit Network. National Report
2003–2004. Universities of Leeds, Leicester and Sheffield, May 2005 (ISBN
0 85316 254 9).
The issue of using UAPs to perform various medical duties has been
debated in the US as well. [Shostek K. Unlicensed Assistive Personnel:
Risk Management Considerations. J Healthc Risk Management 1998
Winter;18(1)] The 'role drift' described by M. McKenna is the result of a
shortage of professional and licensed caregivers like nurses and
technologists with college degrees. The performance of a task (su...
The issue of using UAPs to perform various medical duties has been
debated in the US as well. [Shostek K. Unlicensed Assistive Personnel:
Risk Management Considerations. J Healthc Risk Management 1998
Winter;18(1)] The 'role drift' described by M. McKenna is the result of a
shortage of professional and licensed caregivers like nurses and
technologists with college degrees. The performance of a task (such as
phlebotomy) and the understanding of the complexities of anatomy,
physiology, and human response to disease are not inseparable with
appropriate training and adequate oversight. In light of the need to focus
more on patient safety and less on "turf", teamwork in healthcare may be
the best approach.
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
Dear Editor,
In the Scandinavian countries we have a lot of discussions related to how to publish quality improvement work, and process oriented writing courses are ongoing. Therefore, this article comes on time. I really agree with the authors that a quality improvement report has to follow the IMRaD-model, and the Table 1 "Draft proposed guidelines for stronger improvement evidence" and Table 2 are really helpfu...
Dear Editor,
The no-child-left-behind program grades schools on the basis of test- scores on their pupils. Waters, Lefevre, and Budetti have arguably developed a far more valid and relevant measure of school-performance by assessing malpractice-experience, as a function of medical school.
It seems anomalous, even negligent, that the authors would develop data on which medical schools produce graduates wh...
Dear Editor,
The paper by Spiegelhalter is a valuable contribution to the literature on presenting and displaying performance related outcome measures.[1] It provides further methodological guidance on identifying service providers whose performance falls outside control limits using funnel plot methodology. When reporting on performance it is important to have procedures in place which should be followed when...
Dear Editor
The issue of using UAPs to perform various medical duties has been debated in the US as well. [Shostek K. Unlicensed Assistive Personnel: Risk Management Considerations. J Healthc Risk Management 1998 Winter;18(1)] The 'role drift' described by M. McKenna is the result of a shortage of professional and licensed caregivers like nurses and technologists with college degrees. The performance of a task (su...
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...
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