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Why is improvement so hard? HQIP Annual Conference 2010 Martin Marshall Clinical Director and Director of R&D “You can’t solve a problem by using the thinking that got your there” Albert Einstein 10 percent of patients admitted to hospital experience iatrogenic harm More than half of this harm could have been prevented if staff had followed established good practice Vincent et al., BMJ, 2001 On average, 45% of patients fail to receive recommended care McGlynn et al., NEJM, 2003 Between 2001 and 2006 there was a 450% increase in death rates in England from C. Diff. Clostridium difficile, death certificate mentions, England, 2001 - 2006 7000 6301 6000 5000 4000 3648 3000 2146 1720 2000 1149 1325 1000 0 2001 2002 2003 2004 2005 2006 Source: HPA, Scottish Parliament, NHS Wales, CDSC Northern Ireland, 2007 The overall 5 year survival for all malignancies is 20% higher in Sweden than in the UK 100 Age adjusted 5-year relative survival - all malignancies, males diagnosed 2000-02 90 80 70 60.3 relative survival (%) 60 55.4 54.6 53.2 53.0 49.8 50 47.9 47.1 44.8 42.0 40.2 40 30 20 10 0 Sweden Austria Switzerland Belgium Norway Italy Wales NetherlandsEngland Northern Ireland Scotland Source: EUROCARE-4, 2007 Nearly 60% of patients are not told about the potential side-effects of their prescribed medications Source: Commonwealth Fund, 2005 How are other sectors doing? Safety In the aviation business there is one death per 10 million flights In the health sector there is 1 iatrogenic death per 300 hospital admissions Quality Motorola tolerates 3.4 defects per million manufacturing processes In the health sector the ‘defect’ rate is 900,000/million processes for the management of alcohol dependence How have policy makers, clinicians and managers responded to the quality challenges that we face? Ways of improving patient care Governmental Regulation Performance management Legislation Economic Professional Incentives/sanctions Patient choice Competition Commissioning Education and training Clinical audit Peer review/ collaboration Guidelines ‘Industrial’/ organisational Org. development TQM/CQI, BPR, PDSA, Lean, 6 sigma Factors relating to the intervention Why is improvement so hard? Factors relating to the environment Factors relating to the people involved Factors relating to the intervention Research examining the Research examining the overall Why is characteristics of successful effectiveness of interventions improvement so interventions hard? • Most can be effective but overall effect size small • Variable impact depending on context • Often takes long time to achieve Factors relating change to the e.g. QQuiP evidence reviews environment • Active approaches better than passive ones • Multifaceted interventions more Factors relating effective than single ones • Interventions more effective if to the people • relative advantage • compatible involved • simple • testable • observable/measurable • involving e.g. Grimshaw, Grol, Greenhalgh The policy environment • The organisational environment Factors relating to • Different policy approaches to the intervention achieving change need to be integrated and based on evidence • The unintended consequences of different levers need to be predicted and managed Why is improvement so hard? Factors relating to the environment Change management programmes often fail • High performing organisations have strong leadership, clear vision, commitment to build capacity, well integrated services, excellent IT, focus on users and on measurement, engaged clinical staff through active explicit processes, strong sense of accountability, aligned incentives, sensitivity to local context/culture • Characteristics of failing organisations tend to be mirror image of above Factors relating to the people e.g. Kotter, Baker, Bate, Davies, Shortell, Fullop involved Psychological approaches Sociological approaches • Factors relating to• Improvement can be seen as social the intervention activity rather than technical Change is more likely to be effective when individual characteristics are taken into account achievement • attitudes to new ideas e.g. innovators, early adopters, early and late majority, • Clinicians may behave more like laggards ‘workers’ than as professionals • stage of journey towards change e.g. pre• Professional identity explains many contemplation, contemplation, behaviours e.g. defining and preparation, action, maintenance, Why is legitimising risk, heroic behaviours, completion improvement so e.g. Rogers, Prochaska and Velicer, Grol rituals • There are often inadequatehard? structures of authority and accountability in clinical teams Factors relating to e.g. theRoberts, McDonald, Dixon Woods, Checkland, Greenhalgh environment Factors relating to the people involved Why is improvement so hard? Isn’t it remarkable that we are doing as well as we are?!! So, why is improvement so difficult? • We don’t know as much about large scale and sustained improvement as we should ACTION: We need to build the evidence base underpinning improvement in the health sector • What we do know, we rarely put into practice ACTION: We need to be more systematic about how we design and implement policy and practical approaches to improvement • We are giving insufficient attention to the human side of improvement ACTION: We need to adopt more sophisticated approaches to influencing and motivating people • We have naïve expectations of what we can achieve ACTION: A generous dose of realism and tenacity is required Thanks for listening [email protected] www.health.org.uk